QA Investigation Results

Pennsylvania Department of Health
AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE
Health Inspection Results
AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE
Health Inspection Results For:


There are  18 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


This report is the result of a State Re-licensure survey conducted on January 21, 2021, at Ambulatory Surgery Center at St. Mary, Llc. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.










Plan of Correction:




561.25 LICENSURE
Distressed drugs, devices and cosmetics

Name - Component - 00
561.25 Distressed drugs, devices and cosmetics

Drugs, devices and cosmetics which are outdated, visibly deteriorated, unlabeled or inadequately labeled, recalled, discontinued or obsolete shall be identified by the licensed pharmacist or responsible practitioner and shall be disposed of in compliance with applicable Commonwealth and Federal regulations.


Observations:


Based on facility tour, and a review of facility policies and procedures, and interview with staff (EMP), it was determined that the facility failed to ensure outdated medications were removed from stock.

Findings include:

A tour on January 22, 2021 at 10:49 AM, revealed the following expired medications:

1. In medication refrigerator contained seven (7) bottles of Pardgan Phenylephrine Ophthalmic Solution 2.5% that expired August 2020.

2. In the Anesthia workroom, twenty-four (24) vials of Heparin Sodium Injection 1000 Units per mL each expired December 2020.

A review of nursing policy #413 on January 21, 2021, titled, "Medication Usage and Control", dated last reviewed September 2020, revealed, "Purpose: To establish a system for the use and control of medications ... 19. Designated personnel will check medication storage areas weekly for outdated drugs ..."

An interview conducted on January 21, 2021, at 2:20 PM with EMP2 confirmed the medications in the medication refrigerator and the Anesthia room were outdated and had not been removed from stock.

















Plan of Correction:

Following our survey, we met with the clinical team to reinforce our expired medication policy and use of down-time. We also performed a full review of all medication storage areas and our safety committees are currently reviewing the formulary to remove any unneeded medications. We have instituted a tracking sheet whereby assigned clinical float staff must document their review and check of medication storage areas for expired items. The Director of Nursing is responsible for monitoring this process by reviewing the log sheets weekly. This was already in place in pre-op/PACU, we have expanded this to include the medication refrigerator in the OR and the medication storage room in the OR suite.


Initial Comments:

This report is the result of a full State Re-Licensure survey conducted on January 21, 2021 at Ambulatory Surgery Center at St. Mary, Llc. It was determined the facility was in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: