QA Investigation Results

Pennsylvania Department of Health
PLANNED PARENTHOOD OF CENTRAL PA
Health Inspection Results
PLANNED PARENTHOOD OF CENTRAL PA
Health Inspection Results For:


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Initial Comments:

This report is the result of an annual Registration survey conducted on June 5, 2012, at Planned Parenthood of Central PA - York. 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.







Plan of Correction:




Initial Comments:

This report is the result of an unannounced, on-site pre-licensure and occupancy survey conducted on June 5, 2012, at Planned Parenthood of Central PA - York. It was determined that 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, and the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities.









Plan of Correction:




551.21 (e)(1-3) LICENSURE
Criteria for ambulatory surgery

Name - Component - 00
551.21 Criteria for ambulatory surgery

(e) In obtaining informed consent, the practitioner performing the surgery shall be responsible for disclosure of:
(1) The risks, benefits and alternatives associated with the anesthesia which will be administered.
(2) The risks, benefits and alternatives associated with the procedure which will be performed.
(3) The comparative risks, benefits and alternatives associated with performing the procedure in the ambulatory surgical facility instead of in a hospital.

Observations:

Based on review of medical records and interview with staff (EMP), it was determined the facility failed to ensure practitioners documented informed consent that included the disclosure of the comparative risks, benefits, and alternatives associated with performing a procedure in the ambulatory surgery facility (ASF) instead of in a hospital for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5 and MR6).

Findings include:

1) A review on June 5, 2012, of MR1-MR6 revealed the informed consent did not contain information regarding the physician's disclosure of the comparative risks, benefits, and alternatives associated with performing a procedure in the ambulatory surgery facility (ASF) instead of in a hospital. There was no documentation in MR1-MR6 showing the comparative risks, benefits, and alternatives associated with performing a procedure in the ambulatory surgery facility (ASF) instead of in a hospital were disclosed to the patient.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the informed consent did not address the comparative risks, benefits, and alternatives associated with performing a procedure in the ambulatory surgery facility (ASF) instead of in a hospital were disclosed to the patient.











Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Revised consent form (CIIC-In-Clinic Abortion-702a) has been drafted.
--Expected approval of form by 6/30/2012 by the Planned Parenthood national governing body.
--Staff will be trained on use of form by Director of Clinical Services (DCS) by 7/13/2012. Training will be documented by sign-in sheet.
--Audits of abortion charts by Medical Services Administration will be performed at least quarterly.
--audits will be reviewed through the RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



553.25 (1-6) LICENSURE
Discharge Criteria

Name - Component - 00
553.25 Discharge Criteria

A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.

Observations:

Based on review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that nausea and vomiting were evaluated prior to discharge for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5, and MR6).

Findings include:

1) A review on June 5, 2012, of MR1-MR6 revealed that the MR did not contain documentation that the patients were assessed for nausea and vomiting prior to discharge.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the medical records did not contain documentation that the patients were assessed for nausea and vomiting prior to discharge.





















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Recovery Room documentation has been revised to include assessment of nausea and vomiting as of 6/12/2012
--Recovery Room nurse will be trained by DCS to assess and document nausea and vomiting by 7/13/2012. Training will be documented by sign-in sheet.
--Audits of abortion charts by Medical Services Administration will be performed at least quarterly.
--audits will be reviewed through the RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



555.3 (f) LICENSURE
Requirements

Name - Component - 00
555.3 Requirements for membership and privileges.

(f) The governing body shall request and consider reports from the National Practitioner Data Bank on each practitioner who requests privileges.

Observations:

Based on a review of credential files (CF), and interview with staff (EMP), it was determined that the facility failed to request and consider reports from the National Practitioner Data Bank (NPDB) for two of two physician credential files reviewed (CF1 and CF2).

