There are  19 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP consulted with the Consortium of Abortion Providers (CAPS) regarding the comparative risks, benefits, and alternatives associated with performing a procedure in the ambulatory surgery facility (ASF) instead of in a hospital. CAPS is submitting the revised Client Information for Informed Consent (CIIC) for In-Clinic Abortion to the Planned Parenthood Federation of America (PPFA) for approval on 6/25/12. Upon PPFA approval, all staffs will be informed of the revision by the Medical Director and instructed to implement the new form upon receipt. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor that the revised CIIC is being provided to all clients by conducting a random chart audit for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 21012. PPWP has taken the following steps to ensure compliance: Two staff members are scheduled for PALS training on September 19 and 20, 2012 with the American Academy of Pediatrics and American Health Association, which is the soonest date a training course is available.

Monitoring for compliance will include staff education by the VP of Operations for the staff scheduler to ensure there is awareness and understanding of the requirements for PALS trained staff.

The Quality Assurance calendar currently used by human resources to monitor expiration of licenses, CPR and credentialing on a monthly basis has been modified to include ACLS and PALS expiration dates. Human resources staff will monitor expiration dates and notify staff 4 months prior to any item expiring.

The Surgical Site Supervisor or designee will monitor by doing random site inspections to ensure that a PALS certified staff member is on the premises when a minor is in the facility during clinic hours. The random checks will occur weekly for three months following completed certification.

Monitoring of the Governing Board�s review of completion of PALS training will be the responsibility of the CEO, who will ensure this is included on the Governing Board�s meeting agenda and will sign off on all board minutes to verify discussion of this information at the board meeting.

The PPWP RQM Oversight Committee will be informed of the corrective action taken and the Governing Body will be informed of the deficiency and its resolution.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Board of Directors adopted a Board policy on June 4, 2012 and adopted a second more comprehensive policy on June 20, 2012 that clearly outlines all governing board responsibilities, including a requirement that each medical staff member to sign a job description that includes the responsibilities of that position and the authority delegated to that staff member. The policy also states that the Governing Board approves the PPWP medical standards and guidelines, which serve as the rules and regulation of the medical staff, and the job responsibilities signed by the medical staff acknowledges that services will be delivered and policies followed according to the clinical standards and guidelines. This same policy states that written references must be obtained for the medical staff and states the Governing Body�s responsibility to review legal and ethical matters concerning the ASF including reports of unusual incidents.

Monitoring of this policy will occur with any changes made to this policy to ensure the changes are put into effect.

Monitoring of the elements of the policy will be done to ensure compliance policies through a checklist maintained by human resources staff for the personnel files. This checklist will monitor the medical staff member signature of the job responsibilities and the authority delegated to them, verify that written references were obtained and provide documentation of all other required elements of the personnel file. The CEO will monitor compliance through periodic review of the checklist and review of the documentation in the personnel file.

Monitoring will also be done through an employment law attorney who will review all job descriptions, and this legal review will be monitored through a log maintained by human resources staff showing which job descriptions are under review, the date the review is completed and the date the job description is re-signed if needed.

Monitoring the review of all legal and ethical matters including unusual events will include training staff responsible for patient safety and quality assurance to be aware that these matters and events must be brought to the attention of the CEO for presentation to the Governing Board.

Monitoring of the Governing Board�s review of all legal and ethical matters will be the responsibility of the CEO, who will ensure this is included on the Governing Board�s meeting agenda and will sign off on all board minutes to verify discussion of this information at the board meeting.

PPWP RQM Oversight Committee will be informed of the policy change and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Board of Directors adopted a Board policy on June 20, 2012 that requires the establishment of policies and practices to ensure employment of personnel with appropriate certifications. One staff member has completed ACLS training and a second staff member is registered for the training. Both of these staff members are scheduled for PALS training on September 19 and 20, 2012 which is the first date a training class is available with the required certification. Monitoring of the completion of the required ACLS and PALS course will be done by human resource staff through a checklist of required staff training. The CEO will notify the Governing Board when training is completed and include this notification in the Board minutes.

Each of the agency ASF job descriptions will be revised by management and reviewed by PPWP�s employment law attorney to ensure that the job qualifications, skills and training are appropriate for the responsibilities of the position. All agency job descriptions that are revised will be re-signed by the staff member.

