Nursing Investigation Results -

Pennsylvania Department of Health
HAVEN BEHAVIORAL HOSPITAL OF PHILADELPHIA
Patient Care Inspection Results

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HAVEN BEHAVIORAL HOSPITAL OF PHILADELPHIA
Inspection Results For:

There are  6 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.
HAVEN BEHAVIORAL HOSPITAL OF PHILADELPHIA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
This report is the result of an unannounced onsite Medicare Validation and Recertification Survey conducted on December 3, 2019 to December 6, 2019, at Haven Behavioral Hospital of Philadelphia. 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:


482.12 CONDITION GOVERNING BODY:Not Assigned
There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ...

Observations:


This condition is not met as evidenced by:

Based on the systemic nature of the standard-level and condition level deficiencies related to patient rights, Quality Assurance and Performance Improvement, nursing services medical records and infection control the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with the Conditions of Participation as follows:

(482.12(c)(3), Tag-0067)
The documentation reviewed during the survey provided evidence that the facility failed to provide on-call physician coverage.

(482.13(a)(1), Tag-0117)
The documentation reviewed during the survey provided evidence that the facility failed to provide the "Important Message for Medicare on Admission and Discharge.

(482.13(b)(2), Tag-0131)
The documentation reviewed during the survey provided evidence the facility failed to provide written notice of physician coverage 24 hours a day, 7 days a week

(482.13(b)(3), Tag-0132)
The documentation reviewed during the survey provided evidence the facility failed to ensure patients had the right to form Advance Directives

(482.13(b)(4), Tag-0133)
The documentation reviewed during the survey provided evidence the facility failed to ensure, at the request of the patient, family member, patient representative or primary care doctor were notified of admission

(482.13(c)(2), Tag-0144)
The documentation reviewed during the survey provided evidence the facility failed to follow their Occupational Health Policy

(482.21(a),(b)(1),(b)(2)(i),(b)(3), Tag-0273)
The documentation reviewed during the survey provided evidence the facility failed to develop distinct performance improvement projects for services provided.

(482.21(d), Tag-0297)
The documentation reviewed during the survey provided evidence the facility failed to perform performance projects for services offered at the facility

(482.21, Tag-0308)
The documentation reviewed during the survey provided evidence that the governing body failed to establish a hospital-wide quality program

(482.23(b)(2), Tag-0386)
The documentation reviewed during the survey provided evidence that the facility failed to ensure the director of nurses met the educational requirements

(482.23(c)(1) (c)(1)(i)&(c)(2), Tag-0405)
The documentation reviewed during the survey provided evidence the facility failed to follow their own policy to administer scheduled drugs and biologicals according to the medication orders.

(482.24(b), Tag-0438)
The documentation reviewed during the survey provided evidence that the facility failed to ensure medical records were protected from fire and water damage.

(482.24(c)(4)(viii), Tag-0469)
The documentation reviewed during the survey provided evidence that the facility failed to ensure medical records were completed within 30 days after discharge.

(482.30(e), Tag-0657)
The documentation reviewed during the survey provided evidence the facility failed to perform periodic reviews for current inpatients receiving hospital services.

(482.30(f), Tag-0658)
The documentation reviewed during the survey provided evidence the facility failed to review professional services provided, to determine medical necessity and to promote the most efficient use of available services.


(482.42(a), Tag-0748)
The documentation reviewed during the survey provided evidence that the facility failed to ensure the infection control officer was qualified to conduct the program

(482.42(a)(1), Tag-0749)
The documentation reviewed during the survey provided evidence the to develop a system for controlling infections and communicable diseases of patients.

(482.43(e), (Tag-0843)
The documentation reviewed during the survey provided evidence the failed to reassess its discharge planning process on an on-going basis.


Repeat deficency:
Event ID WNWM11 10/11/2018





















 Plan of Correction - To be completed: 03/09/2020

482.12 GOVERNING BODY
The hospital ensures the governing body has reviewed this plan and is confident the plan of correction presented in this plan brings the facility in compliance with the Conditions of Participation for Hospitals and the deficiencies cited related to patient rights, quality assurance and performance improvement, nursing services, medical records and infection control. Monthly quality committee meeting minutes are reviewed in the board of directors meeting quarterly.

482.12(c)(3) CARE OF PATIENTS - MD/DO ON CALL
The hospital now ensures the on-call schedule reflects that a doctor of medicine or osteopathy is on-call for the facility, 24 hours per day, seven days per week.
1) The Medical Director added a clarification statement to the on-call schedule listing the doctor to call for medical concerns.
2) The Medical Director ensures a psychiatrist is on-call for the hospital, 24 hours per day, seven days per week when the on-call provider is unable to be reached.
3) A doctor of medicine or osteopathy is listed each day on the on-call schedule.
4) Education has been completed to providers for this update process.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
How Monitored:
The monthly on-call scheduled is reviewed before it is posted on the unit.
Deficiencies, if any, will be immediately addressed.
How Monitored
The on call scheduled is reviewed prior to posting for the month to ensure there is a doctor of medicine or osteopathy listed on call 24 hours, 7 days a week.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly

482.13(a)(1) PATIENT RIGHTS: NOTICE OF RIGHTS The Hospital now ensures the medical record contains the "Important Message for Medicare" upon admission and discharge.
1) All social services staff were re-educated on the Important Message from Medicare form and procedure completed at discharge on 12/19/2019,
1/10/2020, and 1/12/2020.
2) All nursing staff were re-educated on the Important Message from Medicare form and procedure completed at admission. Training was completed through Health Stream.
Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Nursing
Director of Social Service
How Monitored:
100% of records are audited at discharge by the Director of Social Services to ensure form was given near discharge.
100% of new admission charts are audit by the Director of nursing to ensure the form was given at the time of admission
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.
482.13(b)(2) PATIENT RIGHTS: INFORMED CONSENT The hospital now ensures the on-call schedule reflects that a doctor of medicine or osteopathy is on-call for the facility, 24 hours per day, seven days per week.

1) The Medical Director added a clarification statement to the on-call schedule listing the doctor to call for medical concerns.
2) The Medical Director ensures a psychiatrist is on-call for the hospital, 24 hours per day, seven days per week when the on-call provider is unable to be reached.
3) A doctor of medicine or osteopathy is listed each day on the on-call schedule.
4) Education has been completed with providers on new process.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored
The weekly provider call scheduled will be audited on a weekly basis to ensure there is a doctor of medicine or osteopathy on call 24 hours, 7 days a week.

Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.13(b)(3) PATIENT RIGHTS: INFORMED DECISION The Hospital now ensures the medical record includes the discharge form indicating that the Advanced Directives of the patient were discussed upon discharge.

1) All Social Service staff were re-educated during staff meetings held on 12/19/2019, 1/10/2020, and 1/12/2020 that the Advanced Directives of the patient need to be discussed upon discharge.
2) The hospital has updated the admission packet to include an Advance Directive / Healthcare Proxy Acknowledgment form that will be completed by the admitting staff member

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Social Services
Director of Nursing

How Monitored:
100% of discharge instructions will be audited for advance directives by the Director of Social Services
100% of new admissions will be audited for a completed Advance Directive / Healthcare Proxy Acknowledgment form by the Director of Nursing.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly

482.13(b)(4) PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s):
The hospital now ensures the patient is given the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

1) The hospital has updated the admission packet to include a Release of Information form that will be completed by the admitting staff member, and contact will be made, if indicated, at the completion of the Release of Information form.
2) All Nursing Staff have been educated about the addition of the Release of Information form to the admission packet.

Person(s) Responsible:
Director of Nursing
Nursing Supervisor
Nurse Manager

How Monitored:
100% of new admissions will be audited and include the evaluation of the admission packet, which now includes this Release of Information form.
Deficiencies will be addressed by the Nursing Supervisor/Nurse Manager upon completion of the audit. The staff will be re-educated and the form will be completed by the reviewer and contact made if requested upon audit completion.
Results of reviews will be aggregated, analyzed, and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING
The hospital now ensures ensure the approved policy for Occupancy Health is followed.
1) As of December 2019, the policy of Occupational Health has been amended to only include Tuberculosis, Hepatitis B, Hepatitis A when appropriate and seasonal flu vaccination upon hire.
2) 100% of current employee files were audited by the Director of Human Resources for compliance with the Occupational Health policy to ensure the employee has had their TB, and offered Hepatitis B and Hepatitis A.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Director of Nursing
How Monitored:
100% of new hire files will be reviewed by the Director of Human Resources for appropriate vaccinations.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee monthly and Governing Board quarterly.

