DEPARTMENT OF HEALTH

pennsYlvania

(717) 783-1379

November 16,2010

H 44 LOcust Street
Philadelphia, PennsyJvania191 07 RE: FaCility Dear

(PPSP)

It> #00238701

On October 19, 2010, anon-sitesurvey was conducted at Planned Parenthood of Southeastern Pennsylvania; The survey findings revealed that the clinic failed toprovide services in accordance with 28 PA. Code Chapter 29, Subchapter D, Ambulatory Gynecological SUrgery in.Hospitals and. Clinics. . Specifically, the clinic did not meet the following requirement

29.33(13) Requirements for Abortion. Each patient shan be supervised constantly while recovering from surgery or anesthesia, until she is released from recovery by a registered nurse or a licensed practical nurse under the direction ofa registered nurse or a physician .. The nurse "Shall evaluate the condition of the patient and enter a report of the evaluation and orders in the medical record of the patient. . Onsitesurveyreview of nlediciil recordS, facllny's policies aud procedures-an.d-i1'lltell'¥«· ~.~1:l1' h..tJ1le_ Facility Director revealed the facility was riot following it's policy for "Post-Procedure Management Recovery Area" for six (6) often (10) patients. who received intravenous sedation. On October 19. 2010 approximately 1:30 PM review of the agency's policy (revision August 2010) for Post-Procedure Management under "Recovery Area" revealed, "# 2. lmmediatepost-operative clientcare shall consist of observation and monitoring a supervised recovery area as long as the clients condition warrants, This includes monitoring vital signs (level of consciousness, blood pressure. pulse, cramps, bleeding and oxygen saturation) every 15 minutes and shortly before discharge from the recovery . area."
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Medical records reviewed on October 19,201 ubetween
following:

I 1:45 AM aod-2:30 PM revealed the
. .

Medi~al record# 1,069950: According to the patient's operative. note record of October 16,2010, the procedure Was completedatn2:46PMII~ The Recovery Room note revealed the registered nurse . documented the vital signs at "1400aod 1445", forty-five minutes Wer. The patient wasdischatgedaf ,II) 440 in stable condition" .. The recovery room note was signed by a physician on October t 6, .~O t 0..
Medical recorc)#·217000: According.to thepatient's operative note. record of September 30, 2010, the procedure was completed at 1;1:05 PM". The Recovery Room noterevealedthe.registerednur~.. .

..

..

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.documented the vital signs

at 111 : 10 PM" and."! :40 PM", thirty

minuteslater, The patient was discharged

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November 16, 2010:

at "1:45 PM in stable condition". The recoveryroom note wassignedby 2010. ''

a physician on September 3. "

,procedure Was completed at "4:35PM", The Recovery Room note revqaled the registered nurse documented the vital signs at "1635" and "1715", forty minutes later. ,the patient was discharged at "1715 in stable condition". The recovery room note was signed by a pfiysician on October 16, 2010 .
.Medical

Medical record# 1143619: According to Ute patient's operative: note record of October 16~2010. the

2010.

procedure was completed at "'!3:20 ·PM".. The Recovery Room note revealed the registered nurse documented the vital signs at "3:20 PM" and "3:50 PM". thirty minutes later. The patient was discharged at ''3:58 PM in stable condition" .. The recovery room note was signed by a physician on October 15.
.... , .

rec~~d# 194066:

According to the patient's operative note record of October 15, 2010, the

Medical record~~98021: According to the patient's operative note record of October 16, 2010, the procedure completed at "1:20 PM". The Recovery Room note revealed the registered nurse documented the vital signs at"1320" and "1400", forty minutes later. The patient was discharged at "1415 instable condition", The recovery room note was signed by a physician on October 16, 2010.

was

Medical record# 1117523: According to the patients operative note record of October 17, 2010, the procedure was completed at "I :25 PM". The Recovery Room note revealed the registerednurse .documented the vital signs at "I: 35 PM" and "1415", forty minutes later. The patient Was discharged at "1425 in stable condition". The recovery room note was signed by a physician on October 17.2010. Interview conducted on October 19, 2010 at approximately the above identified findings, 2:45 PM with the Facility Director confirmed