Human resource staff will be responsible for monitoring the review of job responsibilities and ensuring the re-signing of job descriptions and responsibilities. The legal review will be monitored through a log maintained showing which job descriptions are under review, the date when the review is completed and the date the job description is re-signed, if applicable. Any future revisions of job responsibilities and job descriptions for medical staff will be reviewed by the employment law attorney and monitored according to this procedure. The CEO will monitor completion of this work and include on the governing board�s meeting agenda a report of the job description review and the outcome of the review.

Any staff member who is cross trained for a second position will have evidence of required training for both positions in their personnel file. Currently, there is no planned change in positions or cross training but if someone new is hired or cross-training is needed, the human resource staff will monitor the training and documentation to ensure both are complete and included in the personnel file.

The PPWP RQM Oversight Committee will be informed of the corrective action taken and the Governing Body will be informed of the deficiency and its resolution.

The effective date for this regulation was June
19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The governing board adopted a comprehensive policy on June 20, 2012 that requires the establishment of policies and procedures that licensed staff be hired only after appropriate verification of work experience, and obtaining written references for licensed staff. This policy is included in PPWP�s Human Resource Policies.

Monitoring will be done by human resource staff as new people are hired to ensure the proper information is gathered and included in the personnel file. A checklist will be used to monitor the documents included in the file and to verify that the required information was obtained and that the staff member was hired only after appropriate verification of work experience and after written references were obtained. The CEO will monitor this checklist and periodically review the contents of the personnel file. The governing board will monitor compliance through reports presented by the CEO at the board meeting. The Governing Board minutes will document when ASF medical staff is hired and that all required documentation was obtained for the personnel file.

The PPWP RQM Oversight Committee will be informed of the change and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The governing board adopted a policy on June 20, 2012 that requires the board to review legal and ethical matters concerning the ASF including reports of unusual incidents. Future board meeting agendas will include an agenda item for this review as stated in the board policy.

Compliance will be ensured and monitored through staff education to make them aware that legal and ethical matters concerning the ASF including reports of unusual incidents must be brought to the attention of the CEO for presentation to the Governing Board.
Monitoring of the Governing Board�s review of all legal and ethical matters will be the responsibility of the CEO, who will ensure this is included on the Governing Board meeting agenda and is included in board minutes to verify discussion of this information at the board meeting.

The PPWP RQM Oversight Committee will be informed of the change and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Board of Directors appointed the PPWP Medical Director as Director of Anesthesia Service at its June 4, 2012 Board of Directors meeting. This responsibility is documented in the Medical Director�s signed job description. The Governing Board adopted a Board policy on June 4, 2012 stating the Board�s responsibility for appointing the Director of Anesthesia.

Compliance will be monitored by the CEO who will notify the Governing Board of any change in the Medical Director and be responsible for making sure the Governing Board appoints another physician as Director of Anesthesia if the position is no longer filled. The PPWP RQM Oversight Committee will be informed of the change and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Governing Board adopted a Board policy on June 4, 2012 that requires the governing body to ensure medical staff certification for ACLS and PALS as required in 553.3 and 551.22. One staff member is trained on ACLS and a second staff member has registered for the training. Both of these staff members are scheduled for PALS training on September 19 and 20, 2012 which is the first date a training course is available with the required certification.

Monitoring for compliance will include staff education by the VP of Operations for the staff scheduler to ensure there is awareness and understanding of the requirements for ACLS and PALS trained staff on the premises during clinic hours.

The Surgical Site Supervisor or designee will monitor by doing random site inspections to ensure that ACLS trained staff is always on the premises during clinic hours and that a PALS certified staff member is on the premises when a minor is in the facility during clinic hours. The random checks will occur weekly for three months following completed certification.

The Quality Assurance calendar currently used by human resources to monitor expiration of licenses, CPR and credentialing on a monthly basis has been modified to include ACLS and PALS expiration dates. Human resources staff will monitor expiration dates and notify staff 4 months prior to any item expiring.

Monitoring of the Governing Board�s review of completion of PALS and ACLS training will be the responsibility of the CEO, who will ensure this is included on the Governing Board�s meeting agenda and will sign off on all board minutes to verify discussion of this information at the board meeting.

