Pennsylvania Department of Health
BUCKTAIL MEDICAL CENTER, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BUCKTAIL MEDICAL CENTER, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a State Licensure survey conducted on June 11-13, 2024, at Bucktail Medical Center. It was determined the facility was not in compliance with all applicable requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.

Plan of Correction:

103.36 (b)(1) LICENSURE PERSONNEL RECORDS:

103.36
(b) There shall be an established standard of content for personnel records which contain at least the following:
(1) Information regarding the employe's education, training, and experience, including, if applicable, professional licensure status and license number, sufficient to verify the employe's qualifications for the job in which he is employed. Such information shall be kept current. Applicants for positions requiring a licensed person should be hired only after obtaining verification of their licensure, records of education, and written references.

Observations:

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the required written reference information was provided for four out of five credential files (CF2, CF3, CF4 and CF5).

Findings include:

Review on June 13, 2024 of facility "Bucktail Medical Center Medical Staff Bylaws Rules and Regulations," last reviewed January 31, 2024, revealed "...Article IV-Procedure For Appointment And Reappointment...Section 2...Content - The application form shall include: ... C. References: The names of at least three (3) persons who have recently worked with the applicant and directly observed his professional performance over a reasonable period of time and who can and will provide reliable information regarding the applicant's current clinical ability, ethical character, and ability to work with others. ..."

Review of CF2 on June 13, 2023 revealed CF2 is a provider in the Emergency Department and was hired in March 2024. CF2 did not contain three written references.

Interview with EMP1 on June 13, 2024, at 1101 confirmed the findings noted above for CF2.

Review of CF3 on June 13, 2023 revealed CF3 is a provider in the Emergency Department and was hired in December 2022. CF3 did not contain three written references.

Interview with EMP1 on June 13, 2024, at 1102 confirmed the findings noted above for CF3.

Review of CF4 on June 13, 2023 revealed CF4 is a provider in the Emergency Department and was hired in May 2024. CF4 did not contain three written references.

Interview with EMP1 on June 13, 2024, at 1103 confirmed the findings noted above for CF4.

Review of CF5 on June 13, 2023, revealed CF5 is a provider in the Emergency Department and was hired February 2024. CF5 did not contain three written references.

Interview with EMP1 on June 13, 2024, at 1104 confirmed the findings noted above for CF5.

Plan of Correction - To be completed: 07/01/2024

The employee who is responsible for Personnel Records/Medical Staff Credentialing is the Administrative Secretary. She will begin to attend QA meetings in July 2024. This employee will track and report monthly regarding the completeness of the employee personnel files. She will report on the files that were deficient for the DOH Survey with a goal of having them completed/up to date by the Augst QA meeting. She will work with the Medical Director to get these completed. There will also be a QA indicator added for verification of references checked upon hire. This indicator will remain in effect for 12 months and then may be reduced to random after 12 months of 100% compliance.

103.36 (b)(3) LICENSURE PERSONNEL RECORDS:

103.36(b)
(3) Records of such pre employment health examinations and of subsequent health services rendered to the employes as are necessary to ensure that all hospital employees are physically able to perform their duties.

Observations:

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the employee health records were completed for three out of five credential files (CF) reviewed (CF2, CF4, and CF5).

Findings include:

Review on June 13, 2024 of facility " Employee Health Program," last reviewed February 22, 2024, revealed "Policy: An Employee Health Program is provided to ensure the good health of all Bucktail Medical Center personnel. Such a program against infectious illness, and may detect conditions which an employee may be aware of in regard to his/her own health and ability to reform [sic] as assigned job effectively... Procedure: ...3. All new employees will receive a 2-step P.P.D. test before beginning employee unless there is documentation of a previous positive skin reaction, or there is a current two-step PPD. If that is the case the employee may start orientation while a repeat PPD is being completed. If the second test is positive, the TB control plan P.P.D. testing policy and procedure is followed. Test results shall be made available to Administration/Employee Health prior to assumption of job responsibilities. ... 4. All new health care workers/contracted employees will provide documentation of the following: ... B. Three doses of Hepatitis B vaccine for all employees whose job positions area in category I and II. (may have contact with blood, blood products, body fluids or tissue). Laboratory evidence of immunity is required for those employees already vaccinated and those who will be vaccinated after completion of the series. ... 5. All new employees who have been vaccinated and are found to be without immunity will repeat the Hepatitis series. ..."