482.21(a), (b)(1),(b)(2)(i), (b)(3) DATA COLLECTION & ANALYSIS
The hospital now ensures distinct performance improvement projects that reflect the scope and complexity of services and operations at the facility (dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, and ambulance services).

1) A matrix was created listing the distinct performance improvement projects for services and operations at the facility nursing, social service, dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services.
2)The matrix of projects including the method, frequency, and type of data, was approved at the January Quality Council meeting.
3) The projects will be submitted at the January Medical Executive Committee.

Person(s) Responsible:
Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each department will report updates at monthly Quality Council.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.
The hospital now ensures distinct performance improvement projects that reflect the scope and complexity of services and operations at the facility (dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, and ambulance services).

1) A matrix was created listing the distinct performance improvement projects for services and operations at the facility nursing, social service, dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services.
2) The matrix of projects including the method, frequency, and type of data, was approved at the January Quality Council meeting.
3) The projects will be submitted at the January Medical Executive Committee.

Person(s) Responsible:
Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management
How Monitored:
Each department will report updates at Quality Council.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee monthly and Governing Board quarterly.

482.21 QAPI GOVERNING BODY, STANDARD
The hospital now ensures the Quality Assessment and Performance Improvement (QAPI) monitoring is performed to reflect the scope of services provided at the facility.

1)A matrix was created listing the distinct performance improvement projects for services and operations at the facility nursing, social service, dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services.
2)The matrix of projects, including the method, frequency, and type of data, was approved at the January Quality Council meeting.
3)The projects will be submitted at the January Medical Executive Committee.
4)The projects will be submitted at the 1st quarter Governing Board meeting.
Person(s) Responsible:
Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each department will report updates at monthly Quality Council.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.23(a) ORGANIZATION OF NURSING SERVICES
The hospital now ensures the Director of Nursing is qualified to manage and direct nursing services at the facility.
1)As of 12/4/2019, the Director of Nursing Job Description was amended to include an associate's degree in Nursing with mentorship from a Master's prepared RN along with commiserate experience.
2)The Associate Vice President of Nursing, a Master's prepared RN, provides mentorship and supervision to the Director of Nursing.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Associate Vice President of Nursing

How Monitored:
Notes of the supervision between the Director of Nursing the Associate Vice President of Nursing, are maintained every month and kept in a file by Human Resources.
Deficiencies, if any, will be immediately addressed.

482.23(c)(1), (c)(1)(if) & (c)(2)ADMINISTRATION OF DRUGS
The hospital ensures drugs and biologicals must be prepared and administered in accordance with Federal and State laws.

1)The hospital has updated the "Medication Standard Administration Times" policy.
2) eMAR has been adjusted to reflect the appropriate time frames per updated "Medication Standard Administration Times" policy.
3) All MD/CRNP/ RN/LPN have been re-educated on this policy.
4) A laminated copy of the Medication Standard Administration Times policy was posted in the medication room

Person(s) Responsible:
Director of Nursing
Director of Pharmacy

How Monitored:
Director of Pharmacy monitors 100% of medication administered outside of the scheduled time frame and alerts the Director of Nursing. The Director of Nursing will then instruct the Nurse Manager to provide re-education to the staff member who was non-compliant with the policy.
Results of reviews will be aggregated, analyzed, and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.
482.24(b) FORM AND RETENTION OF RECORDS
The hospital ensures medical records are properly stored from fire, water damage, and other threats.

1)The hospital is replacing the current medical record shelving units with enclosed shelving units which will protect the records from fire and water damage.

Person(s) Responsible:

Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management
How Monitored:
New medical record storage units will be installed.

482.24(c)(4)(viii) CONTENT OF RECORD: FINAL DIAGNOSIS
The hospital now ensures medical records are completed within 30 days of discharge.

1)Medical Staff Rules and Regulations Policy was changed to match the Analysis and Incomplete Medical Records Access System to state records would be completed within 30 days of discharge.
2)The providers and Director of HIM were educated on the policy that all parts of the medical record must be completed within 30 days of discharge.
3) In January's Medical Executive Committee, timely completion of the medical record will be reviewed.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of HIM

How Monitored:
100 % of the medical records are reviewed by the Director of HIM for completeness.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.30(e) EXTENDED STAY REVIEW
The hospital now ensures the Utilization Review Committee make a periodic review for current inpatient receiving hospital services during an extended length of stay.

1. A new Director of Utilization Review was hired in September of 2019.
2.A new agenda for the Utilization Committee meeting was created by the new Director of Utilization Review. The agenda includes a section for current patients receiving hospital services for an extended length of time.
3.Starting in December of 2019, the Utilization Committee meets monthly.
4. The new agenda for the Utilization Committee was reviewed in the December Medical Executive Committee

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Utilization Review

How Monitored:
A copy of the Utilization Committee Meeting Minutes each month is given to the Chief Operating Officer / Director of Performance Improvement/Risk Management for review and tracking.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.30(f) REVIEW OF PROFESSIONAL SERVICES
The hospital now ensures the Utilization Review Committee review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services for current inpatient receiving hospital services during a continuous period of extended duration.

1. A new Director of Utilization Review was hired in September of 2019.
2. A new agenda for the utilization committee meeting was created by the new Director of Utilization Review. The new agenda has a section to review the professional services provided and to determine medical necessity.
3. Starting in December of 2019, the Utilization Committee meets monthly.
Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Utilization Review

How Monitored:
A copy of the Utilization Committee Meeting Minutes each month is given to the Chief Operating Officer / Director of Performance Improvement/Risk Management for review and tracking.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.42(a) INFECTION CONTROL OFFICER(S)CFR(s): The hospital has obtained proof of advanced infection control training by way of certification of course completion
1 The Director of Nursing/ Infection Control Officer has completed additional Training thorough
"Infectioncontroltrainings.com", which includes 4 hours of additional training valid for 2 years.
2) The Director of Nursing / Infection Control Officer has completed APIC"s EPI 101 and 102 courses.
3) The following two requirements of the Infection Control Preventionist were added to the Infection Plan and the Infection Control Officer appointment letter.
1) APIC Membership- The hospital Infection Control Officer must be a member of APIC.
2) Training- The Infection Control Officer must have specific training that pertains to Infection Prevention and Control or must complete EPI 101 and 102 on the APIC website.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Director of Nursing/Infection Control Officer

How Monitored:
Certification Completion through "Infectioncontroltrainings.com" Proof of completion from APIC"s EPI 101 and 102 courses.

482.42(a)(1) INFECTION CONTROL PROGRAM CFR(s): The hospital now ensures the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.
1)The hospital has updated the Management of MDRO and Patient Placement policy to include provider notification to determine the need for isolation precautions which must have a provider order.
2) The eMAR has been updated to prompt the need for isolation precautions for all antibiotic medication orders.
3)Director of Nursing/Infection Prevention and Control Officer and Provider will communicate when isolation precautions have been ordered to allow the formulation of patient-specific isolation plan.
4)All RNs and medical staff have been re-educated about the process when a patient is determined to require isolation precautions.
Person(s) Responsible:
Director of Nursing/ Infection Prevention and Control Officer

How Monitored:
100% of patients who require isolation precautions will have the process audited by the Director of Nursing/Infection Prevention and Control Officer for compliance with isolation protocol.
Results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.12(c)(3) STANDARD CARE OF PATIENTS - MD/DO ON CALL:Not Assigned
[ ...the governing body must ensure that the following requirements are met:]
A doctor of medicine or osteopathy is on duty or on call at all times.

Observations:

Based on review of facility documents and interview with staff (EMP) it was determined the governing body failed to ensure a doctor of medicine or osteopathy was on-call at all times.

Findings include:

Review on November 3, 2019, of facility document "Governing Board Bylaws of Haven Behavioral Health Hospital of Philadelphia," revealed "Article II General Provisions, 1. Hospital Management. The Company, which owns and operates the business of the Hospital, is managed under the direction of the Member thru its officers. The role and purpose of the Hospital is to provide an organization and facility supporting qualified medical professionals in providing quality health care ... The Member has delegated certain rights and duties to the Governing Board, as set forth b these Bylaws ... Article V. Organization of the Medical Staff, The Governing Board shall organize the Physicians and AHPs (Allied Health Professional) who are granted Clinical Privileges and the Hospital ... ."



Review on December 3, 2019, of facility document "Haven Behavioral Hospital of Philadelphia, Medical Staff Rules and Regulations" approved April 20, 2019, revealed "... 11.0, On-Call - There is a physician possessing skills and knowledge in behavioral health and medical services who is on-call to the Hospital on a 24-hour basis to cover assessments, admissions and emergencies ... The Medical Director shall be administratively responsible for maintaining the Hospital's on-call roster ..."


