Initial Comments: This report is the result of a revisit survey conducted on March 14, 2024, at Penn State Health Rehabilitation Hospital, as the result of a previous complaint survey that was conducted on January 5, 2024. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
101.111 LICENSURE CORRECTION OF DEFICIENCY Name - Component - 00 101.111 Policy
Whenever any hospital notifies the
Department that it has completed a
plan of correction and corrected its
deficiencies, the Department will
conduct a survey to ascertain
completion of the plan of correction.
Upon finding full or substantial
compliance, as defined in 101.92(b),
the Department may issue a regular
license.
Observations:
Based on review of the facility's Plan of Correction (POC), facility documents, and staff interview (EMP), it was determined Penn State Health Rehabilitation Hospital failed to follow their POC that was submitted to and accepted by the Department with a completion date of January 30, 2024.
Findings include:
On March 14, 2024, a review of the facility POC revealed, The Chief Nursing Officer (CNO) reviewed Respiratory Therapy Policy 001, Oxygen Administration with the nursing staff. This review emphasized prompt physician notification when oxygen saturation levels cannot be maintained as ordered. Education will be completed on January 25, 2024. As of January 26, 2024, any nursing staff that has not completed this education, will do so prior to working their next scheduled shift.
Review of the facility's documentation revealed that staff training of the Respiratory Therapy Policy 001, Oxygen Administration was not completed.
Interview with EMP1 on March 20, 2024, via telephone confirmed that the Respiratory Therapy Policy 001, Oxygen Administration training was not completed as outlined in the plan of correction.
Plan of Correction:The Chief Nursing Officer (CNO) and the Director of Quality Management (DQM) reviewed the Plan of Correction (POC) deficiency of 101.111 on 3/18/2024. This examination identified that the education provided to the staff did not include the entire Respiratory Therapy Policy 001, Oxygen Administration. On 3/20/2024, the CNO and the DQM developed Power Point education slides that explicitly include Respiratory Therapy Policy 001, Oxygen Administration, with emphasis on prompt physician notification when oxygen saturation levels cannot be maintained as ordered. The entire policy was reviewed during three staff meetings which were all held on 3/20/24 and staff attendance was documented. The entire policy will also be reviewed during the twice a day shift huddles for the next 2 weeks and during scheduled staff meetings. Education will be completed by April 8. Any nursing staff that has not completed this education by April 8 will do so prior to starting their next scheduled shift. Staff policy review acknowledgment will be attached to the Respiratory Therapy Policy 001, Oxygen Administration. Compliance with the above plan will be monitored by the CNO, or designee, by auditing each education list for staff names and policy attachment. This will continue until compliance has been achieved. At that time, findings will be reported to the monthly Quality Assurance Process Improvement (QAPI) Team and quarterly to the Quality and Patient Safety Committee, Medical Executive Committee (MEC) and Governing Board (GB).
The CNO is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
109.23 (b)(1-5) LICENSURE WRITTEN NURSING CARE POLICIES Name - Component - 00 109.23 (b) Nursing care policies and
procedures shall be consistent with
professionally recognized standards of
nursing practice and shall be in
accordance with the Professional
Nursing Law and regulations
promulgated by the State Board of
examiners. These policies shall
include procedures for the following: (1) noting diagnostic and
therapeutic orders (2) assigning the nursing care
of patients (3) infection control (4) patient safety (5) implementing orders for
medication and treatment, consistent
with 107.61-107.65 of this subpart.
Observations:
Based on review of the facility's Plan of Correction (POC), facility documents, and staff interview (EMP), it was determined Penn State Health Rehabilitation Hospital failed to follow their POC that was submitted to and accepted by the Department with a completion date of January 30, 2024
Findings include:
On March 14, 2024, a review of the facility POC revealed, The Chief Nursing Officer (CNO) reviewed Respiratory Therapy Policy 001, Oxygen Administration with the nursing staff. This review emphasized prompt physician notification when oxygen saturation levels cannot be maintained as ordered. Education will be completed on January 25, 2024. As of January 26, 2024, any nursing staff that has not completed this education, will do so prior to working their next scheduled shift.
Review of the facility's documentation revealed that staff training of the Respiratory Therapy Policy 001, Oxygen Administration was not completed.
Interview with EMP1 on March 20, 2024, via telephone confirmed that the Respiratory Therapy Policy 001, Oxygen Administration training was not completed.
Plan of Correction:The Chief Nursing Officer (CNO) and the Director of Quality Management (DQM) reviewed the Plan of Correction (POC) deficiency of 101.111 on 3/18/2024. This examination identified that the education provided to the staff did not include the entire Respiratory Therapy Policy 001, Oxygen Administration.
On 3/20/2024, the CNO and the DQM developed Power Point education slides that explicitly include Respiratory Therapy Policy 001, Oxygen Administration, with emphasis on prompt physician notification when oxygen saturation levels cannot be maintained as ordered. The entire policy was reviewed during three staff meetings which were all held on 3/20/24 and staff attendance was documented. The entire policy will also be reviewed during the twice a day shift huddles for the next 2 weeks and during scheduled staff meetings. Education will be completed by April 8. Any nursing staff that has not completed this education by April 8 will do so prior to starting their next scheduled shift. Staff policy review acknowledgment will be attached to the Respiratory Therapy Policy 001, Oxygen Administration.
Compliance with the above plan will be monitored by the CNO, or designee, by auditing each education list for staff names and policy attachment. This will continue until compliance has been achieved. At that time, findings will be reported to the monthly Quality Assurance Process Improvement (QAPI) Team and quarterly to the Quality and Patient Safety Committee, Medical Executive Committee (MEC) and Governing Board (GB).
The CNO is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
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