Initial Comments:
This report is the result of an annual Registration survey conducted on February 7, 2013, at the Planned Parenthood of Northeast Mid-Penn and Buck County (PPNMPBC - Allentown). It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health Regulations Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
The facility is required to submit a plan of correction for the deficiency cited in Tag 0001 - Requirements for abortion.
Safe and Sanitary recommendations were provided to the facility in Tag 9999 - Recommendations. The facility is encouraged to provide a Plan of Correction for the recommendations, but it is not required.
Plan of Correction:
29.33(1) STANDARD
Requirements for Abortion
Name - Component - 00
Each medical facility shall have readily available equipment and drugs necessary for resuscitation. If local anesthesia is utilized to perform an abortion in a medical facility during the first trimester, then the following equipment shall be ready to use for resuscitative purposes:
(i) Suction Source
(ii) Oxygen Source
(iii) Assorted size oral airways and endotracheal tubes
(iv) Laryngoscope
(v) Bag and mask and bag and endotracheal tube attachments for assisted ventilation
(vi) Intravenous fluids including blood volume expanders
(vii) Intravenous catheters and cut-down instrument tray
(viii) Emergency drugs for shock and metabolic imbalance
(ix) An individual to monitor respiratory rate, blood pressure and heart rate.
Observations:
Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure emergency intravenous solution was not expired in the examination rooms and the emergency drug cart.
Findings include:
A request was made to EMP1 on February 7, 2013, for the policy/plan/procedure for monitoring expiration dates of the facility's emergency intravenous solution. None was provided.
1) Observation on February 7, 2013, of the facility's Examination Room's 3 and 4 revealed each room contained one 1000 milliliter bag of 0.9 percent Sodium Chloride intravenous solution (used to replace blood volume when excessive bleeding occurs and provide an intravenous route for medications when a patient requires emergent care). Further observation of the intravenous solution bags in Examination Room's 3 and 4 revealed expiration dates of November 2012.
Interview with EMP4 on February 7, 2013, at approximately 10:45 AM confirmed Examination Room 3 and 4 each room contained one 1000 milliliter bag of 0.9 percent Sodium Chloride intravenous solution that expired November 2012.
2) Observation on February 7, 2013, of facility's Emergency Drug Cart revealed a 1 liter (1000 cc) intravenous bag of 0.9 percent Sodium Chloride intravenous solution with an expired date of November 2012.
Interview with EMP2 on February 7, 2013, at approximately 10:45 AM confirmed the 1 liter bag of 0.9 percent Sodium Chloride intravenous solution on the Emergency Drug Cart expired November 2012.
Plan of Correction:Center Manager will document completed training re: "Preventative Maintenance Policy" by 3/8/13 and will train pertinent staff by 3/15/13.
All expired 0.9% sodium chloride solution in the building has been removed and replaced with current stock by 3/4/13.
The Emergency Box checklist will be audited monthly by RQM Coordinator to ensure there are no expired supplies in stock for 6 months.
No POC Required STANDARD
Recommendation
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Observations:
Based on review of facility documents, observation and staff interview (EMP), it was determined Planned Parenthood of Northeast Mid-Penn and Buck County (PPNMPBC - Allentown) failed to maintain a safe and sanitary environment.
Findings include:
1) Review on February 7, 2013, of the facility's "Sharps Safety Policy," last revised May 2012, revealed "Policy: ... Planned Parenthood maintains a safe environment for staff, patients and visitors to all facilities by keeping all 'sharps' safely stored. ... Procedures: ... Use of Sharps Containers ... Sharps bins must be located at approximately waist height, and never placed on the floor, on top of high surfaces, or where a patient or visitor can tamper with them. ..."
Observation on February 7, 2013, of the facility's Examination Room 3 and 4 and the Pre-procedure/Post-procedure room revealed unsecured sharps containers, one in each room, containing used needles and sharps in full view on the countertop. Further observation revealed a lockable wall mounted sharps container holder in each of these rooms. The lockable wall mounted sharps container holders in each room were empty.
Interview with EMP1, EMP2, EMP3 and EMP4 on February 7, 2013, at approximately 11:30 AM confirmed the unsecured sharps containers, one in each room, containing used needles and sharps on the countertop in Examination Rooms 3 and 4 and in the Pre-procedure/Post procedure room. EMP1, EMP2, EMP3 and EMP4 confirmed each room had lockable wall mounted sharps container holders which were empty. Further interview with EMP3 confirmed sharp containers must be secured in the wall mounted sharps container holder and not left on the countertop.
2) Review on February 7, 2013, of the facility's "Patient Rights [and] Responsibilities" policy, no review date, revealed "This accredited facility presents these Patient Rights and Patient Responsibilities to reflect the commitment to providing quality patient care. ... 9. The patient has the right to every consideration for privacy throughout his or her medical care experience, including but not limited to, the following. Confidentiality and discreet conduct during case discussions, consultations, examinations and treatments. ..."
Observation on February 7, 2013, of the facility's Pre-procedure/Post-procedure room revealed six reclining chairs for patient use before a procedure and to recover following a procedure. Further observation revealed no curtains between these chairs to provide privacy to patients.
Interview with EMP3 on Pre-procedure/Post-procedure room, at approximately 11:30 AM revealed patient interviews were completed in this room. EMP3 revealed the patient interviews included the patient's medical history and medications. Further interview with EMP3 confirmed there were no curtains between the six chairs in the Pre-procedure/Post-procedure room and that patient privacy was not provide during patient interviews.
Repeat recommendation cited June 16, 2011, and May 1, 2012.
3) A request was made to EMP1 on February 7, 2013, for the policy/plan/procedure for securing of prescription pads. None was provided.
Observation on February 7, 2013, of the facility's Pre-procedure/Post-procedure room revealed an unlocked cabinet containing two prescription pads.
Interview with EMP3 and EMP4 on February 7, 2013, at approximately 11:40 AM confirmed the cabinet containing these two prescription pads was not locked, and the cabinet should have been locked to prevent unauthorized access.
4) Observation on February 7, 2013, of the facility's storage room revealed an ultrasound machine with a sticker indicating the next preventative maintenance to be completed October 2012. There was no documentation the preventative maintenance was completed on this ultrasound machine after October 2012.
Interview with EMP4 on February 7, 2013, at approximately 10:50 AM confirmed the ultrasound machine had a sticker indicating the next preventative maintenance to be completed October 2012, and no current preventative maintenance was completed on this machine since October 2012.
Plan of Correction:POC is optional and not required.
Containers for wall mounted sharps bins have been ordered. When they are in place, all unsecured sharps containers will be disposed of and only secured sharps containers will be used. Center Manager will monitor appropriate disposal of sharps for 6 months.
Privacy curtains are not a requirement of the Abortion Control Act; Planned Parenthood is in full compliance. The reclining chairs are appropriate for client care since they are awake, fully dressed and receive similar post op instructions. Nurses must have unobstructed view of clients for monitoring purposes.
A new "Controlling Prescription Pads" policy is effective 3/8/13. Center Manager will document completed training on this policy by 3/8/15 and will train pertinent staff by 3/15/13. Center Manager will monitor appropriate staorage of prescription pads for 6 months.
The Ultrasound Machine with an expired inspection sticker has been moved out of the facility as of 3/4/13.
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