Review on November 3, 2019 of facility's on-call schedule dated December 1, 2018, to December 31, 2019, revealed a nurse practioner provided call or was scheduled to provide call on the following dates: December 21-23, 2018 and December 28-30, 2018; January 25-27, 2019; February 22-24, 2019; March 22-24, 2019 and March 29-31, 2019; April 26-28, 2019; May 24, 2019 to June 2, 2019, 2019; July 19-21, 2019; August 23-25, 2019 and August 30, 2019 to September 1, 2019; September 27-29, 2019; October 25-27, 2019; November 22-24, 2019 and November 29, 2019 to December 1, 2019; December 20-22, 2019."

Interview on December 4, 2019, at 9:50 AM with EMP1 confirmed the Medical Director was responsible for maintaining the the on-call roster. Further interview with EMP1 confirmed a doctor of medicine or osteopathy was not always on-call.

cross reference with:
482.12 Governing Body
482.13(b)(2) Patient Rights: Informed Consent






 Plan of Correction - To be completed: 03/09/2020

482.12(c)(3) CARE OF PATIENTS - MD/DO
ON CALL
The hospital now ensures the on-call schedule reflects that a doctor of medicine or osteopathy is on-call for the facility,24 hours per day,
seven days per week.

1)The Medical Director added a clarification statement to the on-call schedule listing the doctor to call for medical concerns.
2)The Medical Director ensures a psychiatrist is on-call for the hospital, 24 hours per day, seven days per week when the on-call provider is unable to be reached.
3)A doctor of medicine or osteopathy is listed each day on the on-call schedule.
4)Education has been completed to providers for this update process.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
The monthly on-call scheduled is reviewed before it is posted on the unit.
Deficiencies, if any, will be immediately addressed.
How Monitored
The on call scheduled is reviewed prior to posting for the month to ensure there is a doctor of medicine or osteopathy listed on call 24 hours, 7 days a week.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly

482.13 CONDITION PATIENT RIGHTS:Not Assigned
A hospital must protect and promote each patient's rights.

Observations:


This condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:

(482.13(a)(1), Tag-0117)
The documentation reviewed during the survey provided evidence that the facility failed to provide the "Important Message for Medicare on Admission and Discharge.

(482.13(b)(2), Tag-0131)
The documentation reviewed during the survey provided evidence the facility failed to provide written notice of physician coverage 24 hours a day, 7 days a week

(482.13(b)(3), Tag-0132)
The documentation reviewed during the survey provided evidence the facility failed to ensure patients had the right to form Advance Directives

(482.13(b)(4), Tag 0133)
The documentation reviewed during the survey provided evidence the facility failed to ensure, at the request of the patient, family member, patient representative or primary care doctor were notified of admission

(482.13(c)(2), Tag-0144)
The documentation reviewed during the survey provided evidence the facility failed to follow their Occupational Health Policy


Repeat deficency:
Event ID WNWM11 10/11/2018



 Plan of Correction - To be completed: 03/09/2020

482.13(a)(1) PATIENT RIGHTS: NOTICE OF RIGHTS The Hospital now ensures the medical record contains the "Important Message for Medicare" upon admission and discharge.
1) All social services staff were re-educated on the Important Message from Medicare form and procedure completed at discharge on 12/19/2019,
1/10/2020, and 1/12/2020.
2)All nursing staff were re-educated on the Important Message from Medicare form and procedure completed at admission. Training was completed through Health Stream.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Nursing
Director of Social Services

How Monitored:
100% of records are audited at discharge by the Director of Social Services to ensure form was given near discharge.
100% of new admission charts are audit by the Director of nursing to ensure the form was given at the time of admission
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing
Board quarterly.

482.13(b)(2) PATIENT RIGHTS: INFORMED CONSENT The hospital now ensures the on-call schedule reflects that a doctor of medicine or osteopathy is on-call for the facility, 24 hours per day, seven days per week.

1) The Medical Director added a clarification statement to the on-call schedule listing the doctor to call for medical concerns.
2) The Medical Director ensures a psychiatrist is on-call for the hospital, 24 hours per day, seven days per week when the on-call provider is unable to be reached.
3) A doctor of medicine or osteopathy is listed each day on the on-call schedule.
4) Education has been completed with providers on new process.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored
The weekly provider call scheduled will be audited on a weekly basis to ensure there is a doctor of medicine or osteopathy on call 24 hours, 7 days a week.

Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.13(b)(3) PATIENT RIGHTS: INFORMED DECISION The Hospital now ensures the medical record includes the discharge form indicating that the Advanced Directives of the patient were discussed upon discharge.

1) All Social Service staff were re-educated during staff meetings held on 12/19/2019, 1/10/2020, and 1/12/2020 that the Advanced Directives of the patient need to be discussed upon discharge.
2) The hospital has updated the admission packet to include an Advance Directive / Healthcare Proxy Acknowledgment form that will be completed by the admitting staff member.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Social Services
Director of Nursing

How Monitored:
100% of discharge instructions will be audited each month by the Director of Social Services

100% of new admissions will be audited for a completed Advance Directive / Healthcare Proxy Acknowledgment form by the Director of Nursing.

Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly

482.13(b)(4) PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s):
The hospital now ensures the patient is given the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

1) The hospital has updated the admission packet to include a Release of Information form that will be completed by the admitting staff member, and contact will be made, if indicated, at the completion of the Release of Information form.
2) All Nursing Staff have been educated about the addition of the Release of Information form to the admission packet.

Person(s) Responsible:
Director of Nursing
Nursing Supervisor
Nurse Manager

How Monitored:
100% of new admissions will be audited and include the evaluation of the admission packet, which now includes this Release of Information form.
Deficiencies will be addressed by the Nursing Supervisor/Nurse Manager upon completion of the audit. The staff will be re-educated and the form will be completed by the reviewer and contact made if requested upon audit completion.
Results of reviews will be aggregated, analyzed, and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING
The hospital now ensures ensure the approved policy for Occupancy Health is followed.
1) As of December 2019, the policy of Occupational Health has been amended to only include Tuberculosis, Hepatitis B, Hepatitis A when appropriate and seasonal flu vaccination upon hire.
2) 100% of current employee files were audited by the Director of Human Resources for compliance with the Occupational Health policy to ensure the employee has had their TB, and offered Hepatitis B and Hepatitis A.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Director of Nursing

How Monitored:
100% of new hire files will be reviewed by the Director of Human Resources.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee monthly and Governing Board quarterly.

482.13(a)(1) STANDARD PATIENT RIGHTS: NOTICE OF RIGHTS:Not Assigned
A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

Observations:
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the Important Message from Medicare was provided to all patients receiving inpatient care in nine of 14 medical records reviewed (MR4, MR5, MR6, MR8, MR10, MR11, MR13, MR14, MR15).

Findings include:

Review on December 4, 2019, of facility policy "Medicare Admission Documents," approved May 20, 2018, revealed, " ... This form is to be completed twice, once at admission and again prior to discharge. At admission, it must be completed within 24 hours of the admission ... Second completion should occur 48 hours prior to discharge, but at least 4 hours prior to discharge ... ".

Review on December 5, 2019, of MR4 revealed the patient was admitted to the facility of March 16, 2019, and discharged on March 27, 2019. Further review of MR4 revealed no documentation the Important Message from Medicare was given to the patient at the time of admission.

Review of December 5, 2019, of MR5 revealed the patient awas admitted to the facility on October 28, 2019, and discharged on November 4, 2019. Further review of MR5 revealed no documentation the Important Message from Medicare was given to the patient at the time of discharge.

Review of December 5, 2019, of MR6 revealed the patient was admitted to the facility on October 24, 2019, and discharged on November 11, 2019. Further review of MR6 revealed no documentation the Important Message from Medicare was given at the time of admission.

Review of December 5, 2019, of MR8 revealed the patient was admitted t o the facility on October 4, 2019, and discharged on November 15, 2019. Further review of MR8 revealed no documentation the Important Message from Medicare was given at the time of admission or discharge.

Review on December 5, 2019, of MR10 revealed the patient was admitted to the facility on October 21, 2019, and discharged on October 29, 2019. Further review of MR10 revealed no documentation the Important Message from Medicare was given at the time of admission.

Review of December 5, 2019, of MR11 revealed the patient was admitted to the facility on October 18, 2019, and discharged on October 24, 2019. Further review of MR11 revealed no documentation the Important Message to Medicare was given at the time of admission or discharge.

