Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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VALLEY FORGE MEDICAL CENTER - 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 (CHL23C962V) completed on February 6, 2024, at Valley Forge Medical Center. It was determined 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:

103.34 Personnel policies and practices
The governing body, through the chief executive officer, shall ensure that personnel policies and practices which adequately support sound patient care are established and maintained. The policies shall be reduced to writing and made available to all employes, and they shall be reviewed periodically, but no less often than two years. The date of the most recent review shall be indicated on the written policies. A procedure shall be established for notifying employes of changes in the established personnel polices.

Based on review of facility policy and interview with staff (EMP) it was determined the facility failed to establish a policy that addressed nurse staffing requirements for the hospital.

Findings include:

On February 6, 2024, a request was made to EMP7 for a nurse staffing policy, grid, matrix, or guidelines. None was provided.

Interview on February 6, 2024, with EMP7 confirmed the hospital did not have a policy, grid, matrix, or guidelens that specifically addressed nurse staffing requirements for the hospital.

 Plan of Correction - To be completed: 04/01/2024

The Director of HR or designee, under the authority of the Staff Development Committee, shall ensure that existing staffing policies and procedures are updated to ensure that nurse staffing requirements and ratios are clearly outlined for all units and levels of care.

The Staff Development Committee shall be expected to review and approve the updated policies and procedures no later than 4/1/2024. The Staff Development Committee shall ensure that the policy is reviewed at a minimum of every 2 years.

The Director of HR has the ultimate responsibility to ensure this plan is completed. The Director of HR is responsible to monitor the continued implementation of the plan of correction.

The Staff Development Committee shall be responsible for monitoring compliance with this corrective action plan for a minimum of 3 months.

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