The PPWP RQM Oversight Committee will be informed of the corrective action taken and the Governing Body will be informed of the deficiency and its resolution.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Governing Board adopted a policy on June 4, 2012 that requires the establishment of procedures for the medical review by the medical director of practitioners for recommendation for appointment to the governing body. The policy and procedure for physician appointment is included in PPWP�s Human Resources Manual.

Compliance will be monitored when physicians are hired. A checklist will be used to monitor the documents included in the personnel file and to verify that the required information was obtained for the physician appointment. The CEO will monitor compliance through periodic review of the checklist and the documentation in the personnel file.

The board minutes will document the process for physician appointment and compliance with the established procedure. The CEO is responsible for including physician appointment on the Governing Board agenda and for monitoring board minutes to ensure the process is accurately documented.

The PPWP RQM Oversight Committee will be informed of the policy adoption and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: the PPWP Recovery Room page is in the process of being revised to correct this deficiency as well as deficiency 554D. The nausea and vomiting criteria were added to the client discharge criteria and to the PPWP medical protocol. The finalized form will be presented to all staffs involved in the discharge process and they will be educated about the protocol change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor by conducting a random chart audit for the documentation of nausea and vomiting upon discharge for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 21012. PPWP has taken the following steps to ensure compliance:
The Governing Board adopted a Board policy on June 4, 2012 and adopted a second more comprehensive policy on June 20, 2012 that specifies that the appointed physicians constitute the organized medical staff and the PPWP clinical standards and guidelines serve as the rules and regulations of the medical staff. The Governing Board appointed physicians to the medical staff and approved the PPWP clinical standards and guidelines as the rules and regulations of the medical staff at the June 4, 2012 meeting.

Monitoring will be done for compliance if any changes are made to the Governing Board Policy for the ASF and if any changes are made to the rules and regulations of the medical staff.

The CEO is responsible for bringing these changes to the Governing Board for discussion and approval and for monitoring board minutes to ensure the process is accurately documented.

The PPWP RQM Oversight Committee will be informed of the policy adoption and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Governing Board has adopted a Board policy on June 4, 2012 requiring a procedure for recommending to the Governing Board for its approval the initial, reappointment, assignment and curtailment of privileges to practitioners. A policy and procedures for physician appointment is included in PPWP�s Human Resources Manual. The Governing Board received and approved the Medical Director recommendation for physician appointments at its June 4, 2012 Board meeting. The recommendations were made after Medical Director review of complication rates, performance and peer review by the medical director, third party credentialing, physician education and prior work experience.

Monitoring of this procedure will occur as new physicians are hired. Physician appointment, reappointment, assignment and curtailment procedures will be monitored by the VP for Operations and CEO to ensure the appropriate documentation for appointment purposes is obtained and reviewed by the medical director, presented to the Board and included in the personnel file. The Medical Director will monitor physician qualifications through peer review for periodic performance assessment and for incidences that occur and this documentation will be retained and used for re-appointment. Supervising staff will be educated to notify the CEO of any incidences that have occurred and peer review completed so this information can be presented to the Governing Board and included in the physician file for reappointment purposes. The CEO is responsible for monitoring the Governing Board meeting agenda for inclusion of appointment and reappointment responsibilities, and for monitoring board minutes to ensure the process is accurately documented.


The PPWP RQM Oversight Committee will be informed of the policy adoption and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Governing Board adopted a Board policy on June 4, 2012 that requires medical staff to always act in manner consistent with the highest ethical standards and levels of professional competence. This requirement is included in the appointment/reappointment letter physicians receive and is included as a requirement in the physician job description.

The Medical Director will monitor physician performance, including peer review for routine assessment and unusual incidents and document this review in the personnel file. Physician credentials and National Provider Data Bank reports will be obtained by human resources staff for appointment and reappointment procedures in order to monitor physician compliance with ethical standards and professional competence as required. The CEO will monitor credentialing reports and the Medical Director review of physician performance and advise the Governing Board if a situation occurs where a physician is not acting with the highest ethical standards and level of professional competence so appropriate Governing Board action can be taken regarding with the appointment process.

