Pennsylvania Department of Health
PENN HIGHLANDS MON VALLEY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PENN HIGHLANDS MON VALLEY
Inspection Results For:

There are 203 surveys for this facility. Please select a date to view the survey results.

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PENN HIGHLANDS MON VALLEY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced onsite complaint investigation CHL25C264P completed on April 10, 2025, at Penn Highlands Mon Valley. 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:

103.22 (b)(7) LICENSURE IMPLEMENTATION:

(7) The patient has the right to good quality care and high professional standards that are continually maintained and reviewed.

Observations:

Based on a review of facility policies, medical record (MR), and employee interview (EMP), it was determined the facility failed maintain good quality care and high professional standards by failing to ensure the patient received prescribed medications while admitted and ensure correct medications were ordered at discharge for one of one medical records reviewed (MR1).

Findings include:

On April 10, 2025, a review of policy "Patient's Own Medication" (Last Reviewed: 09/2024) was completed and revealed the following: "... The following special situations define when it may be necessary for the hospital to use a patient's own medication" ... "The medication prescribed is one that the patient brought to the hospital and it is not stocked by or readily attainable by the hospital pharmacy." ... "Procedure: 1. The provider gives an order for the patient to use their own home medication. ...".

On April 10, 2025, a review of policy "Medication Reconciliation Policy" (Last reviewed: 02/2024; Last Revised: 02/2024) was completed and revealed the following: "... 9. All medications on the Home Medication List, included those Home documented as "hold home med" on admission will also be reviewed at the time of : a. Transfer to a different level of care. b. Prior to discharge to ensure all medications are considered and reconciled. ... 1. Medication reconciliation will be completed on all inpatients and observation patients at the time of discharge to home or other institutions. ... Home medications that are not marked as stopped or renewed prior to a Tertiary Hospital will be marked as continued upon transfer. ...".

On April 10, 2025, a review of policy "Safe Use of Medication" (Last Reviewed: 09/2024) was completed and revealed the following: "...Any orders for therapeutic duplication, all prior orders pertaining to that specific therapeutic class are to be discontinued. Pharmacists may discontinue any exact duplications of orders on the patient profile. If a therapeutic duplication exists outside of the following classifications, the Pharmacist may use clinical judgement to discontinue the order. ...".

On April 10, 2025, a review of MR1 revealed the patient was ordered a home medication, clobazam 20 MG to be administered twice a day during two admissions from February 17, 2025 until discharge on February 28, 2025, and from March 6, 2025 until transfer on March 9, 2025. There is no evidence this medication was administered during these admissions.

A further review of MR1 revealed a neurology note dated March 9, 2025, stating "...Spoke to nursing staff he is not getting clobazepam. [sic]". A review of the medication administration log confirmed 26 missed clobazam administrations over the course of two admissions.

On April 10, 2025 a review of MR1 revealed the patient was discharged on February 28, 2025, with a prescription for divalproex sodium (Depakote) 500 MG every eight hours, and valproic acid 500 MG every eight hours. These medications contain the same active ingredient.

A further review of MR1 revealed a neurology note dated March 9, 2025 stating "...his Depakote was double dosed actually he should be taking only 500 mg every 8 hours."

On April 10, 2025, at 12:35 PM EMP2, and EMP6 confirmed the above findings.

Plan of Correction - To be completed: 04/24/2025

The Pharmacy immediately implemented a process for review of communication notes daily for home medications that have not been received. This process will be completed by the daylight pharmacist. During admission order entry, the pharmacist will notify the attending physician that a medication is not on formulary. If a medication is noted to be ordered to "use from home", this will be entered as a communication note on the medication administration record. A report of these communication notes will print daily and reviewed by the Director of Pharmacy or designee. If a medication is not brought from home within 24 hours, this will be re-addressed by the Pharmacist with the attending physician to choose an alternative or possible temporary approval if needed.
100% Pharmacists have been educated on this immediate process. The report of communication notes prints to the pharmacy daily at 0800 and are reviewed by the Director of Pharmacy or designee.
The Pharmacy Director has ultimate responsibility to ensure compliance with this process. The report will be monitored daily for 100% compliance for one week. If compliance is met, monitoring for 100% compliance will then occur three times weekly for one week and then weekly thereafter.
Progress will be reported to the Quality Excellence committee and also to the Board Quality committee. The Pharmacy Director has ultimate responsible for the monitoring of compliance of this plan of correction.
The Hospitalists Director has discussed the event one-on-one with involved provider regarding divalproex sodium (Depakote) and valproic acid both being prescribed at discharge. Hospitalists Director will also provide "Discharge Home Medication" education to all hospitalists and audit for 100% completion by May 9, 2025. The discharge home medication issue will also be discussed collaboratively in the monthly hospitalist group meeting on May 21st 2025.

107.51 (a)(1-3) LICENSURE MEDICAL CARE REVIEW - RESPONSIBILITIES:

107.51 Medical staff responsibilities
(a) In order for the medical staff to take reasonable steps to ensure clinical practice of the highest quality, each staff member should endeavor to:
(1) provide his patients with the best quality of care consistent with the circumstances of each case;
(2) conduct his professional activities in accordance with the bylaws, rules and regulations of the medical staff; and
(3) assist in the promotion and maintenance of high quality care through the analysis, review, and evaluation of the clinical practice which exists within the hospital.

Observations:

Based on a review of facility policies, medical record (MR), and employee interview (EMP), it was determined members of the medical staff failed to ensure correct medication dosages were ordered at discharge.

