QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

This report is the result of an unannounced special monitoring survey initiated on May 11, 2021, and completed on June 2, 2021, at Brandywine Hospital. 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:

103.33 (a) LICENSURE

Name - Component - 00
103.33 Responsibilities

(a) The chief executive officer
shall be the official representative
of the governing body.


Based on review of the Department of Health (Department) database, facility documents and staff interview (EMP), it was determined the Chief Executive Officer (CEO) was also the CEO of a separately licensed acute care hospital. The facility failed to ensure the CEO was exclusive to Brandywine Hospital.

Findings include:

Review on June 2, 2021, of the facility's "Job Information," no review date, revealed "Job Title: Chief Executive Officer ... Job Summary The Chief Executive Officer has full leadership and operations responsibility for the hospital. CEO will ensure success of the hospital through quality enhancement, cost containment, revenue growth and development of strong relationships with hospital staff, board members, and community leaders. The CEO could oversee more than one hospital. ... All activities must be in compliance with Equal Employment Opportunity laws, patient confidentiality, and other Federal, State and Local laws and regulations, as appropriate. ..."

Review on June 2, 2021, of the Department's database revealed Brandywine Hospital is an acute care hospital. The hospital has a licensed bed complement of 173 inpatient beds. These include medical/surgical, pediatric, adult psychiatric, geriatric psychiatric and Intensive/Critical Care inpatient beds.

On November 17, 2020, the Department was notified EMP1 assumed the role of CEO.

Review on June 2, 2021, of the Department's database revealed EMP1 is also the CEO of an additional acute care outside hospital (OSH). The OSH has a licensed bed complement of 52 inpatient beds. These include medical/surgical, Intensive Care and Telemetry inpatient beds. EMP1 assumed the role of CEO at this OSH in 2018.

Interview on May 11, 2021, at 1:00 PM with EMP2 confirmed EMP1 is the CEO at Brandywine Hospital and the OSH.

Plan of Correction:

The CEO currently maintains all the responsibilities as required in the 103.31. The chief executive officer and 103.33. Responsibilities. There is an organized schedule in which a member of the executive leadership team is on site at the hospital. The Executive Leadership team is comprised of the CEO, CNO, CFO, CQO and Director of Clinical Operations. This leader has been delegated the authority to act on behalf of the CEO should she not be available to respond to a need. When the decision was made to have the CEO responsible for 2 facilities, it was based on the Department's regulations for the chief executive officer which do not require that the CEO must be full-time at one hospital, as compared to the regulations for chief nursing officer which do require a full-time commitment at one hospital. The Hospital was aware that there are other hospitals in the Commonwealth where a single CEO has responsibility for two hospitals. Appropriate notification was made to the state regarding this change. The hospital is preparing an exception request to submit to the Department of Health no later than June 30, and pending disposition of the exception request, the delegation of authority process will be used to ensure that the CEO or an appropriate delegate is available.

2. Indicate how the facility will act to protect patients in similar situations;
The patients are protected because there is always the availability of either the CEO or her delegate to respond to any needs, in the same manner as occurs when there is a CEO with responsibility for only one hospital.

3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur.
The CEO Delegation policy has been reviewed and revisions are being made to clarify the delegation process, the policy revision will be complete and communicated to the Executive Leadership Team and Department Directors by June 30, 2021.

4. Indicate how it plans to monitor its performance to make sure that solutions are sustained; and
If there is a situation in which the CEO or her designee is not available, an incident report will be completed by the administrative supervisor. The Risk Manager reviews all event reports on a daily basis. The Risk Manager will submit a PaPSRs report.

If the Requested exception is not approved by the DOH, the hospital will continue this monitoring process to ensure that there is always appropriate coverage.

5. Provide dates when corrective action will be completed.
June 30.