QA Investigation Results

Pennsylvania Department of Health
ABINGTON SURGICAL CENTER, LP
Health Inspection Results
ABINGTON SURGICAL CENTER, LP
Health Inspection Results For:


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Initial Comments:


This report is the result of a State licensure onsite survey initiated on November 21, 2022 and concluded on December 8, 2022, at Abington Surgical Center. 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:




567.41 LICENSURE
MAINTENANCE SERVICE - Principle

Name - Component - 00
567.41 Principle

The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.


Observations:


Based on a review of facility documents and interview with facility staff (EMP) it was determined the facility failed to ensure recorded temperature and humidity readings were consistent with the recommended guidelines for temperature and humidity ranges in the Operating Rooms.
Findings Include:
Review on December 8, 2022 of facility policy on, "Temperature and Humidity Monitoring" dated August 2021 revealed "Policy: It is the policy of the Abington Surgical Center to record daily environmental temperature and humidity levels in the operating rooms and PACU (Post Anesthesia Care Unit) to ensure a safe and sanitary environment in the treatment of patients. ...Procedure: 1. Environmental temperature and humidity levels will be checked and recorded daily in log books in all OR's (operating rooms) and PACU. ...4. If at any time the desired temperature does not meet the recommended standards, the Facilities Manager, or his designee will be notified. The manufacturer, Biomed or our HVAC (Heating, Ventilation, and Air Conditioning) Company will be notified that temperature is not maintained and service is required. 5. The item out of temperature range will not be used and a note will be placed on it that states this until such time that the item is repaired or replaced. 6. If at any time the desired temperature does not meet the recommended standards in an operating room, the temperature or humidity alert form will be filled out by the OR nursing staff and placed in a log book ...Temperature of Humidity ALERT [attached form] The operating room is outside the acceptable parameters for temperature or humidity ...Temperature 68 - 75 degrees ...Humidity 20% - 60%..."
Review on November 22, 2022 of the ANSI/ASHRAE/ASHE Standard 170-2017 (American National Standard Institute/ American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc/ American Society for Health Care Engineering) Table 8.1 Design Parameters for Outpatient Spaces in "The Facility Guidelines Institute Guidelines for Design and Construction of Outpatient Facilities" 2018 edition, revealed the acceptable range for Operating Room Relative Humidity was 20-60%.
Review on November 22, 2022 of facility document "Temperature/Humidity and Terminal Cleaning Logs" for June 1, 2022, to June 30, 2022, revealed temperature and humidity was recorded once daily Monday through Friday in OR1, OR2, OR3, OR4, OR5, OR6 and OR7. Further review revealed the humidity levels in OR1 exceeded the standard maximum of 60% on 20 of the 22 days recorded in June. Humidity levels in OR2 exceeded the standard maximum of 60% on 20 of the 22 days recorded in June. Humidity levels in OR3 exceeded the standard maximum of 60% on 20 of the 22 days recorded in June. Humidity levels in OR4 exceeded the standard maximum of 60% on 20 of the 22 days recorded in June. Humidity levels in OR5 exceeded the standard maximum of 60% on 19 of the 22 days recorded in June. Humidity levels in OR6 exceeded the standard maximum of 60% on 19 of the 22 days recorded in June. Humidity levels in OR7 exceeded the standard maximum of 60% on 10 of the 22 days recorded in June.
Review on November 22, 2022 of facility document "Temperature/Humidity and Terminal Cleaning Logs" for July 1, 2022, to July 29, 2022, revealed temperature and humidity was recorded once daily Monday through Friday in OR1, OR2, OR3, OR4, OR5, OR6 and OR7. Further review revealed the humidity levels in OR1 exceeded the standard maximum of 60% on 17 of the 20 days recorded in July. Humidity levels in OR2 exceeded the standard maximum of 60% on 18 of the 20 days recorded in July. Humidity levels in OR3 exceeded the standard maximum of 60% on 18 of the 20 days recorded in July. Humidity levels in OR4 exceeded the standard maximum of 60% on 17 of the 20 days recorded in July. Humidity levels in OR5 exceeded the standard maximum of 60% on 18 of the 20 days recorded in July. Humidity levels in OR6 exceeded the standard maximum of 60% on 18 of the 20 days recorded in July. Humidity levels in OR7 exceeded the standard maximum of 60% on 7 of the 20 days recorded in July.
Review on November 22, 2022 of facility document "Temperature/Humidity and Terminal Cleaning Logs" for August 1, 2022, to August 31, 2022, revealed temperature and humidity was recorded once daily Monday through Friday in OR1, OR2, OR3, OR4, OR5, OR6 and OR7. Further review revealed the humidity levels in OR1 exceeded the standard maximum of 60% on 23 of the 23 days recorded in August. Humidity levels in OR2 exceeded the standard maximum of 60% on 23 of the 23 days recorded in August. Humidity levels in OR3 exceeded the standard maximum of 60% on 23 of the 23 days recorded in August. Humidity levels in OR4 exceeded the standard maximum of 60% on 21 of the 23 days recorded in August. Humidity levels in OR5 exceeded the standard maximum of 60% on 23 of the 23 days recorded in August. Humidity levels in OR6 exceeded the standard maximum of 60% on 23 of the 23 days recorded in August. Humidity levels in OR7 exceeded the standard maximum of 60% on 2 of the 23 days recorded in August.
Review on November 22, 2022 of facility document "Temperature/Humidity and Terminal Cleaning Logs" for September 1, 2022, to September 30, 2022, revealed temperature and humidity was recorded once daily Monday through Friday in OR1, OR2, OR3, OR4, OR5, OR6 and OR7. Further review revealed the humidity levels in OR1 exceeded the standard maximum of 60% on 19 of the 21 days recorded in September. Humidity levels in OR2 exceeded the standard maximum of 60% on 16 of the 21 days recorded in September. Humidity levels in OR3 exceeded the standard maximum of 60% on 16 of the 21 days recorded in September. Humidity levels in OR4 exceeded the standard maximum of 60% on 16 of the 21 days recorded in September. Humidity levels in OR5 exceeded the standard maximum of 60% on 13 of the 21 days recorded in September. Humidity levels in OR6 exceeded the standard maximum of 60% on 14 of the 21 days recorded in September. Humidity levels in OR7 exceeded the standard maximum of 60% on 2 of the 21 days recorded in September.
An interview conducted on November 21, 2022, at 1:56PM with EMP1 confirmed the relative humidity was frequently higher than the standard maximum of 60% during the days recorded in June, July, August, and September 2022. EMP1 further confirmed OR cases are performed on the dates the humidity levels exceeded the standard maximum of 60%, and the facility physicians were made aware of the humidity levels in the OR's.
Repeat deficiency Event ID: DT3111