Review on December 6, 2019, of MR13 revealed the patient was admitted to the facility on October 21, 2019, and discharged on November 6, 2019. Further review of MR13 revealed no documentation the Important Message from Medicare was given at the time of admission or at the time of discharge.

Review on December 6, 2019, of MR14 revealed the patient was admitted to the facility on November 19, 2019, and discharged on November 23, 2019. Further review of MR14 revealed no documentation the Important Message from Medicare was given at the time of admission.

Review on December 6, 2019, of MR15 revealed the patient was admitted to the facility on October 24, 2019, and discharged on November 11, 2019. Further review of MR15 revealed no documentation the Important Message from Medicare was given at the time of admission.

Interview with EMP4 on December 6, 2019 at 2:00 PM Interview with EMP3 on December 6, 2019, at 11:30 AM confirmed the Important Message from Medicare was not documented as indicated in the above medical records.

cross reference with:
482.12 Governing Body
482.13 Patient Rights









 Plan of Correction - To be completed: 03/09/2020

482.13(a)(1) PATIENT RIGHTS: NOTICE OF RIGHTS The Hospital now ensures the medical record contains the "Important Message for Medicare" upon admission and discharge.

1)All social services staff were re-educated on the Important Message from Medicare form and procedure completed at discharge on 12/19/2019,
1/10/2020, and 1/12/2020.
2)All nursing staff were re-educated on the Important Message from Medicare form and procedure completed at admission. Training was completed through Health Stream.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Nursing
Director of Social Services

How Monitored:
100% of records are checked at discharge by the Director of Social Services to ensure form was given near discharge.
100% of new admission charts are audit by the Director of nursing to ensure the form was given at the time of admission
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.
482.13(b)(2) STANDARD PATIENT RIGHTS: INFORMED CONSENT:Not Assigned
The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care.

The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.

Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP) it was determined the facility failed to provide written notice to patients that a doctor of medicine or osteopathy were not present in the facility or on-call for the facility, 24 hours per day, seven days per week for 53 of 53 medical records reviewed. (MR1 thru MR53)

Finding s include:

Review on December 3, 2019, of facility document "Haven Behavioral Hospital of Philadelphia, Medical Staff rules and Regulations" approved April 20, 2019, revealed "... 11.0, On-Call - There is a physician possessing skills and knowledge in behavioral health and medical services who is on-call to the Hospital on a 24-hour basis to cover assessments, admissions and emergencies ... The Medical Director shall be administratively responsible for maintaining the Hospital's on-call roster ..."

Review on December 3, 2019, of facility document "Condition of Admission-Inpatient" revised July 2019, revealed no written notification a physician provider would not be present at the facility or on-call 24-hours per day, 7 days a week.

Review on December 6, 2019, of CF9 revealed they were a nurse practioner with a current license to practice.

Review on December 3, 2019, of the on-call calendar dated December 2018 to December 2019 revealed CF9 provided on-call services for the following days: December 21-23, 2018 and December 28-30, 2018; January 25-27, 2019; February 22-24, 2019; March 22-24, 2019 and March 29-31, 2019; April 26-28, 2019; May 24, 2019 to June 2, 2019, 2019; July 19-21, 2019; August 23-25, 2019 and August 30, 2019 to September 1, 2019; September 27-29, 2019; October 25-27, 2019; November 22-24, 2019 and November 29, 2019 to December 1, 2019; December 20-22, 2019.

Interview on December 4, 2019, at 9:50 AM with EMP1 confirmed CF9 was not a physician and provided on-call coverage for the facility.


cross reference with:
482.12 Governing Body
482.13 Patient Rights





 Plan of Correction - To be completed: 03/09/2020

482.13(b)(2) PATIENT RIGHTS: INFORMED CONSENT The hospital now ensures the on-call schedule reflects that a doctor of medicine or osteopathy is on-call for the facility, 24 hours per day, seven days per week.

1) The Medical Director added a clarification statement to the on-call schedule listing the doctor to call for medical concerns.
2) The Medical Director ensures a psychiatrist is on-call for the hospital, 24 hours per day, seven days per week when the on-call provider is unable to be reached.
3) A doctor of medicine or osteopathy is listed each day on the on-call schedule.
4) Education has been completed with providers on new process.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored
The weekly provider call scheduled will be audited on a weekly basis to ensure there is a doctor of medicine or osteopathy on call 24 hours, 7 days a week.

Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.13(b)(3) STANDARD PATIENT RIGHTS: INFORMED DECISION:Not Assigned
The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with 489.100 of this part (Definition), 489.102 of this part (Requirements for providers), and 489.104 of this part (Effective dates).

Observations:
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the right to formulate advance directives in three of 14 medical records reviewed. (MR7, MR10, MR15).

Findings include:

Review on December 5, 2019, of facility policy "Advanced Directives," approved February 20, 2019, revealed, " ... Admitting staff will complete the Advance Directives to determine if a patient has executed an Advance Directive and/or desires information related to the process of formulate an Advance Directive. If the patient/legal representative reports and Advance Directive has been formulated the staff will request a copy of the document be provided for verification purposes and to have available in the medical record. If the referring facility has an Advance Directive document they will be requested to provide it if a copy has not accompanied the patient on transfer. If the patient does not have an Advanced Directive, or desires additional information, they will be provided information upon admission. The patient/legal representative shall be requested to sign the Advance Directive form to acknowledge receipt of information regarding Advance Directive."

Review on December 5, 2019, of facility's medical record document that included "Social Services: Emergency/Crisis Planning & Risk Factors" revealed Advance Directives was to be documented by staff with a check mark at one of the following:
"Patient has an Advance Directive (transmit with transition record)
Patient has a health care surrogate (MHPOA, Guardian etc).
Patient is unable to name a surrogate decision maker or provide an advance care plan
Patient refused an advance care plan
Patient has a cultural and/or spiritual believes which preclude a discussion of advance care planning."

Review on December 5, 2019, of MR7 revealed no documentation in the "Social Services: Emergency/Crisis Planning & Risk Factors" for Advance Directives.

Review on December 5, 2019, of MR10 revealed no documentation in the "Social Services: Emergency/Crisis Planning & Risk Factors" for Advance Directives.

Review on December 5, 2019, of MR15 revealed no documentation in the "Social Services: Emergency/Crisis Planning & Risk Factors" for Advance Directives.

Interview with EMP4 on December 5, 2019, at 2:00 PM confirmed the above findings in MR7, MR10, MR15.

cross reference with:
482.12 Governing Body
482.13 Patient Rights




 Plan of Correction - To be completed: 03/09/2020

482.13(b)(3) PATIENT RIGHTS: INFORMED DECISION
The Hospital now ensures the medical record includes the discharge form indicating that the Advanced Directives of the patient were discussed upon discharge.
1) All Social Service staff were re-educated during staff meetings held on 12/19/2019, 1/10/2020, and 1/12/2020 that the Advanced Directives of the patient need to be discussed upon discharge.

2) The hospital has updated the admission packet to include an Advance Directive / Healthcare Proxy Acknowledgment form that will be completed by the admitting staff member.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Social Services
Director of Nursing

How Monitored:
100% of discharge instructions will be audited for advanced directives by the Director of Social Services.
100% of new admissions will be audited for a completed Advance Directive / Healthcare Proxy Acknowledgment form by the Director of Nursing.

Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly

482.13(b)(4) STANDARD PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION:Not Assigned
The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

Observations:
Based on review of facility policy and procedure, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the patient was given the right ot have family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital in five of 14 medical records reviewed (MR6, MR7, MR9, MR13, MR15).

Findings include:

Review on December 5, 2019, of facility policy "Notification of a Family member or Representative," approved February 2019 revealed, " ... The facility will obtain a release of information from the patient upon admission in order to notify the patient's family member or representative and the patient's physician. If the patient states he/she does not want the family member, representative, and/or personal physician notified, the staff member will document this refusal in the chart."

Review on December 5, 2019, of MR6 revealed the patient was admitted to the facility on October 24, 2019. Further review of MR6 revealed no documentation the patient was given the right to have a family member or representative of his or her choice and his or her own physcian notified promptly of his or her admission to the hospital.

Review on December 5, 2019, of MR7 revealed the patient was admitted to the facility on November 22, 2019. Further review of MR7 revealed no documentation the patient was given the right to have a family member or representative of his or her choice notified promptly of their admission to the facility. Continued review of MR7 revealed the physician notification of admission was documented as "pending prior to discharge ... Pt signed ROI (Release of Information)."

