QA Investigation Results

Pennsylvania Department of Health
PLANNED PARENTHOOD OF WESTERN PA (WHS)
Health Inspection Results
PLANNED PARENTHOOD OF WESTERN PA (WHS)
Health Inspection Results For:


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Initial Comments:

This report is the result of an initial registration survey conducted on June 3, 2011, at the Planned Parenthood of Western 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 June 3, 2011, it was determined that Planned Parenthood of Western Pa. failed to maintain a safe and sanitary environment.

Findings:

A tour of the facility was conducted on June 3, 2011 between approximately 12:00 PM. During the tour the following were observed:

1) Exam room #1-14 expired (2/10/2011) Chlamydia culture tubes.

2) Exam room #2- one container of cytology fixative spray that expired December 31, 2005 on the counter of the cabinet.

3) Exam room #3- Multiple unwrapped "clean" speculums, long forceps, etc. in the drawer of the exam table. Upon questioning, staff was unsure why they were being stored there or if they were ever used.

4) Exam room #4-one box of 10 packets of Silver Nitrate sticks that expired in November 2004 in the 1 drawer of the cabinet.

5) Storage in the clean area of the instrument processing room- One box of surgical masks that expired in November 2008.

6) Recovery room-5 boxes of Depo in the bottom of the cabinet where medications are stored that expired February 2008. 31 blood tubes that expired in September of 2010 and one blood tube that expired in January 2011. One of the leather-like recovery chairs that had cracked/split seat cover.

7) Storage in back hall by staff entrance- A trash container marked biohazard lined with a yellow bag.

8) Closet in the patient hallway by Exam room #1-a box of 17 steri strips expired August 1992 located on the second shelf. Boxes sitting on the floor under the shelves. Two cytology fixative sprays in a bin on the box on the floor that expired December 31, 2005.

9) Storage room where the medication safe is located- An unlocked metal box in an unlocked cabinet containing what appeared to be a nearly full prescription pad which had been completely signed by the physician. When questioned, staff and physician stated that when the physician is not present, the nurse may write the prescription on the pad and give it to the patient prior to their leaving the facility. A washer and dryer with heavy coat of dust across the top of each. The dryer had lint and broken lint filter. More than 50 sterile curettes expired in 2008, which included #16 curved, #14 curved and vacuum curettes.

10) Crash cart-left unlocked and unattended by staff authorized to administer the medication containing 8 vials of 20 tablets of Codeine.

11) Non-Emergency Cabinet- 14 Chlamydia culture tubes expired February 10, 2011; two Stenotic dilators expired May 13, 2011 and March 8, 2011. A container of "Aged Monsel's" solution with the expiration date of May 30, 2008.

12) Pathology area-Vacuum curette expired June 2009; long forceps expired March 24, 2011; Suction tubing in an opened "sterile" wrapping; Approximate 12"x 16" cardboard box containing greater than 40 sterilized speculums, forceps, etc. which had expired. The box had a note on the front identifying the instruments' sterilization as "expired".












Plan of Correction:

The following corrective action plans for each observation noted by the Pennsylvania Department of Health were initiated on the day of the initial registration survey and are voluntarily submitted for approval:

1. Correction: There are four exam rooms at PPWP (WHS) rather than the �14� noted in the findings. POC: The expired Chlamydia culture tubes were discarded. The expiration dates on the Chlamydia culture tubes in all exam rooms were checked. Staff responsible for stocking the tubes in the exam rooms were made aware of the oversight and reminded of the PPWP protocol to check expiration dates. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
2. The one container of cytology fixative spray that expired was discarded. All exam rooms were inspected to ensure there were no other similar containers. All staffs were reminded to discard items for services that are no longer provided by PPWP (WHS). Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
3. Multiple unwrapped, "clean" speculums, long forceps, etc. are stocked in the drawers of the exam tables, #2-4 because there are physicians who use these instruments for examinations other than surgery. Before the initiation of the pregnancy termination a sterilized kit, also contained in the exam table, is opened and used. There is no plan to correct this safe and acceptable practice.
4. Silver nitrate sticks in exam room #4 were discarded and the 3 other exam rooms were inspected to ensure there were no similar items. Staff responsible for stocking this clinic area was reminded to notify supervisor or purchasing coordinator of any items that don�t belong in that area for appropriate placement in clinic and monitoring. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
5. One box of expired surgical masks in the instrument processing room was discarded. Staff responsible for stocking this clinic area was reminded to notify supervisor or purchasing coordinator of any items that don�t belong in that area for appropriate placement in clinic and monitoring. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
6. All Depo provera and expired blood tubes in the Recovery area were disposed of and staffs responsible for that area were reminded to discard all medications and items for the provision of services that are no longer conducted at PPWP (WHS) and to communicate with other PPWP (WHS) departments regarding stock no longer utilized in that area. Lab staff responsible for blood tubes was reminded to account for all lab stock in all clinic areas at all times. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
7. The recovery chair with cracked/split seat cover has been discarded. Storage in back hall by staff entrance will be moved to other areas by June 24, 2011. The yellow bag, labeled �Infectious Linen� for laundry in the trash can with the biohazard label was changed to a red bag.
8. Box of expired steri strips in closet in the patient hallway by Exam room #1 and expired cytology fixative sprays in a bin, on the box on the floor were discarded. The boxes sitting on the floor under the shelf were moved up off of the floor. Staff responsible for stocking this area were made aware of the oversights and reminded of the PPWP protocol to check expiration dates. They were also reminded to discard items for the provision of services no longer performed at PPWP (WHS). Other similar areas in the site were inspected for similar oversights. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
9. PPWP (WHS) immediately discontinued the procedure of the Medical Director signing prescription pads for use by other PPWP (WHS) physicians. (These were not used by nurses.) Each physician signs her or his own prescription when working at PPWP (WHS). The staff present at the time of the survey responded that there was not a heavy coat of dust across the washer and dryer but dirt on the floor where they stand. Cleaning staff responsible was directed to clean the area immediately. Monitoring of this area will be targeted during facility inspections on an ongoing basis. Staff responsible for laundry was directed to clean the dryer lint after each load and to check the lint filter before each load when laundry is cleaned. The broken lint filter will be repaired by June 30, 2011. Expired curettes were immediately discarded and staff responsible for stock took note. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).
10. PPWP implemented a change in policy to give the physician working each day a key to the crash cart to unlock it as needed. The key must be returned to the safe at the end of each day by the Clinic Coordinator.
11. Expired Chlamydia culture tubes, stenotic dilators and aged Monsel's in non-emergency cabinet were immediately discarded. PPWP (WHS) discontinued the practice of aging ferric subsulfate because Monsel solution is on order.
12. Expired vacuum curette; long forceps, suction tubing in a cardboard box containing greater than 40 sterilized speculums, forceps, etc. which had expired and was labeled �expired� on the front was removed from the clinic area and expired items that cannot be re-sterilized were discarded immediately. Another facility stock audit is scheduled to be conducted by the Site Supervisor and VP for Operations within 6 months (12/1/2011).