The PPWP RQM Oversight Committee will be informed of the policy adoption and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 21012. PPWP has taken the following steps to ensure compliance: Planned Parenthood of Western Pennsylvania has registered with the National Provider Data Bank and submitted the required notarized documents. PPWP is waiting for approval to access the Data Bank and obtain the required physician reports, which will be included in the physician appointment file and presented to the Board of Directors at its next meeting on September 12, 2012.

Monitoring of the acquisition of Data Bank reports will be done through a checklist maintained by human resources staff of items required for the personnel files. The CEO will monitor compliance through periodic review of the checklist and the documentation in the personnel file. The Governing Board will receive Data Bank reports as part of the appointment and reappointment process and the CEO will monitor the Board meeting agenda and minutes to ensure this information is provided to the Governing Board and review is documented.

The PPWP RQM Oversight Committee will be informed of the corrective action taken and the Governing Body will be informed of the deficiency and its resolution.

PPWP has taken the following steps to ensure compliance: the PPWP Operative Reports are in the process of being revised to correct this deficiency as well as deficiencies 551E, 552E, 5559, 6407 and 6413. The form is being revised for clarity to sufficiently reveal that the physician administers all medications. The finalized forms will be presented to the physicians and physician assistants and they will be educated about the form change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure to ensure that the changes to the form were effective in making it clear that the physicians are administering medications at PPWP. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

PPWP has taken the following steps to ensure compliance: the PPWP Operative Report is in the process of being revised to correct this deficiency as well as deficiencies 551A, 552E, 5559, 6407 and 6413. The form is being revised for clarity to sufficiently reveal that the physician administers all medications. The finalized form will be presented to all staffs and they will be educated about the form change by the Medical Director Monitoring will be done through staff education of the Medical Director and VP for Operations so they are aware of the need to notify the CEO if any changes are made to the PPWP clinical standards and guidelines, which have been approved by the Governing Board as the rules and regulations of the medical staff. The CEO is responsible bringing changes recommended by the Medical Director to the Governing Board for their review and approval, and monitoring the Governing Board meeting agenda so approval is documented in the meeting minutes. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the revised operative reports are in use for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: On 6/21/2012 the Surgical Site Supervisor followed up with all staff responsible for ensuring that the medical history and physical exams are completed. The Surgical Site Supervisor will complete an audit of 50 randomly selected charts by 7/20/2012 to ensure complete documentation of history and physical for the patient. If the results of all of the above are less than 100%, it will be determined on 7/2712 what additional measures need to be implemented and monitored with ongoing audits. . The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Consortium of Abortion Providers (CAPS) is submitting the revised Client Information for Informed Consent for In-Clinic Abortion to the Planned Parenthood Federation of America (PPFA) for approval on 6/25/12. PPWP requested language that clarified the patient may require admission to the hospital in the event of medical need rather than the current statement that PPWP could send the client to the hospital for a problem. Upon PPFA approval, all staffs will be informed of the revision and instructed to implement the new form upon receipt. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the revised CIIC is in use for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.
It was not necessary to submit a request to add written instructions for preoperative procedures that included a responsible person would escort the patient that received sedation home to the Client Information for Informed Consent for In-Clinic Abortion because the Client Information for Informed Consent for Minimal Sedation and the Client Information for Informed Consent for Moderate Sedation Intravenous (IV) Sedation do contain the required documentation.

PPWP has taken the following steps to ensure compliance: the PPWP Laboratory page is in the process of being revised to correct this deficiency. The form is being revised to provide documentation of evaluation, annotation and signature of the person evaluating the tests.The finalized form will be presented to all staffs and they will be educated about the form change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the revised Laboratory page is in use and that there is documentation of evaluation, annotation and signature of the lab staffs and the person evaluating the tests for the next three months. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Medical Director and the VP for Operations are in the process of reviewing resources on best practices for time-out in preparation for a written PPWP time-out policy to add to the PPWP medical protocol. The PPWP Operative Report is in the process of being revised to provide written documentation that the policy is being carried out by all staffs and to correct this deficiency as well as deficiencies 551A, 551E, 5559, 6407 and 6413. All staff that participate in the performance of a procedure will be educated about the new time-out policy and the finalized form will be presented by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the new policy is being implemented by verifying documentation of the identification of the patient and procedure prior to the administration of sedation/anesthesia for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The PPWP governing body reviewed and approved the agency clinical standards and guidelines for pathology and laboratory including the policies and procedures related to tissue and exudates removed during surgery at its Board meeting on June 4, 2012.