Findings include:

On April 10, 2025, a review of policy "Medication Reconciliation Policy" (Last reviewed: 02/2024; Last Revised: 02/2024) was completed and revealed the following: "... 9. All medications on the Home Medication List, included those Home documented as "hold home med" on admission will also be reviewed at the time of : a. Transfer to a different level of care. b. Prior to discharge to ensure all medications are considered and reconciled. ... 1. Medication reconciliation will be completed on all inpatients and observation patients at the time of discharge to home or other institutions. ... Home medications that are not marked as stopped or renewed prior to a Tertiary Hospital will be marked as continued upon transfer. ...".

On April 10, 2025, a review of policy "Safe Use of Medication" (Last Reviewed: 09/2024) was completed and revealed the following: "...Any orders for therapeutic duplication, all prior orders pertaining to that specific therapeutic class are to be discontinued. Pharmacists may discontinue any exact duplications of orders on the patient profile. If a therapeutic duplication exists outside of the following classifications, the Pharmacist may use clinical judgement to discontinue the order. ...".

On April 10, 2025 a review of MR1 revealed the patient was discharged on February 28, 2025, with a prescription for divalproex sodium (Depakote) 500 MG every eight hours, and Valproic acid 500 MG every eight hours. These medications contain the same active ingredient.

A further review of MR1 readmission revealed a neurology note dated March 9, 2025 stating "...his Depakote was double dosed actually he should be taking only 500 mg every 8 hours."

On April 10, 2025, at 12:30 PM the above findings were confirmed by EMP 2, and EMP6.

Plan of Correction - To be completed: 04/24/2025

The Hospitalists Director has discussed the event one-on-one with involved provider regarding divalproex sodium (Depakote) and valproic acid both being prescribed at discharge. Hospitalists Director will also provide "Discharge Home Medication" education to all hospitalists and audit for 100% completion by May 9, 2025. The discharge home medication issue will also be discussed collaboratively in the monthly hospitalist group meeting on May 21st, 2025.

109.65 (b) LICENSURE RECORDING OF DRUGS ADMINISTERED:

109.65
(b) Any medication error or apparent drug reaction shall be reported immediately to the practitioner who ordered the drug. Any entry of the medication given in error or the apparent drug reaction, or both, shall be properly recorded in the medical record of the patient. Any adverse drug reaction shall be immediately noted on the medical record of the patient in the most conspicuous manner possible, in order to notify everyone treating the patient throughout the duration of his hospitalization of his drug sensitivity and thereby prevent a recurrence of adverse reaction. Notification of all drug sensitivities, including any apparent adverse reaction, shall be sent to the physician and to the director of pharmaceutical services. Records of drug sensitivities shall be retained in accordance with 113.23(e) of this title.

Observations:

Based on a review of facility policies, medical record (MR) and employee interview (EMP), it was determined facility staff failed to report missed medication dosages to the ordering practitioner.

Findings include:

On April 10, 2025, a review of policy "Patient's Own Medication" (Last Reviewed: 09/2024) was completed and revealed the following: "... The following special situations define when it may be necessary for the hospital to use a patient's own medication" ... "The medication prescribed is one that the patient brought to the hospital and it is not stocked by or readily attainable by the hospital pharmacy." ... "Procedure: 1. The provider gives an order for the patient to use their own home medication. ..."

On April 10, 2025, a review of MR1 revealed the patient was ordered a home medication, clobazam 20 MG to be administered twice a day during two admissions from February 17, 2025 until discharge on February 28, 2025, and from March 6, 2025 until transfer on March 9, 2025. There is no evidence this medication was administered during these admissions.

A further review of MR1 revealed a neurology note dated March 9, 2025, stating "...Spoke to nursing staff he is not getting clobazepam. [sic]". A review of the medication administration log confirmed 26 missed clobazam administrations over the course of two admissions prior to this documentation without documented notification to the ordering provider.

On April 10, 2025, at 12:30 PM the above findings were confirmed by EMP2 and EMP6.

Plan of Correction - To be completed: 04/24/2025

The Pharmacy immediately implemented a process for review of communication notes daily for home medications that have not been received. This process will be completed by the daylight pharmacist. During admission order entry, the pharmacist will notify the attending physician that a medication is not on formulary. If a medication is noted to be ordered to "use from home", this will be entered as a communication note on the medication administration record. A report of these communication notes will print daily and reviewed by the Director of Pharmacy or designee. If a medication is not brought from home within 24 hours, this will be re-addressed by the Pharmacist with the attending physician to choose an alternative or possible temporary approval if needed.
Education was provided to the Pharmacy with regards to this process. All Pharmacists are aware of this process change and it is effective immediately. The report of communication notes is printing to the pharmacy daily at 0800.
The Pharmacy Director has ultimate responsibility to ensure compliance with this process. The report will be monitored daily for 100% compliance for one week. If compliance is met, monitoring for 100% compliance will then occur three times weekly for one week and then weekly thereafter.
Progress will be reported to the Quality Excellence committee and also to the Board Quality committee. The Pharmacy Director has ultimate responsible for the monitoring of compliance of this plan of correction.
All nursing staff received annual mandatory education on Medication Administration Rights to be completed by April 30, 2025. This will be audited for 100% compliance and any noncompliance will be addressed through the HR process.
All pharmacy staff received annual mandatory education on Medication Safety to be completed by April 30, 2025. This will be audited for 100% compliance and any noncompliance will be addressed through the HR process.

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