Initial Comments:
This report is the result of a full State Licensure survey conducted on February 6, 2024, at Warren General Hospital, with additional documentation review concluding on February 27, 2024. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
The following offsite locations were included in this survey:
St. Clair Family Practice
103 St. Clair Street
Warren, PA 16365
WMG Women Services
2 Crescent Park West
Warren, PA 16365
Plan of Correction:
147.1 LICENSURE
GENERAL PROVISIONS - PRINCIPLE
Name - Component - 00
147.1 Principle
A clean, safe environment shall be
provided and maintained within the
hospital in accordance with standards
specified by the Department of
Environmental Services in 25 Pa. Code
173.1-173.17, in addition to the
provisions of this subpart.
Observations:
Based on facility documentation, a tour of the facility, and employee interviews (EMP), it was determined the facility failed to maintain a clean, safe environment in the St. Clair Family Practice, the Behavioral Health Unit, the Maternal Child Health Department, the Intensive Care Unit, and the IMSAC Unit.
Findings Include:
Review, at approximately 10:36 AM on February 9, 2024, of facility policy "Environmental Services Policies and Procedures," dated October 2023, revealed "... A clean, safe environment shall be provided and maintained within the hospital for all Patients, Employees and Visitors ... Keep all equipment clean and in good condition. ... HIGH DUST: High dust everything above shoulder level or out of reach. Use an extension pole with duster head. Never high dust around or over people. ... Dust all of the horizontal surfaces daily and vertical surfaces as required. ..."
1. A tour of the St. Clair Family Practice was conducted On February 6, 2024, beginning at 10:15 AM. Observation of Exam Room 1 revealed one cabinet with accumulated dust. EMP2 confirmed the above finding at the time of observation.
Observation of Exam Room 2 revealed one cabinet with accumulated dust. EMP2 confirmed the above finding at the time of observation.
Observation of Exam Room 3 revealed one cabinet with accumulated dust. EMP2 confirmed the above finding at the time of observation.
Observation of Exam Room 4 revealed one cabinet with accumulated dust. EMP2 confirmed the above finding at the time of observation.
Observation of Exam Room 5 revealed one cabinet with accumulated dust. EMP2 confirmed the above finding at the time of observation.
2. A tour of the Behavioral Health Unit was conducted on February 6, 2024, beginning at 11:00 AM. Observation of the Medication Room revealed one medication dispensing machine with accumulated dust. EMP2 and EMP13 confirmed the above finding at the time of observation.
3. A tour of the Maternal Child Health Department was conducted on February 6, 2024, beginning at 11:14 AM. Observation of the Medication Room revealed one medication dispensing machine with accumulated dust. EMP2 and EMP13 confirmed the above finding at the time of observation.
4. A tour of the Intensive Care Unit was conducted on February 6, 2024, beginning at 11:31 AM. Observation of Room 257 revealed patient monitoring equipment with accumulated dust. EMP2 and EMP13 confirmed the above finding at the time of observation.
5. A tour of the IMSAC Unit was conducted on February 6, 2024, beginning at 11:45 AM. Observation of the Medication Room revealed two medication dispensing machines and one refrigerator with accumulated dust. EMP2 and EMP13 confirmed the above findings at the time of observation.
Plan of Correction:The Compliance Officer and Manager of Environmental Services reviewed the finding for high dust which was found in Behavioral Health, CCU, IMSAC and an office in the St. Clair building. Most of the high dust was on top of the omnicells in med rooms or on top of cabinets.
Here is our Plan of correction:
1. We have purchased and distributed new Microfiber high dusting products for all of our cleaning schedules.
2. The manager of environmental services has done a department in-service with all staff discussing the importance of high dusting all areas several times a week including Med Rooms and have shown all staff how to properly use the new high dusters.
To monitor the performance to make sure that the plan of correction are complete 100% that the education and high dust has been addressed, weekly audits/ checks will be completed until there is zero high dust found by environmental manager consecutively for at least 3 months.
The compliance officer will also be spot checking and monitoring weekly and monthly during EOC rounds for high dust.
To add to the monitoring- the manager has done the following;
3. The manager of environmental services added all med rooms on my list of weekly room Inspections and will audit those areas weekly to make sure there is no high dust found.
In addition to monitoring by the following committee;
4. The Compliance Officer is part of the safety committee which completed Environmental rounds on units monthly. High dust will be checked and monitored going forward along with following up with environmental services managers on his audits for high dust.
|