The agency clinical standards and guidelines for pathology and laboratory including the policies and procedures related to tissue and exudates did not change with the approval the by the governing board.

Monitoring of the changes related to pathology, laboratory and management of tissue will be done if the policy and procedures change in the future.
Monitoring to ensure changes are brought to the Governing Boards attention will be done through staff education of the Medical Director and VP for Operations so they are aware of the need to notify the CEO if any polices related to pathology and laboratory are changed.

The CEO is responsible bringing any policy and procedure changes recommended by the Medical Director to the Governing Board for their review and approval, and monitoring the Governing Board meeting agenda so approval is documented in the meeting minutes.
The PPWP RQM Oversight Committee will be informed of the policy adoption and the corrective action taken.

The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the unchanged POC protocol continues to be followed after it was formally approved by the Governing Board.

The Surgical Site Supervisor or designee will monitor to ensure the unchanged POC protocol continues to be followed since it was formally approved by the Governing Board. She will conduct a random chart audit of five charts/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: VP for Operations spoke with the Director of Operations at an EMS service after multiple telephone attempts. He stated that in a life-threatening event and for a serious event, PPWP must call 911 first. He said he would contact the VP for Operations to present a contract by 6/25/12. The VP for Operations contacted Director of Operations on 6/26/12 to follow up in order to be in compliance by 7/13/12. He scheduled a PPWP visit for 6/27/12 but cancelled because he is a medic and had to respond to a call. He did not call back later that day as scheduled. The VP for Operations followed up on 6/28/12. The Director of Operations stated the contracts would be ready on 6/29/12. The VP for Operations will continue to monitor the status of acquiring an agreement by contacting him again on 7/2/12, if necessary. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: Beginning 6/19/12, when the regulation became effective, only the Physician Assistant was assigned to supervise clients in the Recovery Room at all times. The LPN job description was revised to exclude Recovery Room supervision and supervision of sedated clients. The Surgical Site Supervisor who schedules staffs was educated about the delineation of responsibilities. As of 6/29/12 LPNs will not be scheduled to work at the ASF until and unless a waiver request is submitted and granted for the supervision of non-sedated patients in the Recovery Room by the LPN. If the policy is changed as a result, the Scheduler will be educated of the current practice and schedules will be monitored. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: One staff member completed ACLS training and is certified. A second staff member is registered for the training. The PPWP Recovery Room page is in the process of being revised to correct this deficiency as well as deficiency 3250. The form is being revised for clarity to sufficiently reveal that there was an ACLS staff present in the facility until discharge and that the anesthetist was present until patients receiving IV sedation were discharged from the facility. The finalized form will be presented to the physicians and physician assistants and they will be educated about the protocol change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure there is documentation of the ACLS staff and the anesthetist on the revised Recovery Room page is for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

PPWP has taken the following steps to ensure compliance: The PPWP Client Information and Instructions (CI), Taking Care of Yourself After an Abortion, which is given to clients to take home in order to care for themselves after the abortion, were revised and approved by the medical director to add an instruction that the client may resume normal diet. Revisions for limitations on activities were not necessary because the form already states, �Plan on relaxing for the rest of the day. Don�t drive if you had any sedation. Most women return to their normal activities the next day, but do NOT do hard work or heavy exercise for several days. This includes swimming, lifting heavy things, bicycling, or jogging.� The finalized form will be presented to all staffs and they will be educated about the form change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the revised CI is in use for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The PPWP Governing Boad reviewed and approved the agency clinical standards and guidelines for the anesthesia service, including the policies and procedures for anesthesia techniques at its Board meeting on June 4, 2012. The PPWP RQM Oversight Committee will be informed of the corrective action taken.

Monitoring will be done through staff education of the Medical Director and VP for Operations so they are aware of the need to notify the CEO if any polices related to the anesthesia service are changed. The CEO is responsible bringing any policy and procedure changes recommended by the Medical Director to the Governing Board for their review and approval, and monitoring the Governing Board meeting agenda so approval is documented in the meeting minutes.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: In ASFs where there is no anesthesiologist, the governing body shall designate a physician or dentist to function as the Director of Anesthesia Services, who shall be responsible for directing the anesthesia services and establishing the general policies and procedures for the administration of anesthesia in the ASF which shall be approved by the governing body. The PPWP Medical Director was appointed by the Board as the Director of Anesthesia Services on 6/4/12. On that date the Board also approved the physician anesthetists who were credentialed by the Director of Anesthesia Services.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The Governing Board appointed the PPWP Medical Director as Director of Anesthesia Service at its June 4, 2012 Board of Directors meeting. This responsibility is documented in the Medical Director�s signed job description.