Review of CF2 on June 13, 2023 revealed CF2 is a provider in the Emergency Department. No documentation was noted of Hepatitis B or TB testing on hire in March 2024.

Interview with EMP1 on June 13, 2024, at 1105 confirmed the findings noted above for CF2.

Review of CF4 on June 13, 2023 revealed CF4 is a provider in the Emergency Department. No documentation was noted of Hepatitis B and TB testing on hire in May 2024.

Interview with EMP1 on June 13, 2024, at 1106 confirmed the findings noted above for CF4.

Review of CF5 on June 13, 2023 revealed CF5 is a provider in the Emergency Department. No documentation was noted of Hepatitis B and TB testing on hire in February 2024.

Interview with EMP1 on June 13, 2024, at 1107 confirmed the findings noted above for CF5.

Further interview with EMP1 on June 13, 2024, at 1108 confirmed TB testing is completed on hire and the Hepatitis B vaccines and testing are only for certain staff; those staff having direct contact with patient care. EMP1 confirmed CF2, CF4, and CF5 have direct contact with patient care.

Interview with EMP2 on June 13, 2024, at 1110 confirmed CF2, CF4, and CF5 have direct contact with patient care.

Plan of Correction - To be completed: 07/01/2024

The employee health nurse will be responsible for making sure that all employees, including physicians follow the Employee Health Program Policy (2 step PPD or t-spot, Immunizations, titers, etc). Physician employee health data will be a separate indicator and will be reported monthly at QA for 12 consecutive months with a goal of 100% compliance. Physician Employee Health will be reported in a separate indicator from other Employees. All physicians have been asked for the missing data. If missing data not available, the physicians will have the testing done the next time they are on the BMC campus. The files that were deficient at the time of the survey will have a goal of being 100% current by the August QA meeting.

107.5 (a) LICENSURE MEMBERSHIP APPOINTMENT/REAPPOINTMENT:

107.5 Membership appointment and appointment
(a) The governing body shall affirm or refuse the appointment of any physician or dentist to the medical staff or the granting of clinical privileges to any practitioner after considering the recommendation of the active medical staff in accordance with the procedure established pursuant to subsection (b) of this section.

Observations:

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the required clearances were current for three out of five credential files reviewed (CF1, CF2, and CF5)

Findings include:

Review on June 13, 2024 of facility policy, "Criminal Background Checks," last reviewed February 28, 2024, revealed "Policy: It is the policy of Bucktail Medical Center (BMC) to require/obtain Pennsylvania State Police (PSP) criminal history background clearance checks on all new BMC and Agency employees (collectively referred to as "employees" from this point on). In addition BMC requires a Department of Public Welfare (DPW) child abuse criminal background clearance check for employees who have a "significant likelihood of regular contact with children" in accordance with Act 179 of 2006. Effective July 1, 2008, new employees with a "significant likelihood of regular contact with children" are required to undergo a fingerprint based federal criminal records check in accordance with Act 73 of 2007. Procedure: 1. PSP Criminal Background checks will be conducted on all applicants for employment (Pennsylvania State Police Request for Criminal Record Check Form - SP 4-164). If the applicant is not or has not been a resident of the Commonwealth of Pennsylvania for two consecutive years (without interruption) immediately proceeding the date of the application for employment, then in addition to the State Police report, a Federal Bureau of Investigation (FBI) criminal history background check must be completed. ... Applicant shall provide the completed form(s) for PSP Criminal Background check and, if needed, a Federal Bureau of Investigation (FBI) criminal history background check .... 2. DPW child abuse criminal background clearance checks (Pennsylvania Child Abuse History Clearance Form -CY-113) and fingerprint based federal criminal records checks are required on new full-time and part-time employees with a significant likelihood of regular contact with children...

Review of CF1 on June 13, 2023 revealed CF1 is a provider in the Emergency Department. No documentation was noted for the PSP clearance on hire in February 2023.

Interview with EMP1 on June 13, 2024, at 1111, confirmed the findings noted above for CF1.

Review of CF2 on June 13, 2023 revealed CF2 is a provider in the Emergency Department. No documentation was noted for the DPW Childline clearance on hire in March 2024.

Interview with EMP1 on June 13, 2024, at 1112, confirmed the findings noted above for CF2.

Review of CF5 on June 13, 2023 revealed CF5 is a provider in the Emergency Department. No documentation was noted for the PSP clearance or the DPW Childline clearance on hire in February 2024.

