Pennsylvania Department of Health
PENN STATE HEALTH REHABILITATION HOSPITAL
Patient Care Inspection Results

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PENN STATE HEALTH REHABILITATION HOSPITAL
Inspection Results For:

There are  45 surveys for this facility. Please select a date to view the survey results.

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PENN STATE HEALTH REHABILITATION HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
This report is the result of a revisit survey conducted on March 14, 2024, at Penn State Health Rehabilitation Hospital, as the result of a previous complaint survey that was conducted on January 5, 2024. 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:


101.111 LICENSURE CORRECTION OF DEFICIENCY:State only Deficiency.
101.111 Policy

Whenever any hospital notifies the Department that it has completed a plan of correction and corrected its deficiencies, the Department will conduct a survey to ascertain completion of the plan of correction. Upon finding full or substantial compliance, as defined in 101.92(b), the Department may issue a regular license.
Observations:

Based on review of the facility's Plan of Correction (POC), facility documents, and staff interview (EMP), it was determined Penn State Health Rehabilitation Hospital failed to follow their POC that was submitted to and accepted by the Department with a completion date of January 30, 2024.

Findings include:

On March 14, 2024, a review of the facility POC revealed, The Chief Nursing Officer (CNO) reviewed Respiratory Therapy Policy 001, Oxygen Administration with the nursing staff. This review emphasized prompt physician notification when oxygen saturation levels cannot be maintained as ordered. Education will be completed on January 25, 2024. As of January 26, 2024, any nursing staff that has not completed this education, will do so prior to working their next scheduled shift.

Review of the facility's documentation revealed that staff training of the Respiratory Therapy Policy 001, Oxygen Administration was not completed.

Interview with EMP1 on March 20, 2024, via telephone confirmed that the Respiratory Therapy Policy 001, Oxygen Administration training was not completed as outlined in the plan of correction.






 Plan of Correction - To be completed: 04/08/2024

The Chief Nursing Officer (CNO) and the Director of Quality Management (DQM) reviewed the Plan of Correction (POC) deficiency of 101.111 on 3/18/2024. This examination identified that the education provided to the staff did not include the entire Respiratory Therapy Policy 001, Oxygen Administration.

On 3/20/2024, the CNO and the DQM developed Power Point education slides that explicitly include Respiratory Therapy Policy 001, Oxygen Administration, with emphasis on prompt physician notification when oxygen saturation levels cannot be maintained as ordered. The entire policy was reviewed during three staff meetings which were all held on 3/20/24 and staff attendance was documented. The entire policy will also be reviewed during the twice a day shift huddles for the next 2 weeks and during scheduled staff meetings. Education will be completed by April 8. Any nursing staff that has not completed this education by April 8 will do so prior to starting their next scheduled shift. Staff policy review acknowledgment will be attached to the Respiratory Therapy Policy 001, Oxygen Administration.

Compliance with the above plan will be monitored by the CNO, or designee, by auditing each education list for staff names and policy attachment. This will continue until compliance has been achieved. At that time, findings will be reported to the monthly Quality Assurance Process Improvement (QAPI) Team and quarterly to the Quality and Patient Safety Committee, Medical Executive Committee (MEC) and Governing Board (GB).

The CNO is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.

109.23 (b)(1-5) LICENSURE WRITTEN NURSING CARE POLICIES:State only Deficiency.
109.23
(b) Nursing care policies and procedures shall be consistent with professionally recognized standards of nursing practice and shall be in accordance with the Professional Nursing Law and regulations promulgated by the State Board of examiners. These policies shall include procedures for the following:
(1) noting diagnostic and therapeutic orders
(2) assigning the nursing care of patients
(3) infection control
(4) patient safety
(5) implementing orders for medication and treatment, consistent with 107.61-107.65 of this subpart.
Observations:

Based on review of the facility's Plan of Correction (POC), facility documents, and staff interview (EMP), it was determined Penn State Health Rehabilitation Hospital failed to follow their POC that was submitted to and accepted by the Department with a completion date of January 30, 2024

Findings include:

On March 14, 2024, a review of the facility POC revealed, The Chief Nursing Officer (CNO) reviewed Respiratory Therapy Policy 001, Oxygen Administration with the nursing staff. This review emphasized prompt physician notification when oxygen saturation levels cannot be maintained as ordered. Education will be completed on January 25, 2024. As of January 26, 2024, any nursing staff that has not completed this education, will do so prior to working their next scheduled shift.

Review of the facility's documentation revealed that staff training of the Respiratory Therapy Policy 001, Oxygen Administration was not completed.

Interview with EMP1 on March 20, 2024, via telephone confirmed that the Respiratory Therapy Policy 001, Oxygen Administration training was not completed.





 Plan of Correction - To be completed: 04/08/2024

The Chief Nursing Officer (CNO) and the Director of Quality Management (DQM) reviewed the Plan of Correction (POC) deficiency of 101.111 on 3/18/2024. This examination identified that the education provided to the staff did not include the entire Respiratory Therapy Policy 001, Oxygen Administration.

On 3/20/2024, the CNO and the DQM developed Power Point education slides that explicitly include Respiratory Therapy Policy 001, Oxygen Administration, with emphasis on prompt physician notification when oxygen saturation levels cannot be maintained as ordered. The entire policy was reviewed during three staff meetings which were all held on 3/20/24 and staff attendance was documented. The entire policy will also be reviewed during the twice a day shift huddles for the next 2 weeks and during scheduled staff meetings. Education will be completed by April 8. Any nursing staff that has not completed this education by April 8 will do so prior to starting their next scheduled shift. Staff policy review acknowledgment will be attached to the Respiratory Therapy Policy 001, Oxygen Administration.

Compliance with the above plan will be monitored by the CNO, or designee, by auditing each education list for staff names and policy attachment. This will continue until compliance has been achieved. At that time, findings will be reported to the monthly Quality Assurance Process Improvement (QAPI) Team and quarterly to the Quality and Patient Safety Committee, Medical Executive Committee (MEC) and Governing Board (GB).


The CNO is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.


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