Plan of Correction:

Elements detailing how the facility will correct the deficiency as it relates to the individual patient(s):

The Medical Director, director of nursing and the infection control nurse will update the temperature and humidity monitoring policy on when the operating rooms are out of range for temperature and humidity that will include:

- Closing operating rooms when they are out of humidity or temperature range

- When a room is out of range and closed it will be reported on to the State through the PSRS system as an infrastructure failure

The Center has engaged an architectural and engineering firm to manage the process to correct the temperature and humidity issue. The architectural firm has extensive experience working on healthcare projects in Pennsylvania.
ALLIANCE architecture, LLC
Relevant Healthcare Project Experience
90% of our business is return or recommendation. A large portion of our regular work is healthcare related. Our current regular clients include two of the largest healthcare networks in our region, Lehigh Valley Hospital and Health Network and St. Luke's University Health Network. We are also solicited by private practice groups and design build contractors for a multitude of various healthcare projects.

D'Huy Engineering, Inc.
D'Huy Engineering, Inc. was founded in 1976 and we offer extensive engineering and design experience in the building construction industry for a wide variety of building types. Our professional engineering services include the design of mechanical, electrical, plumbing and fire protection systems for many specific client-based applications ranging from schools, laboratories, hospitals, to industrial/manufacturing processes. Our experience within the healthcare sector includes the design of cancer centers, medical imaging center, surgical suites and critical care, sterile processing, pharmacies, and morgues. We are knowledgeable of specialized mechanical and electrical systems tailored to healthcare facilities including medical gas systems, emergency power systems, nurse call and paging, fire alarm, HVAC including HEPA filtration and humidification, and domestic water treatment systems.

The Surgical Center will keep in constant contact with the PA DOH throughout the process. The end result will be a corrective action plan and implementation to ensure adequate temperature and humidity control and monitoring at the facility. The proposed scope of work and timeline for completion will be presented to the governing body.

Indicate how the facility will act to protect patients in similar situations:

This deficiency and plan of correction will be reported to the Center's patient safety committee and to the governing body.
The Center will carry out the architectural and engineering firms proposed corrective action plan for temperature and humidity control and monitoring, and oversee the completion and implementation of the work plan. This will include the purchasing of any new HVAC equipment or other parts needed to keep the temperature and humidity at acceptable levels.

Include the measures the facility will take or the systems it will alter to ensure the problem does not recur:
Environmental temperature and humidity levels will be checked and recorded daily in log books in all OR's (operating rooms) and PACU.

Indicate how it plans to monitor its performance to make sure that solutions are sustained:
If at any time the desired temperature does not meet the recommended standards, the Facilities Manager, or his designee will be notified to take corrective action. The Director of Nursing or designee will monitor all operating rooms to ensure compliance with the temperature and humidity policy.
Dates when the corrective action will be completed:
The corrective action will commence immediately with the signing of an agreement between the Center and Alliance Architects. The architects will evaluate the system and proposed fixes to the system. Depending on what is needed this process could take 9 months (or longer) because of the severe supply chain issues affecting the HVAC industry. The goal of the Center is to complete the correction as soon as possible.
Position(s) responsible for the corrective action and monitoring of plan of correction:
Executive Director and the Facilities Manager
This deficiency and plan of correction will be reported to the Center's patient safety committee and to the governing body.