Initial Comments:
This report is the result of an initial registration survey conducted on November 2, 2011, at the American Women's Services. 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.
Recommendations for safety and sanitation are provided to the facility under Tag 9999. Submission of a Plan of Correction by the facility for these recommendations is voluntary and not required.
Plan of Correction:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
Observations:
Based on a tour of the facility on November 2, 2011, documentation review, and staff interview, it was determined that the American Women's Services failed to maintain a safe and sanitary environment.
Findings include:
A tour of the facility was conducted on November 2, 2011, from approximately 10:00 AM to 11:00 AM. The following were observed:
1. Scrub room: Ceiling tile remain stained and one is broken and bulging. By interview it was determined that requests had been made to the corporate office for permission to repair/replace some of areas previously noted.
2. Lab room: When asked how the B Hemoglobin machine (used to measure patient hemoglobins from blood specimens) was cleaned on November 2, 2011 at 10:18 AM, it was revealed that staff cleaned it with alcohol and a Q-tip. Upon request for the manufacturer's recommendations for cleaning, staff were unable to provide manufacturer's recommendations for cleaning. Three undated Methergine syringes were observed in a zip-lock bag with dated Methergine syringes.
3. Office/Medication Storage Cabinet Room: Previously identified environmental issues, including missing wall covering, with exposed pipes and missing ceiling tiles.
4. Janitor's closet located by the patient's restroom: Missing ceiling tile.
5. Recovery room: Stained ceiling tile over one of the recovery chairs from previous moisture problems. Attempts had been made to paint some of the ceiling tiles.
Plan of Correction:POC is optional and not required.
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