QA Investigation Results

Pennsylvania Department of Health
PPSP FAR NORTHEAST HEALTH CENTER
Health Inspection Results
PPSP FAR NORTHEAST HEALTH CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of an annual registration survey conducted on December 16, 2020, and completed off-site on December 18, 2020, at PPSP Far Northeast Health Center. It was determined the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.






Plan of Correction:




Initial Comments:

This report is the result of an annual registration survey conducted on December 16, 2020, and completed off-site on December 18, 2020, at PPSP Far Northeast 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:




555.3. (a-f) LICENSURE
Requirements for membership & privileges a-f

Name - Component - 00
555.3. Requirements for membership and privileges.
(a) To receive favorable recommendation for appointment, or reappointment,
members of the medical staff shall always act in a manner consistent with the
highest ethical standards and levels of professional competence.
(b) Privileges granted shall reflect the results of peer review or utilization
review programs, or both, specific to ambulatory surgery.
(c) Privileges granted shall be commensurate with an individual ' s qualifications,
experience and present capabilities.
(d) Granting of clinical privileges shall follow established policies and procedures
in the bylaws or similar rules and regulations. The procedures shall provide
the following:
(1) A written record of the application, which includes the scope of privileges
sought and granted. The delineation ' ' clinical privileges ' ' shall address
the administration of anesthesia.
(2) A review, summarized on record with appropriate documentation, of
the qualifications of the applicant.
(e) Reappraisal and reappointment shall be required of every member of the
medical staff at regular intervals no longer than every 2 years.
(f) The governing body shall request and consider reports from the National
Practitioner Data Bank on each practitioner who requests privileges.

Observations:


Based on review of facility policy, credential files (CF), and interview with staff (EMP), it was determined the facility failed to adhere to the facility's policy for certifying the privileges of the medical staff every two years for two of two credential files reviewed (CF1 and CF2).

Findings include:

A review on December 16, 2020, of facility policy "Abortion Provider Privileging and Medical Staff Appointment" last revised October 18, 2018, revealed "Per ASF (ambulatory surgery facility) and Quad-A regulations and the PPSP Abortion Policy Manual, abortion providers must apply to the PPSP Board of Directors for appointment to the medical staff of PPSP, upon hire/engagement and every two years thereafter. For initial appointments and biennial re-appointments, all of these actions must be completed by one (1) month prior to the Board's scheduled review: 1. The Medical Director will certify the provider's clinical privileges related to abortion care (Medication Abortion, Surgical Abortion, Ultrasound, Local Paracervical Block, Molar Pregnancy Management, Ectopic Pregnancy Management, Early Pregnancy Loss Management) by completing a Certification of Clinical Privilege form and submitting it to the Director of Human Resources. If the provider seeking privileging and appointment is the Medical Director, then the responsibility for certifying the Medical Director's clinical privileges will be delegated by the Medical Director to a physician who holds all relevant privileges."

Review on December 16, 2020, of facility document for CF1, doctor of osteopathic medicine dated December 14, 2020, revealed "It is my pleasure to inform you that the Board of Directors has approved your appointment to the active medical staff of Planned Parenthood Southeastern Pennsylvania, with the granting of requested privileges as documented in your personnel file. This is a two-year appointment and is for the period December 11, 2020 to December 31, 2022."

Review on December 16, 2020, of CF1 with EMP1 revealed no evidence of documentation of a application for the credentialing period of December 11, 2020, to December 31, 2022.

An interview conducted on December 16, 2020, at 10:00 AM with EMP1 confirmed that an application for the credentialing period of December 11, 2020, to December 31, 2022, had not been completed nor was required by the facility.
_________
Based on review of facility policy, credential files (CF) and interview with staff (EMP), it was determined the facility failed to ensure the privledges of certified registered nurse anesthetist were certified every two years in accordance with the registration status approved by the "Department" for a Abortion/Class B surgical facility for two of two credential files reviewed (CF2).