Compliance will be monitored by the CEO who will notify the Governing Board of any change in the Medical Director and be responsible for making sure the Governing Board appoints another physician as Director of Anesthesia if the position is vacant.

The PPWP RQM Oversight Committee will be informed of the change and the corrective action taken.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The PPWP Operative Report is in the process of being revised and a new Sedation Record is being created to correct this deficiency as well as deficiencies 551A, 551E, 552E and 6413. The physicians and physician assistants will be advised to document that the clients elected their type of sedation, as is the case at the PPWP facility, along with the current practice of documenting the pre-anesthesia assessment for anesthesia contraindications. The finalized form will be presented to the physicians and physician assistants by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure documentation that explains why the type of anesthesia was chosen for the patients for three months after sedation services resume. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The PPWP medical protocol was revised to require EKG monitoring during sedation procedures. The operative report and the Recovery Room form are in the process of being revised for documentation of EKG monitoring. EKG machines were purchased and are on site. They are scheduled to be inspected by a biomedical company on 7/12/12. Sedation services are not being provided until all above are implemented and physicians and physician assistants are educated and trained to operate the equipment. The expected date of compliance is 7/24/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit for three months after resuming sedation services to ensure there is documentation in the medical record that the EKG Monitoring was applied. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: The VP for Operations is in the process of reviewing and revising the current PPWP OSHA Compliance Program which contains protocols for occupational health and an exposure control plan to include additional ASF requirements for infection control. Infections are being reported and are included in in the complications statistics for each physician. It has been the standard practice at PPWP for the Medical Director to review the statistics quarterly and discuss them at the PPWP RQM Oversight Commttee meeting quarterly. The physicians review their own statisics quarterly as well. The RQM Coordinator will be notified the future the RQM minutes must contain more detail about the items reviewed and discussed so that it is more obvious for compliance surveys. The minutes will be monitored by the Medical Director for the next year, evidenced by her initialing them. The expected date of compliance is 7/13/12. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP intends to submit a waiver request to permit a physician assistant to serve on the committee to be consistent with the waiver already granted by the PA DOH for a physician assistant to supervise sedation clients and to be the PALS certified staff on the premises when minors are in the facility at PPWP rather than an RN with the justification that it would be a higher standard of care. We will monitor that the PA is taking part in RQM activities and in attendance at the RQM Oversight Meetings by having the Medical Director initial the meeting minutes.The Governing Body will be made aware of the deficient practice and corrective action.

The VP for Operations is in the process of revising the current PPWP OSHA Compliance Program. The PPWP policies for occupational health will be updated to include a plan for tracking staff illnesses for trending purposes to identity potential infections in the workplace. Staff will be educated about the revisions in the new plan by the VP for Operations.
PPWP already tracks infections related to the abortion procedure. The Medical Director and the Patient Safety Committee reviews all cases of infection and the Risk and Quality Management Oversight Committee receives those reports. A review of the standards of practice will be documented in those cases going forward and The minutes will be monitored by the Medical Director for the next year, evidenced by her initialing them. The expected date of compliance is 7/13/12. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: A training addendum was created and it will be reviewed by the Medical Director and added to the personnel file of the existing Physician Assistant at PPWP on 6/26/12. The PPWP credentialing form for licensed staffs was revised to include the documentation of postoperative care of pediatric patients for new PA and RN hires going forward. Compliance will be monitored by human resources staff by adding this training requirement to the HR checklist used to monitor the documents included in the personnel file and verify that required information was obtained. The CEO will monitor compliance through periodic review of the checklist and the documentation in the personnel file.

