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 a special monitoring survey conducted on July 2, 2012, with additional review of materials on July 3, 2012, 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:




Initial Comments:

This report is the result of a full State Licensure survey conducted on July 1, 2012, at Planned Parenthood of Western PA WHS. 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.






Plan of Correction:




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 staff interview (EMP), it was determined that the facility failed to document complete discharge criteria for five out of five medical records reviewed (MR1, MR2, MR3, MR4 and MR5).

Findings include:

1. Review of MR1, MR2, MR3, MR4, and MR5 on July 2, 2012, at approximately 10:45 AM revealed that there was no documentation in the medical records that the patient's temperatures were at the normal range for the patient's age or at the preoperative level when the patients were discharged. Further review revealed there was no preoperative temperatures documented for the patients.

2. Interview with EMP1 on July 2, 2012, at approximately 1:15 PM confirmed that the temperatures were not obtained or documented for MR1, MR2, MR3, MR4 and MR5. EMP1 further indicated, " No, we would not typically take the patient's temperature unless there was some kind of emergency ... "

3. Interview with EMP1 on July 2, 2012, at approximately 1:15 PM confirmed that the facility does not have a policy regarding temperature and discharge criteria.






Plan of Correction:

PPWP has taken the following steps to ensure compliance: the PPWP
Laboratory Page and the Recovery Room page were revised immediately and distributed staff on 7/3/12. Staffs responsible were educated about the revised PPWP medical protocol for preoperative and postoperative measurement of temperature and PPWP was in compliance on 7/3/12. The Surgical Site Supervisor or designee will monitor by conducting a random chart audit for the documentation of temperature preoperatively and 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.