Findings include:

1) A review on June 5, 2012, of CF1 and CF2 revealed that there were no reports from the National Practitioner Data Bank in the physician credential files.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed the facility had not obtained a report from the National Practitioner Data Bank prior to recredentialing CF1 and CF2.




















































Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Registration for the National Practitioner Data Bank (NPDB) was completed on 6/5/12
--Upon receiving written confirmation of our registration, practitioners´┐Ż credential files will be updated.
--Monitoring for compliance will occur during the credentialing process every two years.
--Assurance that reports have been entered in credential files will be reviewed through the RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



555.22 (a)(1-2) LICENSURE
Surgical Services - Preoperative Care

Name - Component - 00
555.22 Pre-operative Care

(a) Pertinent medical histories and physical examinations, and supplemental information regarding drug sensitivities documented day of surgery or one of the following:
(1) If medical evaluation, examination and referral are made from a private practitioner's office, hospital or clinic, pertinent records thereof shall be available and made part of the clinical record at the time the patient is registered and admitted tot he ASF. This information is considered valid no more than 30 days prior to the date of surgery.
(2) A practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The information shall be clearly documented in the medical record.



Observations:

Based on a review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to assign a Physical Status Classification (an evaluation of the patient's overall health as it would influence the conduct and outcome of anesthesia or surgery or both) for patients who received local anesthesia in six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5 and MR6).

Findings include:

1) A review on June 5, 2012, of MR1-MR6 revealed that there was no physical status assigned for MR1-MR6.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that there were no physical status classifications assigned for MR1-MR6.































Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Pre-operative notes are revised to include an assessment of Physical Status Classification as of 6/12/2012
--Physicians will be trained by DCS to assess and document their findings by 7/13/2012. Training will be documented by sign-in sheet.
--Audits of abortion charts by Medical Services Administration will be performed at least quarterly.
--audits will be reviewed through the RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



555.22 (e) LICENSURE
Surgical Services - Preoperative

Name - Component - 00
555.22 Pre-operative Care

(e) Prior to the administration of anesthesia, it is the responsibility of the primary operating surgeon and the person administrating anesthesia to properly identify the patient and the procedure to be performed and to document this identification in the patient's medical record. This procedure shall be in written policies designating the mechanism to be used to identify each surgical patient.

Observations:

Based on a review of medical records, (MR) and interview with staff (EMP), it was determined the facility failed to ensure patients were properly identified by the operating surgeon prior to the start of a procedure for six of six medical records reviewed, (MR1, MR2, MR4, MR4, MR6, and MR6).

Findings include:

1) A review on June 5, 2012, of MR1-MR6 revealed that there was no documentation that the surgeon identified the patient prior to the start of the procedure.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that there was no documentation in MR1-MR6 that the surgeon identified the patient prior to the start of the procedure.



















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Pre-operative notes are revised to include verification of patient identity by name and birth date as of 6/12/2012
--Physicians will be trained by DCS to verify patient identity by name and birth date prior to starting a procedure and documenting the information in pre-op notes by 7/13/2012. Training will be documented by sign-in sheet.
--Audits of abortion charts by Medical Services Administration will be performed at least quarterly.
--Audits will be reviewed through the RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



555.24 (a) LICENSURE
Surgical Services - Postoperative Care

Name - Component - 00
555.24 Postoperative Care

(a) The findings and techniques of an operation shall be accurately and completely written or
dictated immediately after procedure by the practitioner medical staff member who performed the operation. If a physician assistant or certified registered nurse practitioner performed part of the operation, the findings and techniques of the procedure shall be accurately and completely recorded and the report shall be countersigned by the medical staff member. This description shall become a part of the patient's medical record.


Observations:

Based on review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that post operative surgical report was written or dictated for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5 and MR6).

1) A review on June 5, 2012, of MR1-MR6 revealed that the MR did not contain an operative report.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that MR1-MR6 did not contain an operative report.
















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Post-operative notes have been revised to include findings as of 6/12/2012
--Physicians will be trained by DCS to document the findings immediately after the procedure is complete by 7/13/2012. Training will be documented by sign-in sheet.
--Audits of abortion charts by Medical Services Administration will be performed at least quarterly.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



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 documentation and interview with staff (EMP), it was determined that the facility failed to ensure that a Registered Nurse (RN) was a member of the Quality Assurance and Improvement Committee (QA/PI).

