QA Investigation Results

Pennsylvania Department of Health
FOUNDATIONS BEHAVIORAL HEALTH
Health Inspection Results
FOUNDATIONS BEHAVIORAL HEALTH
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced onsite complaint investigation (CEN16C916V) completed on November 14, 15, and 16, 2016, at Foundations Behavioral Health. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.






Plan of Correction:




482.13(b)(4) STANDARD
PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION

Name - Component - 00
The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.


Observations:


Based on review of policies and procedures, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the patient's right to have his or her choice physician notified promptly of his or her admission to the hospital for twenty-four of twenty-five medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, and MR25).


Findings include:


Review on October 15, 2016, of facility policies failed to reveal a policy to notify the patient's physician of his or her admission to the hospital.


Review on October 15, and 16, 2016, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, and MR25, revealed no documented evidence the patient's physician was notified of his or her admission to the hospital.


Interview on October 16, 2016, at 10:35 AM, with EMP1 confirmed the facility did not have a policy to notify the patient's physician of his or her admission to the hospital. Further interview with EMP1 confirmed MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, and MR25 did not have any documented evidence that the patient's physician was notified of his or her admission to the hospital.
















Plan of Correction:

Upon admission to Foundations Behavioral Health, it is requested that all patients and/or their guardians sign an authorization to release/obtain medical record information from the patient's primary care physician. On November 18, 2016, the form was revised by the Director of Admissions to include a section for the admissions staff to document that patient's PCP was contacted at the time of admission and if the physician was not contacted, the reason why. An in-service training conducted by the Director of Admissions on this procedure was provided to all admission staff by November 21, 2016. This will be monitored through monthly chart audits by the Director of Admissions, who maintains ultimate responsibility for compliance, and reported to Performance Improvement Committee on a quarterly basis.


482.13(h) STANDARD
PATIENT VISITATION RIGHTS

Name - Component - 00
A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation ....



Observations:


Based on facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure patients were allowed visitors of their own choice.


Findings include:


Review on November 15, 2016, of policy "Visitation", dated January 2016, revealed "Patients have the right to receive visitors. This right can only be limited on an individual basis by a physician for reasons of psychiatric necessity or security."


Review on November 15, 2016, of "Inpatient Treatment Program Applewood Program Handbook", no date, revealed "Visiting ... No one under the age of 18 is ever permitted on the unit."


Interview with EMP1, on November 15, 2016, at 3:34 PM, confirmed the Inpatient Treatment Program Applewood Program Handbook stated "No one under the age of 18 is ever permitted on the unit." EMP1 further confirmed the restriction did not address why the visitation restriction was reasonably or clinically necessary.





Plan of Correction:

Effective November 18, 2016 the visitation section of the Inpatient Treatment Program Applewood Program Handbook was updated by the Director of Performance Improvement to eliminate age limitations. All patients have the ability to accept visitors on the unit of any age unless contraindicated by physician order. Additionally, on November 18, 2016, the Visitation Policy (titled Visitation RI 036) was amended to eliminate age restrictions for patients' visitors. This change was communicated to all staff in their monthly department meetings. Visitation will continue to be monitored during Monthly Patient Safety Committee Meetings. Additionally, visitation and ensuring compliance remains a discussion topic for monthly nursing meetings. Nursing meetings are led by our Chief Nursing Officer, who has the ultimate responsibility for ensuring visitation compliance.


482.21(a), (c)(2), (e)(3) STANDARD
PATIENT SAFETY

Name - Component - 00
(a) Standard: Program Scope
(1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors.
(2) The hospital must measure, analyze, and track ...adverse patient events ...

(c) Program Activities .....
(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

(e) Executive Responsibilities, The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ...
(3) That clear expectations for safety are established.





Observations:

Based on review of facility policy and procedures, review of facility documents and interview with staff, it was determined the facility failed to follow their policy to include two residents of the community served by the Foundation on their interdisciplinary committee responsible for quality, safety, and risk management.


Findings include:


Review on November 15, 2016, of facility policy "Patient Safety Plan," reviewed/revised January 2016 revealed, " ... Foundation Patient Safety Improvement and Management Committee will include the patient safety officer, hospital in-house legal counsel, and identified member from the hospital's board of directors, and two residents of the community served by the Foundation.


Review on November 15 ,2016, of monthly Patient Safety Council Reports dated November 5, 2015, through November 8, 2016, revealed no documentation that two residents of the community served by the Foundation were members of the committee.


Interview with EMP3 on November 15, 2016, at 2 PM confirmed there was no documentation that two residents of the community served by the Foundation were members of the Patient Safety Improvement and Management Committee.







Plan of Correction:

As of December 21, 2017, Foundations Behavioral Health identified two community members to participate in monthly Patient Safety Council meetings conducted by the Director of Risk Management. The first community member is the Clinical Coordinator and Adjunct Professor for the Psychology Graduate program at the local community college. The second community member is a Crisis Intake Coordinator at a local Crisis Response Center. Both community members have committed to attending monthly meetings at Foundations held the third Wednesday of each month.


482.42(a) STANDARD
INFECTION CONTROL OFFICER(S)

Name - Component - 00
A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.



Observations:


Based on a review of job descriptions, personnel files (PF), and staff interviews (EMP), it was determined the facility failed to designate in writing a qualified Infection Control Officer (ICO).

Findings include:

ICO job description was requested from EMP10 on November 14, 2016 at 2:26 PM. None was provided, as requested.

Review on November 14, 2016 of EMP7's "Staff Development Instructor and Support Manager" job description, dated February 14, 2016, revealed there was no documented evidence that EMP7 was designated as the ICO.

Interviews conducted on November 15, 2016, at 1:45 PM, with EMP2 and EMP7 confirmed there was no documented evidence that EMP7 was designated in writing as the ICO.

Review on November 14, 2016, of the "2016 Infection Prevention and Control Plan" revealed the plan identified an "Infection Control Preventionist" as part of the Infection Control Plan, however the facility failed to identify in writing an individual to fulfill this role.

Review on November 14, 2016 of "Infection Control Meeting Minutes" for October 3, 2016 and May 25, 2016 revealed EMP7 was present during these meetings, but was not identified as the ICO.








Plan of Correction:

On November 15, the Registered Nurse in the positon of Staff Development Instructor and Support Manager was identified, in writing, as the facilities Infection Control Preventionist. The Director of Human Resources developed a job description and the identified individual signed the job description. It should be noted that this individual had been identified as the facilities Infection Control Preventionist and carried out those responsibilities, however his role and responsibilities were solidified in the revised job description.