I

. The (acility needs todevelbp and implement a collect~et1eBi1laR1 ipleasesulUbJl,mUJiLLt n!.!·tte~n~~___:__ :1'yQ~uwr~w!!J' . corrective action plan to the Department of Health, Division of Home Health 132 Kline Plaza, Suite A, Harrisburg, PA 11104, along with evidence for a mechanism for monitoring. You have 10 calendar days . from the date of this letter to submit a.correctlveaction plan. Thank you and your staff for the . consideration shown at the time of the survey . .If you have questions, please feel free to contact Sinoerelv •

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iii Planned Parenth· od' II=' Southeastern Pennsylvania
Thursday, December 16,.2010

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. Department of Health Division of Home Health
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Harrisburg Pa.l7104

RE: facility IDlIOOi38701 Plan of eorection

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I had a death hi my family which hindered
.. .

I apologize f~r t~e deJay in providinglthls Plan of correction.
my abifity to getthis to you lna tim1y manner.

~closed will· find the P!an of~ofrection for our locustSt., Philadelphia site: facility 10 #00238?O1. Included IS the audit tool with WhlChjWe will use to assess adherence to our polICyfor the monItoring of patients in our recovery room. .. have also enclosed a quality assuraace plan for our West Chester site asan addendum to their . previously submitted Plan of Correct on related to·Rh testing. .
f

you

Please let me know if there Isanythl

further you need.

Sincerelv.
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1FiI Planned Parenthood'
fl::fl
Southeastern Pennsylvania
Plan of

Correctlon - ~ecember 16, 2010

Facility1D#00238701

1. All, nursing staff will receive re~ training on Poliev VIJ~A-l Surgical Abortion, Section XII Post. Procedure.Managernant: Recovery Room. Specifically,the need for monitoring patients' vital signs every fifteen minutes until discharge from the. Recovery Room will be stressed, Documentation of this training witfbe kept in the surgical office files and the employees' Human Resources file"

All re-tralnlngs

will be completed by January 5, 2011.
2~ All agency nurses will be required to read all Surgical policies prior to working at PPSP. They will have an opportunity have questions answered either by a PPSPsurgical nurse or the Clinical Services' Coordinator prior-to working. Documentation of this will be kept in thesur.gical office as well as Human Resources, (A copy of the form to be signed is enclosed]

to

3.

Charts will be audited February 7, 2011 training. Audit results whether

following

to assess level of compliance with a benchmark set at 95% will be summarized and presented to M~HY Banecker, VP of Patient
further intervention(s) is necessary.

Services, who will determine

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n Planned Paremhood' II='
Southeastern Pennsylvania

Plan of Correction
".
.

Re-training

of SULO Recovery

Room

Nurses

I have received training

on Policy VfI-A-l

Surgical Abortion, Section XII Post Procedure Management:

Recovery Room and understand that Vital Signs are to be done upon admission to the recover room, and every 15ininutesthereafier, with a final set immediately priot to discharge from the recovery room. I understand that each set of Vital Signs include blood pressure, pulse, and 02 Sat (IV sedation patients onl~ ..

Ihave been given an opportunityto

answer any questions I have had.

Signature

Printed Name

Date

.i

n." II='

Southeastern Pennsy!.vania

Planned Paremhood'
Training for Agency' Nurses

I have read the following Planned Parenthood S~PApoliciesand satisfaction. . • • • • • VII-A-1 Surgical Abortion VII-A-2 Surgical Abortion VII-B·1 Mifepristone VII-B-3 Mifeprex High Alert - Post-op Protocol Medkal.Abortlon

have had my questions answered to my

Misoprostol

Abortion Adverse Event Report

XIII-A':1 Medical & Surgical Emergencies.

XIII..c-l Psychosocial Emergencies

Signature

Printed Name

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