Findings include:

1) A review on June 5, 2012, of the QA/PI Committee meeting minutes revealed that there was no RN on the committee.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that there was no RN on the QA/PI Committee.















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--An RN will be appointed to the RQM Committee at the next scheduled meeting on 6/26/2012
She will be oriented to the committee and her responsibilities by DCS by 7/13/2012 as documented by sign-in sheet.
--Compliance will be monitored through review of RQM Minutes
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



563.6 (c) LICENSURE
Preservation of Medical Records

Name - Component - 00
563.6 Preservation of medical records

(c) If an ASF discontinues operation, it shall make known to the
Department where its records are stored. Records are to be stored in a
facility offering retrieval services for at least 5 years after the closure
date. Prior to destruction, public notice shall be made to permit former
patients or their representatives to claim their own records. Public notice
shall be in at least two forms, legal notice and display advertisement in a
local newspaper of general circulation.


Observations:

Based on interview with staff (EMP) it was determined that the facility failed to ensure there was a written policy regarding the preservation of medical records.

Findings include:

1) A request was made to EMP1 on June 5, 2012 for the written policy regarding the preservation of medical records. None was provided.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the facility did not have a policy regarding the preservation of medical records.











Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Policy will be developed to ensure preservation of medical records in the event that PPCP discontinues operation.
--The policy will be incorporated into the Center Operations Manual, Administrative Section
--The policy will be reviewed and revised annually by the DCS.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



563.13 (a) LICENSURE
Entries

Name - Component - 00
563.13 Entires

(a) Entries in the record shall be dated and authenticated by the person making the entry.

Observations:

Based on review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that each entry in each medical record was dated, and authenticated by the person making the entries for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5, and MR6).

Findings include:

1) A review on June 5, 2012, of MR1-MR6 revealed that the physician's pre-operative admission order set and inter-operative note did not each contain a separate physician signature.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the physician's pre-operative admission order set and inter-operative note for MR1-MR6 did not each contain a separate physician signature.




















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Forms have been revised so that the physician´┐Żs pre-operative orders, and inter-operative notes contain separate and distinct signatures as of 6/12/2012
--Physicians will be trained by DCS in use of forms by 7/13/2012. Training will be documented by sign-in sheet.
--Audits of abortion charts by Medical Services Administration will be performed at least quarterly.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



567.2 (1) LICENSURE
INFECTION CONTROL - Committee Responsibility

Name - Component - 00
567.2 Committee responsibilities

The quality assurance committee shall be responsible for:

(1) The prevention, control and investigation of infection in the ASF
and for assuring the effectiveness of current procedural techniques in all
departments.


Observations:

Based on review of facility policy and interview with staff (EMP), it was determined the facility failed to ensure that a committee was established for the prevention, control and investigation of infection in the ambulatory surgery facility (ASF) to assure the effectiveness of procedural techniques in all departments.

Findings include:

1) A review on June 5, 2012, Infection Control Committee meeting minutes revealed that the Committee did not report their findings to the Governing Body.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the Infection Control Committee did not report their findings to the Governing Body.














Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Reports to the Board will be reflected in the minutes of the Infection Control Committee beginning with the meeting scheduled for June 26, 2012.
--Compliance will be monitored through review of RQM Minutes
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



567.3 (a) LICENSURE
Policies and Procedures

Name - Component - 00
567.3 Policies and procedures

(a) Only authorized persons, who are properly attired, shall be allowed int he surgical area.

Observations:

Based on review of facility policy and procedures and interview with staff (EMP), it was determined the facility failed to ensure that Infection Control policies were established to address that only authorized persons in the proper attire could be in the surgical area.


Findings:

1) An interview with EMP1 revealed that the facility did not have written policies and procedures that addressed that only authorized persons in the proper attire could be in the surgical area.





Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--A policy will be developed to address proper attire and who appropriate personnel are to be permitted in the procedure area by 7/13/2012
--Staff will be trained by DCS in policy by 7/20/2012. Training will be documented by sign-in sheet.
--Compliance will be monitored through observation during RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



567.3 (b) (12) LICENSURE
Policies and Procedures

Name - Component - 00
567.3 Policies and procedures

(b) Current written policies and procedures to assure definite and
valid infection control shall include,but not be limited to, the
following:
(12) Infection control inservice education for personnel

Observations:

Based on review of personnel files (PF), and interview with staff (EMP), it was determined that the facility failed to assure Infection Control training or education was provided for three of three personnel files reviewed (PF1, PF2, and PF3).

Findings include:

1) A review on June 5, 2012, of PF1-PF3 failed to reveal any documentation of infection control training or education.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that there was no documentation in PF1-PF3 of Infection Control training or education.


















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Annual Infection Control training was completed for all clinical staff on 12/9/2011 and documentation is included in personnel records.
--Physician infection control training will be completed by DCS by 7/20/2012 and documentation will be included in personnel records.
--Compliance with annual infection control training will be monitored through RQM process.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to comply with training will result in re-training or disciplinary action.



567.11 (2) LICENSURE
Operating Suite Equipment

Name - Component - 00
567.11 Operating suite equipment

The operating suite shall be adequately equipped with age appropriate
equipment for the types of procedures to be performed and the recovery area shall
be adequately equipped for the proper care of postanesthesia recovery
of surgical patients. All equipment and supplies shall be age and size approprate
for the patients treated. The following equipment shall be available in the operating
suite and recovery area:
(2) Emergency call system

Observations:

Based on observation and interview with staff (EMP), it was determined the facility failed to adequately equip the operating room and recovery area with an emergency call system.

Findings include:

1) Observation on June 5, 2012, of the Procedure Rooms and Recovery area revealed that there was no emergency call system.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed there were no emergency call systems located in the Procedure Rooms and the Recovery area.

















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--One-touch emergency call system was installed and tested 6/12/2012.
--Staff will be trained by DCS in use of system by 7/13/2012
--Monitoring for operability will occur during scheduled RQM visits
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



567.43 LICENSURE
Ventilation System

Name - Component - 00
The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under
Chapter 571 (relating to construction standards).


Observations:

Based on review of policies and procedures and interview with staff (EMP), it was determined the facility failed to ensure the ventilation system was inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements was provided in critical areas such as the surgical and recovery suites.


Findings include:

1) A request was made to EMP1 on June 5, 2012 for the written policy regarding the monitoring of temperature and humidity levels in the procedure rooms and recovery area. None was provided.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the facility did not have a policy for monitoring of temperature and humidity levels in the procedure rooms and recovery area and there was no inspection of the ventilation system.










Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Temperature and humidity monitors werepurchased and installed in each procedure room by 6/18/2012
--A monitoring log was developed by 6/18/2012
--A policy for the monitoring of temperature and humidity will be developed by Medical Services Administration by 7/20/2012
--Staff will be trained by DCS in the use of Monitors and logs by 7/20/2012. Training will be documented by sign-in sheet.
--Compliance will be monitored through scheduled RQM visits.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012
--Failure to adhere to this policy will result in re-training or disciplinary action.



569.11 LICENSURE
INTERNAL DISASTER PLAN - Fire Fighting

Name - Component - 00
569.11 Firefighting service

The person in charge of the ASF shall establish a workable plan with
the nearest fire department for fire fighting service. The ASF shall
provide the fire department with a current floor plan of the building
showing the location of firefighting equipment, exits, patient rooms,
storage places of flammable and explosive gases and other information
as the fire department requires or as may be necessary.


Observations:

Based on review of facility documentation and interview with staff (EMP), it was determined the facility failed to establish a workable plan with the nearest fire department.