The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

� Revised POC: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: Beginning 6/22/2012 a fanny pack was worn by all physicians during clinic hours which contains controlled substances not included in this citation. The fanny pack will be used until a locksmith alters the crash cart to include a second lock the drawers where narcotics are stored at which time staffs responsible for the security of controlled substances will be educated about the new procedures. The Surgical Site Supervisor or designee will monitor by doing ongoing random crash cart inspections to ensure that the controlled substances are double locked at all times. This quality assurance check will be added to the PPWP Risk and Quality Management weekly activities schedule. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. On those dates PPWP did have a policy and procedure outlining under what conditions the medical record could be removed from the premises. The PPWP policy did not restrict the removal of medical records from the premises except for court purposes. PPWP has taken the following steps to ensure compliance: The PPWP protocol was revised on 6/18/12. All staffs will be educated by 7/13/12 and adherence to the revised policy will be monitored by logging the date that the original record was removed from the premises for court and the return date. The Clerical Coordinator who is responsible for the medical records storage will be charged with maintaining the log and ongoing monitoring to make sure that the only reason records are removed are for court purposes. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

PPWP has taken the following steps to ensure compliance: the PPWP Operative Report is in the process of being revised and a new Sedation Record are being created to correct this deficiency as well as deficiencies 551A, 551E, 552E, 5559 and 6413. The Sedation Record will provide clarity to accurately reflect that the anesthetist administered anesthesia/sedation. The finalized form will be presented to the physicians and they will be educated about the form change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the Sedation Record is in use with complete documentation; to confirm the documentation of which staff person administered the medication for three months after sedation services resume. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

PPWP has taken the following steps to ensure compliance: the PPWP Operative Report is in the process of being revised to correct this deficiency as well as deficiencies 551A, 551E, 552E, 5559 and 6407. The form is being revised for clarity to sufficiently reveal that the physician administers all medications. The finalized form will be presented to the physicians and they will be educated about the form change by the Medical Director. The expected date of compliance should be on or before 7/13/12. The Surgical Site Supervisor or designee will monitor the plan of correction by conducting a random chart audit to ensure the revised operative reports are in use for the next three months. Five charts must be audited/week for a total of 65 charts by October 11, 2012. If the results are less than 100%, it will be determined on October 18, 2012 what additional measures need to be implemented and monitored with ongoing audits. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP�s architect has conferred with a representative of the Division of Safety Inspection about this regulation at length. PPWP intends to seek exceptions to the Guidelines requirements of minimum operating room sizes. PPWP will follow the compliance timeline submitted on June 11, 2012 to achieve full compliance by December 19, 2012.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP purchased cardiac monitors and defibrillators for the remaining procedures rooms and the recovery room. The defibrillators are currently on site and the cardiac monitors were backordered and are scheduled to arrive 6/29/12. Upon arrival equipment will staffs responsible for using the equipment will be informed and instructed to ensure the equipment is in operating condition at the beginning of each clinic day. An equipment inspection will be performed by an external biomedical company before the equipment is used and annually thereafter as required by the PPWP Risk and Quality Work Plan.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: Tracheostomy and pulmonary reexpansion supplies were ordered for the procedure rooms and the recovery room. The pulmonary reexpansion supplies are on site. The tracheostomy supplies were backordered and the expected date of delivery is 7/1/12. Upon arrival of equipment, staffs responsible for using the equipment will be informed. Those staffs and purchasing staffs were educated about equipment requirements in the ASF including the location of the equipment. An equipment check will be performed monthly for expiration dates and purchasing needs.

The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP staffs have been and are currently monitoring the temperature and humidity and keeping a log to document that temperature and humidity are appropriate in procedure rooms and recovery daily and when staffs suspect atmospheric changes. The quality assurance check or monitoring which is the responsibility of the Surgical Site Supervisor or designee has been added to the PPWP Risk and Quality Management schedule of daily activities in the work plan. PPWP intends to seek exceptions to the Guidelines requirements in June 2012. PPWP will follow the compliance timeline submitted on June 11, 2012 to achieve full compliance by December 19, 2012.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: A fire inspection of the faclity was completed by the local fire department on June 25, 2012.

Compliance with the annual fire inspection will be monitored through the annual quality management calendar which lists all required compliance issues, when they must be completed and the staff member who is responsible for completing the task. The Risk and Quality Management Coordinator will be responsible for adding this requirement to the list, monitoring its completion and reporting to the Risk Management Committee.

