QA Investigation Results

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


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Initial Comments:

This report is the result of a Registration survey conducted on April 24, 2012, at the Planned Parenthood of Southeastern Pennsylvania in Norristown. 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:

A tour of the facility on April 24, 2012 resulted in the following recommendations.
Submission of a plan of correction is encouraged but not required.

Findings:

Lab Room: (1) A Sure Temp Thermometer had an expired biomed tag (08/11).
(2) A plastic gallon container located next to the sink was used to collect
urine strips and other non-sharps which may have come into contact with
bodily fluids.

A review of facility documents revealed:
(1) No 2011 Fourth Quarter Patient Safety Meeting.
(2) No community member was present for 2012 First Quarter Patient
Safety Meeting.
(3) One medical record revealed that medication treatment did not end the
pregnancy. There was no evidence this was reported as an incident or
documented for tracking.




Plan of Correction:

POC is optional and not required.
Thermometer was replaced and inspected 5/12/12.

The plastic container has been moved to a different location in the lab where it will not come in contact with urine samples. The container is used only for non-sharps disposal.

Patient Safety Meeting was held on 11/8/11 and minutes are available. Note: PPSP follows a fiscal year calendar and therefore we consider the November meeting as 3rd quarter which could have led to confusion. The meeting scheduled for March 2012 was rescheduled and then canceled; the Patient Safety Officer provided an update to all members via email that included a summary of reports an actions. The next meeting is scheduled for June 14, 2012 and at this meeting the committee will set the meeting schedule for the next year. The committee will meet quarterly.

The community member was unable to attend the meeting due to illness however they always receive the agenda and minutes. At the June 14th meeting, the committee will discuss adding a second community member to the group to ensure regular community member attendance at the quarterly meetings. Minutes will now include the full name and title of attendants to allow for easy identification of the community member.

Medication abortion complications, like continued pregnancy are tracked on our internal Abortion Complication Log and reported online to PA-Patient Safety Reporting System. The patient record found has been reported on PASRS and the staff involved has been reminded of the timeline requirement for reporting. It is important to note that failure to terminate pregnancy while rare is an anticipated outcome that patients are made aware of during the informed consent process that covers all risks and the patient chooses to continue with the medication abortion with this known outcome.