Interview with EMP1 on June 13, 2024, at 1114, confirmed the findings noted above for CF5.

Further interview with EMP1 on June 13, 2024, at 1115 confirmed CF1, CF2, and CF5 have the likelihood of regular contact with children when working in the Emergency Department. EMP1 confirmed CF1, CF2, CF3, CF4, and CF5 have been a resident in Pennsylvania for two consecutive years.

Plan of Correction - To be completed: 07/01/2024

The employee who is responsible for Personnel Records/Medical Staff Credentialing is the Administrstive Secretary. She will create a spreadsheet on which to track Membership Appointment and Reappointment Requirements- PSP criminal history background clearance checks, DPW child abuse criminal background checks, FBI criminal history background checks as required per policy. This employee will notify employees when they are due to renew (if required) and will then track renewal dates on the spreadsheet. This will be reported monthly in the Medical Staff meeting. The three files that were deficient for the survey will be corrected by the August Medical Staff Meeting.

147.2 LICENSURE MAINTENANCE OF SAFETY & SANITATION:

147.2 Maintenance of safety and sanitation

The hospital shall be equipped, operated, and maintained so as to sustain its safe and sanitary characteristics and to minimize all health hazards in the hospital, for the protection of both patients and employes.

Observations:

Based on observations, review of policy and staff interview (EMP), it was determined the facility failed to follow general infection control principles for maintaining a safe and sanitary environment through failure to replace stained ceiling tiles, ensure appropriate storage of clean supplies to minimize contamination, and ensure a method of breakdown of boxes outside of the clean supply area.

Findings include:

Review of facility policy "Infection Control Program," last reviewed on February 28, 2024, revealed "II. Policy It is the policy of Bucktail Medical Center to adopt, maintain, and enforce Infection Control procedures in patient care to minimize the occurrence of infection incidents. Bucktail Medical Center Infection Control procedures are developed from the guidelines of the Centers for Disease Control (CDC) and other agencies. ... IV Authority Statement ... B. It is the responsibility of the Infection Control Practitioner to: ... 3. Represent the ICC with respect to the interpretation and application of Infection Control Policies and ... 4. Institute appropriate infection control measures ... "

Tour and observations conducted on June 12, 2024, between 0940 and 1035 revealed multiple areas with stained ceiling tiles including one stained ceiling tile in the hallway near the business office, one stained ceiling tile in the hallway near room 219, three stained ceiling tiles in the laboratory waiting area, two stained ceiling tiles in the laboratory processing area, and one stained ceiling tile near the maintenance office.

Interview with EMP4 on June 12, 2024, at 1036 confirmed there was an issue with leaking from the two main pipes that run the length of the building and the facility was awaiting an outside contractor to make additional repairs prior to replacing the ceiling tiles.

Tour and observation conducted on June 13, 2024, at 0950 revealed clean supplies including one box of dressings, one box of syringes, and one box of ventilator circuits stored directly on the floor in the Materials Management/clean supply area. There was also cardboard from boxes that were broken down within the clean supply area.

Interview with EMP5 on June 13, 2024, confirmed the above findings in the clean supply area.

Plan of Correction - To be completed: 07/01/2024

The Risk Manager will be assigned the task of walking around and inspecting the ceiling tiles bi- monthly until there are at least 6 consecutive months in which no stained tiles are found. Any stained ceiling tiles are to be reported in the monthly infection control meeting. Maintenance will be present for the infection control meetings and will then be responsible for changing any stained tiles. The Risk Manager will then reinspect the week following the IC meeting to ensure tiles have been changed.
The leaking pipes will be fixed through a USDA grant that is currently in process. This step is currently being held up because we are awaiting response from the roof warranty company regarding a ventilation duct that the contracted company needs to install. After the boiler project is complete, the company will move on to replace the leaking hot water loop.
The materials management personnel have been made aware that no items are to be stored on the floor, ever. There will be signs placed in the materials management area indicating that there is no storage on the floor.
Boxes will be picked up each day by housekeeping or maintenance and taken outside for breakdown at the cardboard storage area. The risk manager will also inspect the materials management area to ensure that there are not boxes being broken down in the area and that no patient care supplies are being stored on the floor. These will be added as indicators for QA and will be reported monthly for until 100% compliance is achieved for 6 months and then can be moved to random.

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