Initial Comments:
This report is the result of an unannounced initial registration survey conducted on August 10, 2011, at Berger and Benjamin. It was determined that 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.
Safe and Sanitary recommendations were provided to the facility in Tag 9999 - Recommendations. The facility is encouraged to provide a plan of correction.
Plan of Correction:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
Based on an observation tour and interview with staff (OTH), it was determined that facility failed to maintain a safe and sanitary environment.
Findings:
Observation tour of the facility on August 10, 2011, between approximately 11:30 AM and 12:30 PM revealed:
1) Three ampules of Isuprel 1:5000 0.2mg dated expired on March 1, 2011. One ampule was located in Treatment A, one ampule was located in Treatment B, and one ampule was located in Treatment C.
2) A medication refrigerator located in the Biohazard Room identified with a biohazard identification sticker on the door that contained one patient specimen stored next to medications on the door shelf of the refrigerator.
3) One multidose vial of Ondansetron (medication for nausea and vomiting) dated expired on January 1, 2011, located in a hallway closet.
4) Twelve intravenous bags of Sodium Chloride 0.9%, dated expired on January 1, 2011, located in a clean storage closet.
Interview with OTH1 on August 10, 2011, between approximately 11:30 AM and 12:30 PM confirmed the above findings.
Plan of Correction:All expired items were discarded on the discovered date. An in-service meeting with the staff addressed the importance of checking expiration dates on all items not only at the time of use but routinley including infrequently used emergency drugs and supplies. This will be monitored over the next year by the practice manager for compliance.
The indications for use of the different
refrigereation devices (medication, food, and specimens) were reviewed with staff and the importance of not storing specimens in the medication refrigerator were stressed. The contents of the refrigerators will be checked daily at the time of the daily temperture check to insure compliance. The specimen in question was awaiting pickup by law enforcement officials and was sealed in a container surounded by two heavy plastic bags. There was no evidence of contamination that needed to be addressed. This type of specimen will be stored in a seperate refrigerator in the future.
Updates to reflect these changes will be noted in policy and procedure manuals and in staff inservice logs.
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