Findings include:

1) A review on June 5, 2012, of facility documentation revealed no evidence of a plan with the nearest fire department.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed the facility did not establish a workable plan with the nearest fire department.











Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--PPCP has received regular walk-throughs from the fire departmentt for many years, most recently in June 2012. Documentation will be obtained from the fire department if possible and maintained at PPCP.
--Records of annual invitations for fire inspections will be kept on file in the Clinical Services office.
--Monitoring for compliance will occur during RQM review of inspection records.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



569.12 LICENSURE
Fire Warning and Safety Systems

Name - Component - 00
569.12 Fire Warning and Safety Systems

An ASF shall have an automatic and manually activated fire alarm system
installed to transmit an alarm automatically to the fire department
by the most direct and reliable method approved by local ordinances.


Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to have an automatic fire extinguishing system.

Findings:

1) An interview with EMP1 confirmed that the facility did not have automated fire extinguishing systems or automatic or manual alarms.





Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
PPCP is optimistic that we will be able to obtain accreditation, but in the event that we are not successful, PPCP intends to pursue licensure as a Class B ASF. To that end, if the Class A accreditation process concludes unsuccessfully, PPCP will pursue the alternate plan of compliance submitted by the Planned Parenthood health centers seeking licensure as Class B ASFs, adjusting the dates as appropriate. Accordingly, at that time and if necessary, PPCP will confer with its architect and the Division of Safety and Inspection to identify feasible alterations to its health center and seek any necessary exceptions.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Section 569.12 does not require an automatic fire extinguishing system.
--PPCP guarantees the safety of its staff and patients through a Gamewell box system and Knox box for notifying the fire department in an emergency.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



569.21 (a) LICENSURE
EVACUATION - Fire Drills

Name - Component - 00
569.21 Fire Drills

(a) Fire, internal disaster and evacuation drills shall be held at
least quarterly for ASF personnel and under varied conditions.


Observations:

Based on review of facility documentation and interview with staff (EMP), it was determined the facility failed to ensure that quarterly fire drills were conducted.

Findings include:

1) A review on June 5, 2012, of facility documents revealed no evidence that fire drills were conducted quarterly.

2) An interview conducted on June 5, 2012, 1:30 PM with EMP1 confirmed that the facility did not conduct quarterly fire drills.











Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--Fire and Safety Training was presented to all clinical staff by the York Fire Department on 6/14/2012. Documentation of training is by sign-in sheet.
--A fire drill will be scheduled prior to 6/30/2012 and will be held quarterly thereafter. All drills will be documented and attendance records will be kept as a part of RQM records.
--Monitoring for compliance will occur during RQM reviews.
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



569.35 (1-7) LICENSURE
General Safety Precautions

Name - Component - 00
569.35 General Safety Precautions

The following safety precautions shall be met:
(1) Doorway, corridors and stairwells shall be properly lighted and free of obstructions.
(2) Doors into patient rooms may not be locked.
(3) Exit doors may not be locked from the inside while patients are in the ASF.
(4) Doors opening to shafts shall be equipped with self-closing devices and positive latches.
(5) Wastebaskets, cubicle curtains, window shades and drapes shall be rendered flame retardant.
(6) Call bells in the shower, tub room or water closet shall be easily accessible to patients.
(7) Only nonflammable agents may be present in a surgical suite.

Observations:

Based on observation and interview with staff (EMP), it was determined the facility failed to ensure that an emergency call bell was located in the patient bathroom.

Findings include:

1) Observation on June 5, 2012, of the patient bathroom revealed that there was no emergency call bell located within the bathroom.

2) An interview conducted on June 5, 2012, at 1:30 PM with EMP1 and EMP2 on May 28, 2012, at 9:15 AM, confirmed that there was no emergency call bell located within the bathroom.

