Review on December 5, 2019, of MR9 revealed the patient was admitted to the facility on November 15, 2019. Further review of MR9 revealed no documentation the patient was given the right to have a family member or representative of his or her choice or his or her own physician notified promptly of their admission.

Review on December 5, 2019, of MR13 revealed the patient was admitted to the facility on October 21, 2019. Further review of MR14 revealed no documentation the patient was given the right to have his or her own physician notified promptly of their admission.

Review on December 5, 2019, of MR15 revealed the patient was admitted to the facility on October 24, 2019. Further review of MR15 revealed no documentation the patient was given the right to have a family member or representative of his or her choice or his or her own physician notified promptly of their admission.

Interview with EMP4 on December 5, 2019, at 1:30 PM confirmed the "Release of Information" provided to the patient at admission for signature was to send information to the patient's family or representative and the patient's physician at the time of discharge.

Continued interview with EMP4 on December 5, 2019 at 1:30 PM and interview with EMP3 on December 6, 2019, at 11:30 AM confirmed there was no documentation if the patient was given the right to have a family member of representative of his or her choice and/or his or her own physician notified promptly of their admission to the hospital in the above medical records.

cross reference with:
482.12 Governing Body
482.13 Patient Rights





 Plan of Correction - To be completed: 03/09/2020

482.13(b)(4) PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s):
The hospital now ensures the patient is given the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

1) The hospital has updated the admission packet to include a Release of Information form that will be completed by the admitting staff member, and contact will be made, if indicated, at the completion of the Release of Information form.
2) All Nursing Staff have been educated about the addition of the Release of Information form to the admission packet.

Person(s) Responsible:
Director of Nursing
Nursing Supervisor
Nurse Manager

How Monitored:
100% of new admissions will be audited and include the evaluation of the admission packet, which now includes this Release of Information form.
Deficiencies will be addressed by the Nursing Supervisor/Nurse Manager upon completion of the audit. The staff will be re-educated and the form will be completed by the reviewer and contact made if requested upon audit completion.
Results of reviews will be aggregated, analyzed, and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.13(c)(2) STANDARD PATIENT RIGHTS: CARE IN SAFE SETTING:Not Assigned
The patient has the right to receive care in a safe setting.
Observations:

Based on review of facility policy and procedures, review of facility documents, review of personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure their approved policy for Occupancy Health was followed in eight of eight personnel files reviewed for facility health requirements (PF1, PF2, PF3, PF4, PF5, PF6, PF7, PF8).

Findings include:

Review on December 3, 2019, of facility policy and procedures, "Occupancy Health," approved January 2019 revealed, "The primary functions of occupational health for Haven Behavioral Health hospitals are: 1. The health assessment of employees on hire regarding TB status and eligibility for seasonal influenza vaccine ... 2. Establishing the immunity status of employees for MMR, varicella, TDAP, Hepatitis B. Titers or proof of vaccination will be provided for newly hired employees. If an employee chooses to decline a vaccination then document and place in confidential medical personnel file. Federal law requires Hepatitis B vaccination to be offered to all employees providing direct care ... ".

Review on December 3, 2019, of facility document "Employee Tuberculosis Screening," revealed, "Federal law requires ALL EMPLOYEES to have a current 2-Step Tuberculosis Screening upon hire. Further review of the facility document revealed the employee was given the choice to check off one of the following for "Consent":

"- I am a new employee. I consent to receive the PPD Tuberculosis screening.
- I am a new employee. I have a negative chest Xray or negative PPD which will be less than one year old on my first scheduled working day. I will forward these results before my first scheduled working day.-
- I consent to the receive the two-step PPD Tuberculosis Screening.
- I have a history of PPD's and need a chest x-ray for screening."

Review on December 3, 2019, of PF1 revealed the date of hire was October 14, 2019. Further review of the "Employee Tuberculosis Screening" revealed no documentation of PPD#1 of PPD#2 on hire. Further review of PF1 revealed no documentation or delineation of Hepatitis B, TDAP, Varicella or MMR titers or proof of vaccination.

Review on December 3, 2019, of PF2 revealed the date of hire was September 16, 2019. Further review of PF2 revealed no documentation of a 2 Step Tuberculosis Screening on hire.

Review on December 3, 2019, of PF3 revealed the date of hire was October 14, 2019. Further review of PF2 revealed no documentation of PPD#2 on hire, no documentation or declination Hepatitis B, influenza, TDAP, or Varicella titers or proof of vaccination.

Review on December 3, 2019, of PF4 revealed the date of hire of was December 10, 2018. Further review of PF4 revealed no documentation of a two-step Tuberculosis Screening on hire. Further review of PF4 revealed no documentation or declination of influenza, MMR or Varicella titers or proof of vaccination.

Review of December 3, 2019, of PF5 revealed the date of hire was December 4, 2018. Further review of PF5 revealed no documentation of PPD#2 on hire. Further review of PF5 revealed no documentation or declination of MMR, TDAP or Varicella titers or proof of vaccination.

Review on December 3, 2019, of PF6 revealed the date of hire was October 28, 2019. Further review of PF6 revealed no documentation of PPD#2 Tuberculosis Screening on hire. Further review of PF6 revealed no documentation or declination of MMR TDAP, or Varicella titers or proof of vaccination.

Review on December 3, 2019, of PF7 revealed the date of hire was December 14, 2018. Further review of PF7 revealed no documentation or declination of Hepatitis B, TDAP, Varicella or MMR titers or proof of vaccination.

Review of December 3, 2019, of PF8 revealed the date of hire was October 14, 2019. Further review of PF8 revealed no documentation of PPD#2 on hire and no documentation or declination of Hepatitis B, MMR, Varicella or TDAP titers or vaccination.

Interview on December 4, 2019, with EMP3 at 1:15 PM confirmed the above findings for direct care staff in PF1 through PF8.

cross reference with:
482.12 Governing Body
482.13 Patient Rights
482.42(a) Infection Control Officer

Repeat deficency:
Event ID WNWM11 10/11/2018







 Plan of Correction - To be completed: 03/09/2020

482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING
The hospital now ensures ensure the approved policy for Occupancy Health is followed.
1) As of December 2019, the policy of Occupational Health has been amended to only include Tuberculosis, Hepatitis B, Hepatitis A when appropriate and seasonal flu vaccination upon hire.
2) 100% of current employee files were audited by the Director of Human Resources for compliance with the Occupational Health policy to ensure the employee has had their TB, and offered Hepatitis B and Hepatitis A.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Director of Nursing

How Monitored:
100% of new hire files will be reviewed by the Director of Human Resources for appropriate vaccinations.

Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee monthly and Governing Board quarterly.

482.21(a), (b)(1),(b)(2)(i), (b)(3) STANDARD DATA COLLECTION & ANALYSIS:Not Assigned
(a) Program Scope
(1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ...
(2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations.

(b)Program Data
(1) The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization.
(2) The hospital must use the data collected to--
(i) Monitor the effectiveness and safety of services and quality of care; and ....
(3) The frequency and detail of data collection must be specified by the hospital's governing body.





Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to develop distinct performance improvement projects that reflect the scope and complexity of services and operations at the facility (dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services).
Findings include:
A request was made on December 5, 2019, at approximately 10:30 AM for a list of performance improvement projects for dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, nursing services and ambulance services. None provided.
Interview on December 5, 2019, at approximately 12:30 PM with EMP2 confirmed the hospital does not conduct distinct performance projects for dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, nursing services and ambulance services.

cross reference with:
482.12 Governing Body
482.21 Qapi Governing Body, standard tag

Repeat deficency:
Event ID WNWM11 10/11/2018




 Plan of Correction - To be completed: 03/09/2020

482.21(a), (b)(1),(b)(2)(i), (b)(3) DATA COLLECTION & ANALYSIS
The hospital now ensures distinct performance improvement projects that reflect the scope and complexity of services and operations at the facility (dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events, and ambulance services).

1) A matrix was created listing the distinct performance improvement projects for services and operations at the facility nursing, social service, dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services.
2)The matrix of projects including the method, frequency, and type of data, was approved at the January Quality Council meeting.
3) The projects will be submitted at the January Medical Executive Committee.

Person(s) Responsible:
Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each department will report updates at monthly Quality Council.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.21 STANDARD QAPI GOVERNING BODY, STANDARD TAG:Not Assigned
... The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

Observations:
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) monitoring was performed that reflected the scope of services provided at the facility.

Findings include:

Review on December 5, 2019, of facility document "Haven Behavioral Hospital of Philadelphia Performance Improvement Plan" approved September 2019, revealed "Responsibility- The Governing Board has the ultimate authority and responsibility for adopting an organization-wide plan to assess and improve the quality of care provided ..."