The PPWP RQM Oversight Committee will be informed of the corrective action taken and the Governing Body will be informed of the deficiency and its resolution.

The effective date for this regulation was June 19, 2012, and the survey took place May 31 and June 1, 21012. PPWP has taken the following steps to ensure compliance:
1. Procedure room sizes: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP�s architect has conferred with a representative of the Division of Safety Inspection about this regulation at length. PPWP intends to seek exceptions to the Guidelines requirements of minimum operating room sizes.

2. Cubicle curtains: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP is in the process of conferring with its architect to discuss possible options for installing cubicle curtains for patient privacy, and will have further conversations with the Division of Safety Inspection upon further planning related to this item.

3. Scrub sinks: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP�s architect has conferred with a representative of the Division of Safety Inspection about this regulation at length. PPWP sought an exception to the requirement on April 30, 2012, and the Department deferred decision on that request by letter dated June 1, 2012. PPWP intends to submit further information to the Department in support of its pending exception request.

4. Double locked storage for controlled substances: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: Beginning 6/22/2012 a fanny pack was worn by all physicians during clinic hours which contains controlled substances not included in this citation. Both fentanyl and versed are not being offered to patients and will, therefore, are stored under double lock at all times. The fanny pack will be used until a locksmith alters the crash cart to include a second lock the drawers where narcotics are stored at which time staffs responsible for the security of controlled substances will be educated about the new procedures. The Surgical Site Supervisor or designee will monitor by doing ongoing random crash cart inspections to ensure that the controlled substances are double locked at all times. This quality assurance check will be added to the PPWP Risk and Quality Management weekly activities schedule. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

5. Clean/dirty work rooms: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP�s architect has conferred with a representative of the Division of Safety Inspection about this regulation at length. PPWP is in the process of conferring with its architect to discuss possible feasible alterations to the health center to satisfy the requirements for the separation of clean and dirty/soiled workrooms. PPWP�s architect will engage in further conversations with the Division of Safety Inspection upon the development of a plan the meets the Guidelines requirements, and if necessary, may seek limited exceptions from the Guidelines in furtherance of a renovation or alteration that is agreeable to the Division of Safety Inspection.
While this process continues, PPWP will review with its staff the proper infection protocols for handling soiled, clean and sterile instruments and avoiding cross-contamination. The quality assurance committee will be tasked with reviewing this protocol and recommending any necessary improvements at its next meeting.

6. Monitoring humidity and ventilation in sterile storage: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: Humidity and temperature monitors will be purchased and implemented in the autoclave area where wrapped sterile supplies are stored on 6/26/2012. A log will be maintained to document that temperature and humidity are appropriate in the area where sterile packages are kept. The PPWP RQM Oversight Committee will be informed of the change and the Governing Body will be made aware of the deficient practice and corrective action.

7. Ceiling coverings: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP�s architect has conferred with a representative of the Division of Safety Inspection about this regulation at length. PPWP is in the process of conferring with its architect to discuss possible feasible alterations to its health center to satisfy the requirements. PPWP�s architect will engage in further conversations with the Division of Safety Inspection upon the development of an acceptable solution. PPWP intends to seek limited exceptions from the Guidelines as necessary in furtherance of a renovation or alteration that is agreeable to the Division of Safety Inspection.

8. Floor coverings: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP�s architect has conferred with a representative of the Division of Safety Inspection about this regulation at length. PPWP is in the process of conferring with its architect to discuss possible feasible alterations to its health center to satisfy the requirements. PPWP�s architect will engage in further conversations with the Division of Safety Inspection upon the development of an acceptable solution. PPWP intends to seek limited exceptions from the Guidelines as necessary in furtherance of a renovation or alteration that is agreeable to the Division of Safety Inspection.

9. Door width and toilet room doors: The effective date for this regulation was June 19, 2012, and the survey took place on May 31 and June 1, 2012. PPWP has taken the following steps to ensure compliance: PPWP is in the process of conferring with its architect to discuss possible options, and will have further conversations with the Division of Safety Inspection upon further planning related to this item.

The PPWP RQM Oversight Committee and the Governing Board will be updated on all the status of all of these deficiencies and corrective actions.
PPWP will follow the compliance timeline submitted on June 11, 2012 to achieve compliance as indicated by December 19, 2012.