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
The effective date for this regulation is June 19, 2012, and the survey took place on June 5, 2012. PPCP has taken the following steps to ensure compliance.
--One-touch emergency call system was installed and tested 6/12/2012.
--Staff will be trained by DCS in use of system by 7/13/2012
--Monitoring for operability will occur during scheduled RQM visits
--PPCP governing board will be informed of this deficiency and corrective action at its meeting on 6/26/2012



571.1 LICENSURE
CHAPTER 571 - Construction Standards

Name - Component - 00
571.1 Minimum Standards

ASF construction shall be in accordance with the latest edition of the "Guidelines for Design and Construction of Hospital and Health Care Facilities," as published by the American Institute of Architects/Academy of Architecture for Health including those guidelines established for various outpatient facilities. In the alternative, a facility shall meet the construction guidelines for specified types of surgical procedures as listed in appendix A. Where renovation or replacement work is performed within an existing facility, all new work or additions shall comply with the requirements for new construction.

Observations:

Based on review of the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities, observation, and interview with staff (EMP), it was determined the facility failed to ensure it was in compliance with the current construction guidelines.

Findings include:

1) A review on June 5, 2012, of the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities revealed: "3.7-7.2.3.4 Ceilings: Ceiling finishes shall be appropriate for the areas in which they are located and shall be as follows: ...(2) Restricted areas. (a) Ceilings in restricted areas such as operating rooms shall be monolithic, scrubbable, and capable of withstanding chemicals. Cracks or perforations in these ceilings is not allowed, (b) All access openings in ceilings in restricted areas shall be gasketed."

Observation on June 5, 2012, of the procedure rooms revealed that the ceilings consisted of textured tiles that were not scrubbable or gasketed.

An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the ceilings in the procedure rooms were textured tiles that were not scrubbable or gasketed.

2) A review on June 5, 2012, of the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities revealed: "3.8-3.6.5 Scrub facilities ... 3.8-3.6.1 Hands free scrub station(s) shall be provided outside of but near the entrance to each operating room."

Observation on June 5, 2012, of the procedure room area revealed that there were no scrub sinks located outside of the procedure rooms. Further observation revealed that the sinks inside the procedure rooms were not hands free.

An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that there were no scrub sinks located outside of the procedure rooms and that the sinks in the room were not hands free.

3) Review of the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities revealed "3.8-7.2.2.2 Door openings: (1) The minimum clear width of ... door openings requiring gurney/stretcher access ... shall have a normal width of 3 feet 8 inches (1.11 meters)."

Observation on June 5, 2012, of the procedure room door openings revealed that the door measured 2 feet 10 inches.

Interview on June 5, 2012, at 1:30 PM with EMP1 confirmed that the procedure room door openings revealed that the door measured 2 feet 10 inches.

4) Review of the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities revealed "3.8-7.2.2.2 Door openings ... (2) Toilet room doors for patient use shall open outward or be equipped with hardware that permits access from the outside in emergencies."

Observation on June 5, 2012, of the patient restroom revealed that the door opened inward and did not permit access from the outside in emergencies.

An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed the patient restroom door opened inward and did not permit access from the outside in emergencies.

5) A review on June 5, 2012, of the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities revealed" "3.8-7.2.3.2 Flooring ... (2) Vinyl composition tiles or similar products shall not be permitted in these areas."

Observation on June 5, 2012, of the procedure rooms revealed that the floors were tiles composite.

An interview conducted on June 5, 2012, at 1:30 PM with EMP1 confirmed that the floors were tile composite.



















Plan of Correction:

PPCP is seeking accreditation as a Class A ASF. Our site inspection is scheduled for July 13, 2012.
PPCP is optimistic that we will be able to obtain accreditation, but in the event that we are not successful, PPCP intends to pursue licensure as a Class B ASF. To that end, if the Class A accreditation process concludes unsuccessfully, PPCP will pursue the alternate plan of compliance submitted by the Planned Parenthood health centers seeking licensure as Class B ASFs, adjusting the dates as appropriate. Accordingly, at that time and if necessary, PPCP will confer with its architect and the Division of Safety and Inspection to identify feasible alterations to its health center and seek any necessary exceptions.