On December 5, 2019, at approximately 10:00 AM a request was made to EMP2 for a list of Quality Assessment and Performance Improvement (PI) projects approved by the Governing Board that provided information for the reason PI projects were selected, the scope, frequency and method of data collection, and analysis of collected data. None provided.

Interview on December 5, 2019, at approximately 11:50 AM with EMP2 confirmed there was no documentation Performance Improvement projects were selected and approved by the Governing Board to assess and improve the quality of care at the facility.


cross reference with:
482.12 Governing Body
(482.21(a),(b)(1),(b)(2)(i),(b)(3) Data Collection and Anlaysis






 Plan of Correction - To be completed: 03/09/2020

482.21 QAPI GOVERNING BODY, STANDARD
The hospital now ensures the Quality Assessment and Performance Improvement (QAPI) monitoring is performed to reflect the scope of services provided at the facility.

1)A matrix was created listing the distinct performance improvement projects for services and operations at the facility nursing, social service, dietary, radiology, laboratory, medical records, pharmacy, infection control, adverse drug events and ambulance services.
2)The matrix of projects, including the method, frequency, and type of data, was approved at the January Quality Council meeting.
3)The projects will be submitted at the January Medical Executive Committee.
4)The projects will be submitted at the 1st quarter Governing Board meeting.
Person(s) Responsible:
Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each department will report updates at monthly Quality Council.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.23(a) STANDARD ORGANIZATION OF NURSING SERVICES:Not Assigned
The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.

Observations:

Based on review of facility documents and staff interview (EMP) it was determined the facility failed to ensure the Director of Nursing was qualified to manage and direct nursing services at the facility. (PF21)

Findings include:

Review on December 4, 2019, of facility document "Haven Behavioral Healthcare, Job Description, Director of Nursing," reviewed May 2017, revealed "... Qualifications: Education- Bachelor's Degree in Nursing from an accredited program. Master's preferred ..."

Review on December 4, 2019, of PF21 documentation revealed "Education Reference: Completed October 10, 2019," revealed "Major-Nursing, Level attained- Associates in Applied Sciences ..."

Interview on December 4, 2019, at 2:00 PM with EMP1 confirmed the employee in CF21 was recently hired in October 2019 and confirmed CF21 did not possess the educational requirements for the Director of Nursing position.

cross reference with:
482.12 Governing Body





 Plan of Correction - To be completed: 03/09/2020

482.23(a) ORGANIZATION OF NURSING SERVICES
The hospital now ensures the Director of Nursing is qualified to manage and direct nursing services at the facility.
1)As of 12/4/2019, the Director of Nursing Job Description was amended to include an associate's degree in Nursing with mentorship from a Master's prepared RN along with commiserate experience.
2)The Associate Vice President of Nursing, a Master's prepared RN, provides mentorship and supervision to the Director of Nursing.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Associate Vice President of Nursing

How Monitored:
Notes of the supervision between the Director of Nursing the Associate Vice President of Nursing, are maintained every month and kept in a file by Human Resources.
Deficiencies, if any, will be immediately addressed.

482.23(c)(1), (c)(1)(i) & (c)(2) STANDARD ADMINISTRATION OF DRUGS:Not Assigned
(1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under 482.12(c), and accepted standards of practice.

(i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under 482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

(2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.
Observations:
Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their own policy to administer scheduled drugs and biologicals according to the medication orders of a practioner for one of one medical record reviewed (MR54).

Findings include:

Review on December 5, 2019 of facility policy, " Medication, Standard Administration Times," revised October, 2019, revealed, "... Definitions: ... C. "Scheduled" medication orders ... Medications such as Insulin, ... must be administered within 30 minutes of scheduled time (1/2 hour before to 1/2 hour after the scheduled time) ... ."

Review of MR54 revealed a physician order for Insulin Lispro on December 5, 2019 scheduled to be administered at 8:00 AM. Further review of MR54 revealed Insulin Lispro was administered on December 5, 2019 at 8:45 AM.

Interview on December 5, 2019 at 1 PM with EMP3 confirmed facility failed to follow their own policy for scheduled administration of Insulin Lispro to patient related to MR54.

cross reference with:
0386 482.23(b)(2) Organization of Nursing Services








 Plan of Correction - To be completed: 03/09/2020

482.23(c)(1), (c)(1)(if) & (c)(2)ADMINISTRATION OF DRUGS
The hospital ensures drugs and biologicals must be prepared and administered in accordance with Federal and State laws.

1)The hospital has updated the "Medication Standard Administration Times" policy.
2) eMAR has been adjusted to reflect the appropriate time frames per updated "Medication Standard Administration Times" policy.
3) All MD/CRNP/ RN/LPN have been re-educated on this policy.
4) A laminated copy of the Medication Standard Administration Times policy was posted in the medication room

Person(s) Responsible:
Director of Nursing
Director of Pharmacy

How Monitored:
Director of Pharmacy monitors 100% of medication administered outside of the scheduled time frame and alerts the Director of Nursing. The Director of Nursing will then instruct the Nurse Manager to provide re-education to the staff member who was non-compliant with the policy.
Results of reviews will be aggregated, analyzed, and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.24(b) STANDARD FORM AND RETENTION OF RECORDS:Not Assigned
The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

Observations:

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to properly store medical records from fire, water damage and other threats.

Findings include:

Review on December 4, 2019, of facility policy "Confidentiality and Security of Medical Records," approved December 2019, revealed "... Record Security: In the event of a fire-assigned staff will immediately go to the medical records storage area with a fire extinguisher ... Medical records is [sic] protected by a fully operational sprinkler system ... In the event of probable water damage, if there is time, staff will remove charts on the lower shelves moving them to higher level for safety ..."

Observation on December 4, 2019, at 10:45 AM of the medical record storage area revealed a locked room that contained 7- 12 ft. long x 8 ft. high, open-metal shelves and ceiling mounted fire suppression sprinklers. Further observation revealed the open metal shelving contained paper medical records for patients that received treatment at the facility for the prior 24 months.

Interview on December 4, 2019, at 11:00 AM with EMP5 confirmed the metal shelving did not provide protection for stored medical records in the event the fire suppression sprinklers were activated.



 Plan of Correction - To be completed: 03/09/2020

482.24(b) FORM AND RETENTION OF RECORDS
The hospital ensures medical records are properly stored from fire, water damage, and other threats.

1)The hospital is replacing the current medical record shelving units with enclosed shelving units which will protect the records from fire and water damage.

Person(s) Responsible:

Chief Executive Officer
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
New medical record storage units will be installed.

482.24(c)(4)(viii) STANDARD CONTENT OF RECORD: FINAL DIAGNOSIS:Not Assigned
[All records must document the following, as appropriate:]

Final diagnosis with completion of medical records within 30 days following discharge
Observations:
Based on review of facility documents and staff interview (EMP) it was determined the facility failed to ensure medical records were completed within 30 days of discharge for 33 of 33 medical records reviewed. (MR19 thru MR53)

Findings include:


Review on December 4, 2019, of facility policy "Deficiencies and Delinquencies," approved November 2019, revealed "Purpose: to clearly define deficiency, delinquency and a complete medical record ... Definition of Delinquency-A medical record is considered delinquent when 1 or more required elements have not been competed and in the medical record within established timeframes ... It is required medical records be closed no later than 30 days after discharge ..."


Review on December 4, 2019, of facility document "Haven Behavioral Hospital of Philadelphia, Medical Staff Rules and Regulations," approved April 2019, revealed
"... 7.14 Completion of Medical Records - all discharge summaries and other medical record documentation shall be completed within (15) days following the patient ' s discharge. Incomplete records exceeding (15) fifteen days following discharge will be considered delinquent ..."

A request was made on December 4, 2019, at 10:50 AM for the Medical Records Committee Meeting Minutes. None provided.

Review on December 6, 2019 of facility delinquent medical records as of December 6, 2019, revealed:

20 Medical records were 31-59 days delinquent
12 Medical records were 60-89 days delinquent
1 Medical record were 90-119 days delinquent

Interview with EMP5 on December 4, 2019, at approximately 11:05 AM, confirmed the above listed delinquent medical records.
cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects





 Plan of Correction - To be completed: 03/09/2020

482.24(c)(4)(viii) CONTENT OF RECORD: FINAL DIAGNOSIS
The hospital now ensures medical records are completed within 30 days of discharge.

