QA Investigation Results

Pennsylvania Department of Health
PPSP FAR NORTHEAST HEALTH CENTER
Health Inspection Results
PPSP FAR NORTHEAST HEALTH CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of a Special Monitoring survey completed on February 16, 2018, at PPSP Far Northeast Health Center. It was determined 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:




553.3 (1) LICENSURE
Governing Body Responsibilities

Name - Component - 00
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.


Observations:


Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.

PPSP Far Northeast Health Center was not in compliance with the following State law:

Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 3, Patient Safety, Section 308. Reporting and notification ... (b) Duty to notify patient.--A medical facility through an appropriate designee shall provide written notification to a patient affected by a serious event or, with the consent of the
patient, to an available family member or designee within seven days of the occurrence or discovery of a serious event. If the patient is unable to give consent, the notification shall be given to an adult member of the immediate family. If an adult member of the immediate family cannot be identified or located, notification shall be given to the closest adult family member. For unemancipated patients who are under 18 years of age, the parent or guardian shall be notified in accordance with this subsection. The notification requirements of this subsection shall not be subject to the provisions of section 311(a). Notification under this subsection shall not constitute an acknowledgment or admission of liability.

This is not met as evidenced by:

Based on review of facility policies and procedures and medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure patients were notified within seven days of serious event in three of five medical records reviewed (MR1, MR3, and MR4).

Findings include:

Review on February 16, 2018, of the facility's "Patient Safety Plan," dated November 2017, revealed "Written Notification: When a serious event occurs and the patient has not been notified [at time of event or via phone], the PSO (Patient Safety Officer) generates the written notification that will be sent to the patient or designee." This policy does not meet the requirements of Act 13 which requires written notice for all serious events.
Review of MR1 revealed the patient had a procedure at the facility on November 3, 2017. The facility's confirmation date that a serious event occurred was November 30, 2017. A request was made to EMP2 on February 16, 2018, for MR1's written notification for the serious event. None was provided.

Interview with EMP2 on February 16, 2018, at 1:20 PM confirmed there was no written notification to MR1 for the serious event.

Review of MR3 revealed the patient had a procedure at the facility on May 6, 2017. The facility's confirmation date that a serious event occurred was August 17, 2017. Review of the written notification of the serious event that was provided to the patient revealed the patient received this notification on September 8, 2017

Interview with EMP2 on February 16, 2018, at 1:20 PM confirmed the patient in MR3 did not receive the written notification for the serious event within seven days.

Review of MR4 revealed the patient had a procedure at the facility on April 19, 2017. The facility's confirmation date that a serious event occurred was May 1, 2017. A request was made to EMP2 for MR4's written notification for the serious event. None was provided.

Interview with EMP2 on February 16, 2018, at 1:20 PM confirmed there was no written notification to MR4 for the serious event.










Plan of Correction:

PPSP Far Northeast Health Center's Patient Safety Plan will be revised by 3/19/18 to include the requirement of written notification as described in Section 308. PPSP's Patient Safety Office or designee will provide written notification to any patient affected by a serious event or, with the consent of the patient, to an available family member within seven days of occurrence or discovery of a serious event. PPSP will follow Section 308 guidance on notification if patient is unable to give consent and/or if patient is a minor (under age of 18 years of age).
The Director of Clinical Services is responsible for ensuring revision of the Patient Safety Plan and for monitoring compliance to ensure that this deficiency does not reoccur.

To ensure notification occurs within seven days, the Patient Safety Officer will prepare and mail the notification letter to affected patients on the day the serious event is reported to PA-PSRS. A copy of the letter will be maintained by the Patient Service Administrative Coordinator. This correction was implemented on March 9, 2018. The Chief Operating Office will ensure the updated Patient Safety Plan is presented for approval by the governing board at the next PPSP Board Meeting which is scheduled for 4/19/18.

The Director of Clinical Services will review the updated Patient Safety Plan with the ASF person-in-charge and ensure that the update Plan is maintained on site available for Department review. The Director of Clinical Services will audit for compliance monthly for at least 6 months and periodically then after (at least twice a year).