Initial Comments:
This report is the result of an initial Registration survey conducted on September 29, 2011, at the Planned Parenthood of Central PA. 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:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
Based on a tour of the facility on September 29, 2011, it was determined that Planned Parenthood of Central PA failed to maintain a safe and sanitary environment.
Findings:
A tour of Planned Parenthood of Central PA was conducted on September 29, 2011, during the tour the following were observed:
Exam Room 5:
On the top shelf of the three shelf plastic cart behind the door a blue, plastic, two ounce mist spray bottle, unlabeled, containing a brown liquid was noted.
On the second shelf of the three shelf plastic cart behind the door were two 10 cc syringes with a clear fluid, labeled as Lidocaine 1% with Sodium Bicarbonate, dated September 28, 2011, at 1:00 PM
On the third shelf of the three shelf plastic cart behind the door were three sterilized packs of instruments that showed water or other marks in the integrity of the packaging,
On the third shelf of the three shelf plastic cart behind the door were expired gynecological cannula ranging in size from 5 mm to 10 mm, expired January 2010, March 2010, and August 2011.
An ultrasound monitor screen, which was unattended by staff, was observed to be turned on with patient information that was clearly visible including, patient name, date of birth, last menstrual period, estimated date of delivery, as well as an alphabetical listing of other patients whose last name begins with the letter "A".
Laboratory:
Room labeled "Lab", with bi-fold doors, had specimen pass through windows on either side to the procedure rooms. Both windows had blood stains on the sills.
Room labeled "Lab" that contained the autoclave, revealed an emergency drug box that included Diphenhydramine HCl injectable, USP 50 mg/ml, expired August 2011, Lidocaine HCl 1% with epinephrine 1: 100,000 injectable USP 30 ml, unopened, multiple dose vial expired January 2011. A 50 ml vial labeled as Sodium Bicarbonate 8.4%, single dose, marked opened August 11, 2011. An oxygen sphere in the bottom cabinet next to the AED, was not anchored, and appeared outdated.
Recovery room:
The Recovery Room storage room contained two sealed plastic bags each containing 50 individually wrapped gynecological procedural cannulas, and four opened plastic bags with individually wrapped gynecological procedural cannulas, ranging in size from 5 mm to 10 mm, expired January 2010, March 2010, and August 2011.
The Recovery Room had a refrigerator marked "Medications Only" that contained five cans of soda.
The cabinet above the Recovery Room refrigerator contained numerous outdated blood testing tubes. The same cabinet also contained packages of crackers.
A review of medical records and interviews with staff revealed that each of the three physicians had dispensed Valium. Only one physician has a DEA registered to the address of the facility. Interview with staff revealed that the other two physicians have stopped dispensing Valium as of September 1, 2011.
Plan of Correction:Exam Room 5:
The three shelf plastic carts have supplies used during procedures. They will be inspected prior to and after procedure days; all containers will be clearly labeled with contents and dates. Open containers will be discarded after 30 days if no expiration date is noted. All unused syringes will be discarded after procedures are completed in accordance with PPCP policy. All unlabeled and expired supplies are discarded.
Complete Date: 10/6/11
Exam Room 5: Continued
Sterilized packages will be inspected prior to making them available for use and will not be used if they appear to be compromised or expired. All instruments have been re-sterilized.
Complete Date: 10/6/11
Exam Room 5: Continued
The surveyor arrived for their inspection visit during a time that clients were being seen. The Coordinator was called away from her clinical responsibilities and was not able to prepare the room as she normally does between patients. Patients are offered the opportunity to see and have a copy of their ultrasound image in accordance with PA law, but are only given access to their own information. Ultrasound monitors are turned off when no staff is present.
Complete Date: 10/6/11
Laboratory:
Pass through windowsills will be protected from blood drips and will be cleaned after prodecures are complete.
Complete date: 10/6/11
Laboratory: Continued
All emergency boxes have been opened and inspected. Expired supplies are removed and replacements are ordered. Procedure for monthly inspection of emergency boxes is being reviewed and revised.
Complete Date: 10/6/11
Laboratory: Continued
We continue to look for a supplier to remove the O2 sphere from the facility.
Complete Date: 11/1/11
Recovery Room:
All storage areas of the recovery room (including supply and food areas) will be inspected monthly for expiration dates and appropriated storage. Cabinets and storage areas will be clearly labeled.
Complete Date: 11/1/11
Recovery Room: Continued
All expired items have been discarded.
Complete Date: 10/6/11
Recovery Room: Continued
Applications have been submitted for the two physicians without current DEA licenses registered to the facility, although they do have current DEA licenses. Valium will not be dispensed by these physicians at the facility until licenses are current. We expect will take 4 - 6 weeks from the date of application.
Complete Date: 11/30/11
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