1)Medical Staff Rules and Regulations Policy was changed to match the Analysis and Incomplete Medical Records Access System to state records would be completed within 30 days of discharge.
2)The providers and Director of HIM were educated on the policy that all parts of the medical record must be completed within 30 days of discharge.
3) In January's Medical Executive Committee, timely completion of the medical record will be reviewed.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of HIM

How Monitored:
100 % of the medical records are reviewed by the Director of HIM for completeness.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.30(e) STANDARD EXTENDED STAY REVIEW:Not Assigned
(1) In hospitals that are not paid under the prospective payment system, the UR committee must make a periodic review, as specified in the UR plan, or each current inpatient receiving hospital services during a continuous period of extended duration.

The scheduling of the periodic reviews may --
(i) Be the same for all cases; or
(ii) Differ for different classes of cases.

(2) In hospitals paid under the prospective payment system, the UR committee must review all cases reasonably assumed by the hospital to be outlier cases because the extended length of stay exceeds the threshold criteria for the diagnosis, as described in 412.80(a)(1)(i). The hospital is not required to review an extended stay that does not exceed the outlier threshold for the diagnosis.

(3) The UR committee must make the periodic review no later than 7 days after the day required in the UR plan.

Observations:

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to have Utilization Review Committee make a periodic review for current inpatient receiving hospital services during a continuous period of extended duration.

Findings include:

Review on December 4, 2019 of facility's, "Utilization Review Committee Minutes," dated 12/20/18, 2/12/19, 3/13/19, 6/28/19 and 7/17/19 , revealed, "... no documented evidence of review of current inpatient receiving hospital services during a continuous period of extended duration.

Review on December 4, 2019 of facility's, "Utilization Management Plan," revised June 2016, revealed, no specification for periodic review of extended stay inpatient cases.

Request was made on December 4, 2019 to EMP6 for documented evidence that the Utilization Review Committee periodically reviewed extended stay cases. None provided.

Interview with EMP6 on December 5, 2019 between 10:11 AM and 10:21 AM confirmed facility failed to have the Utilization Review Committee make a periodic review for current inpatient receiving hospital services during a continuous period of extended duration. Further confirmed the Utilization Management Plan does not specify periodic review of extended stay inpatient cases.

cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects
482.21 Qapi Governing Body, standard tag








 Plan of Correction - To be completed: 03/09/2020

482.30(e) EXTENDED STAY REVIEW
The hospital now ensures the Utilization Review Committee make a periodic review for current inpatient receiving hospital services during an extended length of stay.

1. A new Director of Utilization Review was hired in September of 2019.
2.A new agenda for the Utilization Committee meeting was created by the new Director of Utilization Review. The agenda includes a section for current patients receiving hospital services for an extended length of time.
3.Starting in December of 2019, the Utilization Committee meets monthly.
4. The new agenda for the Utilization Committee was reviewed in the December Medical Executive Committee

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Utilization Review

How Monitored:
A copy of the Utilization Committee Meeting Minutes each month is given to the Chief Operating Officer / Director of Performance Improvement/Risk Management for review and tracking.
Deficiencies, if any, will be immediately addressed and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.30(f) STANDARD REVIEW OF PROFESSIONAL SERVICES:Not Assigned
The committee must review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services.
Observations:

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to have UR (Utilization Review) committee review professional services provided, to determine medical necessity and to promote the most efficient use of available services.

Findings include:

Review on December 4, 2019 of facility's, " Plan for Service," revised May 2017, revealed, "... Description of Clinical Services ... Consultation and Referrals, Dental Services, Diagnostic Testing and Procedures, Dietary Services, Emergency Services, Medical Services Nursing Services, Pharmacotherapy, Physical/Occupational Therapy, Psychological Services, Social Services and Speech, Language, Hearing ... ."

Review on December 4, 2019 of facility's, "Utilization Management Plan," revised June 2016, revealed, " ... The purposes of the Utilization Management Plan are: 1. To assure appropriate utilization of all services provided by the hospital ... Scope of Service The Utilization Management Department and Utilization Review Committee evaluate and monitor services to patients provided by medical and other professional staff ... ."

Request was made on December 4, 2019 to EMP6 for documented evidence that the Utilization Review Committee reviewed professional services provided, to determine medical necessity and to promote the most efficient use of available services. None provided.

Interview with EMP6 on December 5, 2019 between 10:11 AM and 10:21 AM confirmed facility failed to have the Utilization Review Committee review professional services provided, to determine medical necessity and to promote the most efficient use of available services.

cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects
482.21 Qapi Governing Body, standard tag
0657 482.30(e) Extended Stay Review







 Plan of Correction - To be completed: 03/09/2020

482.30(f) REVIEW OF PROFESSIONAL SERVICES
The hospital now ensures the Utilization Review Committee review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services for current inpatient receiving hospital services during a continuous period of extended duration.

1. A new Director of Utilization Review was hired in September of 2019.
2. A new agenda for the utilization committee meeting was created by the new Director of Utilization Review. The new agenda has a section to review the professional services provided and to determine medical necessity.
3. Starting in December of 2019, the Utilization Committee meets monthly.
Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Utilization Review

How Monitored:
A copy of the Utilization Committee Meeting Minutes each month is given to the Chief Operating Officer / Director of Performance Improvement/Risk Management for review and tracking.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

482.41 CONDITION PHYSICAL ENVIRONMENT:Not Assigned
The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.
Observations:


The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on November 07, 2019. Further details are outlined in that Division of Life Safety Survey Report.




 Plan of Correction - To be completed: 03/09/2020

482.41 PHYSICAL ENVIRONMENT
The hospital now ensures the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community


482.15(c)(2) Emergency Officials Contact Information
The hospital now ensures there is the contact information included in the Emergency Preparedness Plan for the State Licensing and Certification Agency and the Office of the State Long-Term Care Ombudsman.

1) Personal contract information for the State Licensing and Certification Agency and the Office of the State Long-Term Care Ombudsman were added to the Emergency Preparedness plan.

Person(s) Responsible:

Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each year the plan is reviewed and updated if needed.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

482.15(c)(7) Information on Occupancy/Needs The hospital now ensures communication plan that includes a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting the entire facility.

1.The plan was updated, listing the facility's limited occupancy and the ability to provide assistance in medical emergencies.
Person(s) Responsible:

Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each year the plan is reviewed and updated if needed.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

482.15(d)(1) EP Training Program The hospital now ensures an emergency preparedness training program for staff and individuals providing services to the facility, including volunteers.

1) Instruction on how volunteers, if there were any, would be trained for emergency preparedness was added to the EOP.

Person(s) Responsible:
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Each year the plan is reviewed and updated if needed.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

NFPA 101 General Requirements
The hospital ensures accurate floor plans outlining designated rated partition.

1) The stenciled rating on one wall was changed to accurately reflect the rating of the wall.

Person(s) Responsible:

Chief Operating Officer / Director of Performance Improvement/Risk Management
Building Owner

How Monitored:
Each year a Haven staff with the building staff will review the rating of the wall in the area Haven rents.

NFPA 101 Vertical Openings - Enclosure
The hospital now ensures vertical openings between floors maintained a fire-resistance rating.
1) During the survey, the surveyor educated the building maintenance supervisor on the standard.
2) The building owner sealed the penetration following the manufacture's instruction for the product used.

Person(s) Responsible:
Building Owner
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
The corrected item was inspected by Chief Operating Officer / Director of Performance Improvement/Risk Management Once a quarter a Haven staff member will tour the building with the building maintenance supervisor to confirm his report of no issues.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

Hazardous Areas - Enclosure
The hospital now ensures enclosure hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9.

1) During the survey, the surveyor educated the building maintenance supervisor on the standard.
2) The building owner corrected the issue by installing a new spring closure on the panel door.
3) The penetration in the wall was sealed by following the manufacture's instruction for the product used in the one hour wall.

Person(s) Responsible:
Building Owner
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
The corrected item was inspected by Chief Operating Officer / Director of Performance Improvement/Risk Management Once a quarter a Haven staff member will tour the building with the building maintenance supervisor to confirm his report of no issues.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

Fire Alarm - Control Functions The hospital ensure the fire alarm control functions were maintained for the four elevators.

1) The building owner contacted the vendor and was informed the elevators will only recall when the smoke detectors in the elevator lobby's are activated. The vendor provided a copy of an excerpt from NFPA72 (2013 edition) regarding the Elevator Capture/Recall requirements. 21.3.3 Unless otherwise required by the authority having jurisdiction, only the elevator lobby, elevator hoistway, and elevator machine room smoke detectors, or other automatic fire detection as permitted by 21.3.9, shall be used to recall elevators for fire fighters' service. During the survey, the alarm system was activated using a pull station.