Findings include:

Review of facility policy "Governing Body Responsiblities" last revised November 30, 2019, revealed "Board Appointments: The board may grant clinical privileges to qualified, licensed practitioners (physicians, certified registered nurse anesthetists, nurse practitioners) working in the ASF... A written record of the application for clinical privileges, and the scope of privileges granted, shall be maintained. The board shall conduct a review, summarized on the record with appropriate documentation of the qualification of the applicant."

Review on December 16, 2020, of facility document for CF2, a certified registered nurse practitioner (CRNA) dated December 19, 2019, revealed "It is my pleasure to inform you that the Board of Directors has approved your appointment to the active medical staff of Planned Parenthood Southeastern Pennsylvania, with the granting of requested privileges as documented in your personnel file. This is a one-year appointment and is for the period 12/19/19 to 12/19/20."

An interview conducted on December 16, 2020, at 9:50 AM with EMP1 confirmed CF2 did not contain evidence of documentation of clinical privileges for providing monitored anesthesia care services. Further interview revealed CF2 did not contain an application for the appointment date of December 19, 2019, through December 19, 2020.














Plan of Correction:

By 3/31/21, facility leadership (Director of Patient Services and Director of Human Resources) will review and update the facility policy "Abortion Provider Privileging and Medical Staff Appointment" including the development of a new medical appointment and clinical privileges application form. The updated policy will be presented to the Governing Board for approval at the March meeting and the new appointment process will be implemented once approved. The Director of Human Resources will audit credentialing files against new policy and initiate updates to existing providers privileging certification, obtaining attestation from Facility Medical Director as needed. Human Resources will audit credential files at time of appointment or reappointment, and annually to ensure ongoing compliance. The Director of Patient Services will ensure Plan of Correction is completed and monitor facility for compliance.

By 5/31/21, all contracted CRNAs will have documentation of granted clinical privileges for monitored anesthesia care in their credential files. To complete the privileging process, CRNAs will submit an application for privileges and medical staff appointment. The Director of Patient Services and Director of Human Resources will develop the application and update the CRNA policy "Credentials and Training Requirements for CRNAs" to reflect this new procedure. The policy will be presented to the Governing Body at the March 2021 meeting. The Director of Anesthesia will conduct peer review and initial privileging of all CRNAs and prepare recommendation for the Governing Body. Recommendations will be presented at the April and May Board Meetings. CRNAs application, evidence of privileges, and peer view will be maintained in the credential files. The Director of Human Resources will audit credentialing files at time of appointment and annually to ensure compliance. The Director of Patient Services will ensure Plan of Correction is completed and monitor facility for compliance.





557.4 (a)(1-4) LICENSURE
Quality Assurance & Improvement Committee

Name - Component - 00
557.4 Quality Assurance & Improvement Committee

(a) The committee shall consist of the following:
(1) A practitioner who is not an owner,
(2) A representative of administration,
(3) A registered nurse,
(4) Other health care personnel, as appropriate.


Observations:

Based on a review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to ensure the required committee members of the Quality Committee (QC) Meeting were in attendance as representatives of the ambulatory surgical center (ASC) during the Compliance, Risk & Quality Management Committee meetings.

Findings include:

Review on December 16, 2020, of facility document "Planned Parenthood Southeastern Pennsylvania Risk and Quality Management ..Program Overview and Work Plan revealed " ... Committee members include: ... A Center Manager or Assistant Center Manager ... Other staff as assigned based upon agenda items and/or program review".


Review on December 16, 2020, of the facility's Quality Committee (Compliance, Risk & Quality Management) meeting minutes dated June 16, 2020, and September 29, 2020, revealed facility representatives from administration and an other health care personnel was not in attendance at the Compliance, Risk & Quality Management Committee meetings.

An interview conducted on December 16, 2020, at 10:34 AM with EMP1 and EMP2 confirmed the required QC members were not in attendance at the Compliance, Risk & Quality Management Committee meetings conducted on June 16, 2020, and September 29, 2020, for the ambulatory surgical center.





















