QA Investigation Results

Pennsylvania Department of Health
CHAN SOON-SHIONG MEDICAL CENTER AT WINDBER
Health Inspection Results
CHAN SOON-SHIONG MEDICAL CENTER AT WINDBER
Health Inspection Results For:


There are  45 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.



Initial Comments:

This report is the result of an unannounced onsite Medicare Recertification Survey conducted on March 11-13, 2019, at Chan Soon-Shiong Medical Center at Windber. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.








Plan of Correction:




482.41(b)(5) STANDARD
FIRE CONTROL PLANS

Name - Component - 00
(5) The hospital must have written fire control plans that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel and guests; evacuation; and cooperation with fire fighting authorities.

Observations:

Based on a review of facility documents, and staff interviews (EMP), it was determined that the facility failed to conduct quarterly fire drills at their provider-based satellites.

Findings:

Review of the facility's policy entitled "Emergency Preparedness Management Plan," reviewed July 2014, "... The purpose of the Emergency Preparedness Management Plan is to establish and maintain a Plan to ensure an effective response to disasters or emergencies affecting the environment of care ... This Plan ... shall cover all areas owned or leased by the hospital ... ."

Review of "Windber Medical Center Department Policies and Procedures Subject: Off Site Fire Drills/Evacuation Plan ... Policy 1. All off site personnel will be trained to participate in quaterly fire drills at their scheduled locations. ..."

1. A review of hospital owned off site satellites locations (locations 1-4) fire drills log, it was revealed that only one fire drill was conducted on November 5, 2018, at all four locations during the calendar year of 2018.

2. EMP5 confirmed the above findings that quarterly drills did not occur.













Plan of Correction:

Off-Site Satellite Fire Drills - Laboratory
Provide re-education to Laboratory Staff on Policy
"Off-site Fire Drill/Evacuation Plan" (Original date of implementation 8/18/2014)
Drills will be held Quarterly in each off-site location
Drills will be conducted by the Laboratory Safety Office or designee.
Records of Drills will be kept in the laboratory and provided to the Hospital Safety Committee.
This information will be reviewed and recorded at the Hospital Safety Committee Quarterly (April for Q1, July for Q2, October for Q3, and January for Q4) following the drills by the Safety Committee Representative from the Lab.
Education:
For new hires, education will be provided during the Lab Department Specific Orientation by the laboratory manager.
For existing staff, re-education will be provided at the Lab Staff Meeting by the Lab Manager on March 26, 2019 and then annually.
Drills will be held by March 31, 2019 for the 1st Quarter 2019, and then at random times during the following quarters not to exceed the last month of the quarter.
Drills were completed at 1 site on March 20, 2019 and a second site on March 22, 2019. The drill for the third site will be planned for March 27, 2019.
Measure will be added to Job Description for Lab Manager
Key Measure
Maintain oversight of off-site draw stations
- Provide orientation to the site for phlebotomists
- Maintain and log all off-site fire drills and evacuation plans per policy
- Visit, at least annually, each off-site location to ensure locations are kept up-to-date with DOH/CMS regulations as they pertain to the hospital licensure
The Plan of Correction will be presented and reviewed in detail at the Hospital Quality Committee on 4/4/2019, to the full Board of Directors at the next scheduled quarterly meeting on 4/17/2019 and at the Board Quality Meeting in May 2019 (date TBD).




Initial Comments:

This report is the result of a full State Licensure survey conducted on March 11-13, 2019, at Chan-Soon-Shiong Medical Center Windber. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.







Plan of Correction:




151.21 (a) LICENSURE
EVACUATION DRILLS - FIRE DRILLS

Name - Component - 00
151.21 Fire drills
(a) Fire, internal disaster, and evacuation drills shall be held at least quarterly for each shift of hospital personnel and under varied conditions.

Observations:

Based on a review of facility documents, and staff interviews (EMP), it was determined that the facility failed to conduct quarterly fire drills at their provider-based satellites.

Findings:

Review of the facility's policy entitled "Emergency Preparedness Management Plan," reviewed July 2014, "... The purpose of the Emergency Preparedness Management Plan is to establish and maintain a Plan to ensure an effective response to disasters or emergencies affecting the environment of care ... This Plan ... shall cover all areas owned or leased by the hospital ... ."

Review of "Windber Medical Center Department Policies and Procedures Subject: Off Site Fire Drills/Evacuation Plan ... Policy 1. All off site personnel will be trained to participate in quaterly fire drills at their scheduled locations. ..."

1. A review of hospital owned off site satellites locations (locations 1-4) fire drills log, it was revealed that only one fire drill was conducted on November 5, 2018, at all four locations during the calendar year of 2018.

2. EMP5 confirmed the above findings that quarterly drills did not occur.













Plan of Correction:

Off-Site Satellite Fire Drills - Laboratory
Provide re-education to Laboratory Staff on Policy
"Off-site Fire Drill/Evacuation Plan" (Original date of implementation 8/18/2014)
Drills will be held Quarterly in each off-site location
Drills will be conducted by the Laboratory Safety Office or designee.
Records of Drills will be kept in the laboratory and provided to the Hospital Safety Committee.
This information will be reviewed and recorded at the Hospital Safety Committee Quarterly (April for Q1, July for Q2, October for Q3, and January for Q4) following the drills by the Safety Committee Representative from the Lab.
Education:
For new hires, education will be provided during the Lab Department Specific Orientation by the laboratory manager.
For existing staff, re-education will be provided at the Lab Staff Meeting by the Lab Manager on March 26, 2019 and then annually.
Drills will be held by March 31, 2019 for the 1st Quarter 2019, and then at random times during the following quarters not to exceed the last month of the quarter.
Drills were completed at 1 site on March 20, 2019 and a second site on March 22, 2019. The drill for the third site will be planned for March 27, 2019.
Measure will be added to Job Description for Lab Manager
Key Measure
Maintain oversight of off-site draw stations
- Provide orientation to the site for phlebotomists
- Maintain and log all off-site fire drills and evacuation plans per policy
- Visit, at least annually, each off-site location to ensure locations are kept up-to-date with DOH/CMS regulations as they pertain to the hospital licensure

The Plan of Correction will be presented and reviewed in detail at the Hospital Quality Committee on 4/4/2019, to the full Board of Directors at the next scheduled quarterly meeting on 4/17/2019 and at the Board Quality Meeting in May 2019 (date TBD).