Person(s) Responsible:
Building Owner
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
Once a month Haven receives a report from the maintenance supervisor confirming the testing of the four cars.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

Sprinkler System - Maintenance and Testing The hospital ensures the spare sprinklers and wrench are stored in a sprinkler cabinet.

1) During the survey, the surveyor educated the building maintenance supervisor on the standard.
2) The building owner installed a cabinet to store the spare sprinklers and wrench.

Person(s) Responsible:
Building Owner
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
The corrected item was inspected by Chief Operating Officer / Director of Performance Improvement/Risk Management Once a quarter a Haven staff member will tour the building with the building maintenance supervisor to confirm his report of no issues.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

Fire Drills
The hospital now ensures a system to provide documentation that fire drills had been conducted.
1) Starting in January 2020 a copy of the reviewed drill report is kept in a file in addition to the fire drill binder.
2) A copy of the form is part of the EOC minutes.

Person Responsible
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
The form is shared monthly at the Environment of Care committee meeting.
Deficiencies, if any, will be immediately addressed. The plan is monitored monthly through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee monthly and Governing Board quietly.

Electrical Systems - Other The hospital ensures electrical systems requirements.

1) During the survey, the surveyor educated the building maintenance supervisor on the standard.
2) The building owner installed protective blanks in the following locations: Substation Falls 4, Panel DEP-4; 2nd floor Falls 4, Panel EGAS-2;2nd floor Falls 4, Panel EEAS-2.
3) The building owner installed junction box covers on the junction boxes in the following locations: Substation Falls 4; Falls 2 main switchgear room, above panels.

Person(s) Responsible:
Building Owner
Chief Operating Officer / Director of Performance Improvement/Risk Management

How Monitored:
The corrected item was inspected by Chief Operating Officer / Director of Performance Improvement/Risk Management Once a quarter a Haven staff member will tour the building with the building maintenance supervisor to confirm his report of no issues.
Deficiencies, if any, will be immediately addressed. The plan is monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board.

482.42(a) STANDARD INFECTION CONTROL OFFICER(S):Not Assigned
A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.


Observations:

Based on review of facility documents and interview with staff it was determined the facility failed to ensure the employee designated as the infection control officer was qualified, through specialized training or certification. (PF21)

Findings include:

Review on December 4, 2019, of facility document "Haven Behavioral Health Infection Prevention and Control Plan, 2019" revealed no documentation for educational requirements or specialized certification for the designated infection control officer.

Review on December 4, 2019, of facility document "Infection Prevention and Control Officer Appointment Letter" approved April 2019, revealed no documentation specialized training or certification were required to carry out the responsibilities of the Infection Control Officer.

Review on December 4, 2019, of PF21 revealed no documentation the employee possessed any specialized training or certification to oversee the infection control program.

Interview on December 4, 2019, with EMP1 at 1:00 PM confirmed PF21 does not have any specialized training or certification to meet the requirements of the Infection Control Officer.

cross reference with:
482.12 Governing Body

Repeat deficency:
Event ID WNWM11 10/11/2018






 Plan of Correction - To be completed: 03/09/2020

482.42(a) INFECTION CONTROL OFFICER(S)CFR(s):
The hospital has obtained proof of advanced infection control training by way of certification of course completion
1) The Director of Nursing/ Infection Control Officer has completed additional Training thorough "Infectioncontroltrainings.com", which includes 4 hours of additional training valid for 2 years.
2) The Director of Nursing / Infection Control Officer has completed APIC"s EPI 101 and 102 courses.
3) The following two requirements of the Infection Control Preventionist were added to the Infection Plan and the Infection Control Officer appointment letter.
1) APIC Membership- The hospital Infection Control Officer must be a member of APIC.
2) Training- The Infection Control Officer must have specific training that pertains to Infection Prevention and Control or must complete EPI 101 and 102 on the APIC website.

Person(s) Responsible:
Chief Executive Officer
Director of Human Resources
Director of Nursing/Infection Control Officer

How Monitored: Certification Completion through "Infectioncontroltrainings.com" Proof of completion from APIC's EPI 101 and 102 courses

482.42(a)(1) STANDARD INFECTION CONTROL PROGRAM:Not Assigned
The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.


Observations:

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to develop a system for controlling infections and communicable diseases of patients and personnel, as evidenced by not having an established process to place a patient in isolation precautions for one of one medical records reviewed (MR55) .

Findings include:

Review on December 3, 2019 of facility's, "Precaution Categories-Standard, Droplet, Contact, Airborne," revised 12/2016, revealed, " ... Contact Precautions contact transmission occurs when an infected person transfers microorganisms to another person. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms ... These illnesses include: ... skin infections that are highly contagious: diphtheria, herpes, impetigo, noncontained abscesses, cellulitis or decubiti, pediculosis, scabies, zoster ..."

Review on December 5, 2019 of MR55's, "History and Physical," dated October 25, 2019, revealed this patient, "... comes in on oral antibiotics for the right thumb infection ... Assessment: Acute: ... 2. Acute Cellulitis of the right hand after an injury. He is on Bactrim until October 28th ... ."

Review on December 5, 2019 of MR55's, "Nursing Reassessment," dated October 25, 2019 at 1720 revealed, " Received lab results from Dr. ... office with confirmation of +staph infection in right thumb. Patient is currently on Bactrim. PA [Physician Assistant] notified. Continue Bactrim full course ... ." Further revealed no documented evidence of patient placement on isolation precautions.

Request was made on December 5, 2019 to EMP3 for policy on how isolation precautions would be requested and implemented for patient in MR55. None provided.

Interview with EMP3 on December 5, 2019 at approximately 2:30 PM confirmed facility failed to have a process to request and implement isolation precautions.

cross reference with:
482.12 Governing Body
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.42(a)(1) Infection Control Officer(s)











 Plan of Correction - To be completed: 03/09/2020

482.42(a)(1) INFECTION CONTROL PROGRAM CFR(s):
The hospital now ensures the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

1)The hospital has updated the Management of MDRO and Patient Placement policy to include provider notification to determine the need for isolation precautions which must have a provider order.
2) The eMAR has been updated to prompt the need for isolation precautions for all antibiotic medication orders.
3)Director of Nursing/Infection Prevention and Control Officer and Provider will communicate when isolation precautions have been ordered to allow the formulation of patient-specific isolation plan.
4)All RNs and medical staff have been re-educated about the process when a patient is determined to require isolation precautions.

Person(s) Responsible:
Director of Nursing/ Infection Prevention and Control Officer

How Monitored:
100% of patients who require isolation precautions will have the process audited by the Director of Nursing/Infection Prevention and Control Officer for compliance with isolation protocol.
Results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.


482.43(e) STANDARD REASSESSMENT OF DISCHARGE PLANNING PROCESS:Not Assigned
The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.
Observations:

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to reassess its discharge planning process on an on-going basis.

Findings include:

Review on December 5, 2019, of facility document "Haven Behavioral Hospital of Philadelphia Performance Improvement Plan" approved September 2019, revealed "Responsibility- The Governing Board has the ultimate authority and responsibility for adopting an organization-wide plan to assess and improve the quality of care provided ..."

Request was made on December 6, 2019 to EMP2 for documented evidence that the facility reassesses its discharge planning process on an on-going basis. None provided.

Interview with EMP2 on December 6, 2019 at approximately 10:30 AM confirmed facility failed to reassess its discharge planning process on an on-going basis.

cross reference with:
482.12 Governing Body
482.21(d) Qapi: Performance Improvement Projects
482.21 Qapi Governing Body, standard tag
482.23(b)(2) Organization of Nursing Services









 Plan of Correction - To be completed: 03/09/2020

482.43 REASSESSMENT OF DISCHARGE PLANNING PROCESS
The hospital now ensures it reassess its discharge planning process on an on-going basis.

1.A new Director of Utilization Review was hired in September 2019
2.A new agenda for the utilization committee meeting was created by the new Director of Utilization Review. The agenda has a section to review metrics, which include patients readmitted within 30 days.
3.The Utilization Review Committee meets monthly.

Person(s) Responsible:
Chief Executive Officer
Medical Director
Chief Operating Officer / Director of Performance Improvement/Risk Management
Director of Utilization Review
Director of Social Services

How Monitored:
A copy of the Utilization Committee Meeting Minutes each month is given to the Chief Operating Officer / Director of Performance Improvement/Risk Management for review and tracking.
Deficiencies, if any, will be immediately addressed, and results of reviews will be aggregated, analyzed and used for performance improvement. Performance Improvement initiatives are monitored through monthly Quality Council meetings. Quality Council minutes are presented to the Medical Executive Committee and Governing Board quarterly.

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