Plan of Correction:

The Compliance, Risk and Quality Management (CRQM) Plan will be updated to include required attendance of a physician that is not an owner, administrator, registered nurse and "an other healthcare personnel per PA regulations. The updated CRQM Plan will be submitted to the Board of Directors (Governing Body) for approval at next meeting (scheduled 4/29). The Director of Patient Services will meet with the Center Manager to review the updated facility Compliance, Risk and Quality Management (CRQM) Plan and confirm the requirement of attendance at the (CRQM) Committee meetings. To ensure required facility administrator representation, the Center Manager will identify an alternative member of the facility leadership team that will attend if she is unable. In addition, the RN for the facility will begin attending these meetings. Meeting attendance is documented in the CRQM Committee meeting minutes. Evidence of Center Manager retraining and understanding of requirements will be documented via email. The Director of Patient Services will monitor quarterly CRQM Committee meeting minutes for compliance to required attendance. The Director of Patient Services will ensure Plan of Correction is completed by 5/15/21.


567.1 Principle LICENSURE
CHAPTER 567 - ENVIRONMENTAL SERVICES

Name - Component - 00
567.1 Principle

The ASF shall have a sanitary environment, properly constructed,
equipped and maintained to protect surgical patients and ASF personnel from
cross-infection and to protect the health and safety of patients.


Observations:

Based on observation, review of facility policy and interview with staff (EMP), it was determined the facility failed to ensure a safe and sanitary environment in accordance with the facility approved policy for medication and specimen storage.

Findings include:

Observation tour conducted on December 16, 2020, with EMP2 revealed a specimen refrigerator which contain containers of tissue specimens revealed an open vial of tuberculin solution and quality control solutions. Further review revealed the tuberculin solution did not have a date of opening nor a date of discard.

Observation tour conducted on December 16, 2020, with EMP2 of the Operating Room revealed rust on brackets of the OR, stains on the OR floor and paint chips on the floor.

Review of facility policy "Infection Control Plan-Far Northeast Surgical Center last revised February 20, 2020, revealed "In using Standard Precautions, we assume all human blood, certain human body fluids and Other Potentially Infectious Materials (OPIM) are known to be infectious and use precautions with every patient and every procedure to reduce risk in the workplace. These practices are designed to both protect health care staff and to prevent staff from spreading infections among patients."

An interview conducted on December 16, 2020, with EMP2 confirmed the above findings in the operating room and the issues of non-compliance identifed in the specimen refrigerator during the observation tour in the facility.















Plan of Correction:

The Center Manager is responsible for ensuring the facility maintains a safe and sanitary environment and will address findings no later than 4/30/21.

1) The facility maintains two refrigerators, one for lab reagents/lab specimens and another for medication. The opened vial of tuberculin solution was removed/discarded immediately. All facility staff will receive training (retraining) on the Infection Control Plan related to proper storage and labeling of medication. The Center Manager (in collaboration with Director of Clinical Services) will provide staff retraining, obtain documentation of training, and monitor compliance. Additionally, labels with storage requirements will be added to the refrigerators. The Center Manager will monitor the refrigerators weekly for one month and monthly thereafter. Monitoring and any findings will be documented on the temperature logs, which are specific to each fridge. The CM will report on monitoring efforts at next quarterly Infection Control Committee. Reports from the Infection Control Committee are included in the quarterly Compliance, Risk, and Quality Management (CRQM) report to the Governing Board. The Director of Patient Services will ensure completion of the Plan of Correction.

2) As of 2/15/21, our Facilities Manager had serviced the Operating Room and the rust, stains and paint chips have been removed. The Center Manager (CM) will conduct monthly visual inspection of facility, looking for any items/areas needing repair (stains, rust, paint) and work with Facilities Manager to address any issues. The CM will report on monitoring efforts at next quarterly Infection Control Committee. Reports from the Infection Control Committee are included in the quarterly RQM report to the Governing Board. The Director of Patient Services will ensure completion of the Plan of Correction.