Initial Comments:
This report is the result of an occupancy survey conducted on January 31, 2024, at Thomas Jefferson University Hospitals Inc,-main campus which included renovations to the 3 Thompson Observation and Extended Stay Unit (a closed rehabilitation unit). Based on the survey, 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 and the current edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities.
Plan of Correction:
51.3 (l) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(l) A health care facility may not
commence the provision of new health
care services or provide services in
new beds until it has been informed by
the Department that it is in
compliance with all licensure
requirements.
Observations:
Based on observation, review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure occupancy approval was granted and maintained from the "Department" prior to permitting patients to occupy a hospital space not currently approved by the "Department" in compliance with the State of Pennsylvania Regulations for Hospitals-Chapter 51.3 and the applicable Guidelines for Design and Construction of Hospitals.
Findings include:
An observation tour conducted on January 31, 2024, at approximately 2:05 PM with EMP2 and EMP3, of the closed rehabilitation unit referred to by the facility as "3 Thompson Observation and Extended Stay Unit" revealed the unit was occupied with inpatients receiving patient care services by licensed staff and the facility had not received occupancy approval from the "Department" prior to permitting patients to occupy and receive patient care services in this unapproved space.
Review of facility document received to the "Department" dated April 27, 2023, authored by EMP1 revealed the facility permitted patients to occupy and receive care in the following unapproved spaces without obtaining occupancy approval from the "Department for the following areas: "3 Thompson as an Observation and Extended Stay Unit, 3 Main as an Observation/Extended Recovery Unit, 7 Southeast-Gibbon Building as a telemetry bed Unit and Kaiserman Conference Room-D side for Emergency Department Overflow.
Review of facility document received to the "Department" dated November 13, 2023, authored by EMP1 revealed "I am reaching out to provide an updated regarding our progress in preparing 3 Main and 3 Thompson for licensure. ...We have made many improvements to the existing spaces which have made care safer for patients. As you are aware, these are very old spaces, and they need to be gutted in order to bring them fully up to today's standards, and that is our plan."of facility document dated January 3, 2024, revealed the facility confirmed on January 3, 2024, that patient care was delivered to patients in 6 unlicensed telemetry beds on 7 Southeast Unit. The facility did not have occupancy approval for the space from the "Department" .
Review of facility document dated January 4, 2024, revealed the facility confirmed on January 4, 2024, that patient care was delivered to patients in unlicensed beds on the previously closed rehabilitation unit referred to by the facility as 3 Thompson Observation and Extended Stay Unit. The facility did not have occupancy approval for the space from the "Department " .
Review of facility document dated January 8, 2024, revealed the facility confirmed on January 8, 2024, that patient care was delivered to patients on 3 Main Observation/Extended Recovery Unit. The facility did not have occupancy approval for the space from the "Department" .
Review of facility document dated January 14, 2024, revealed the facility confirmed on January 14, 2024, that patient care was delivered to patients in unlicensed beds on the previously closed rehabilitation unit referred to by the facility as 3 Thompson Observation and Extended Stay Unit. The facility did not have occupancy approval of the space from the "Department" .
Review of facility document dated January 19, 2024, revealed the facility confirmed on January 19, 2024, that patient care was delivered to patients in unlicensed beds on the previously closed rehabilitation unit referred to by the facility as 3 Thompson Observation and Extended Stay Unit. The facility did not have occupancy approval for the space from the "Department".
Review of facility document dated January 25, 2024, revealed the facility confirmed on January 25, 2024, that patient care was delivered to patients in unlicensed beds on the previously closed rehabilitation unit referred to by the facility as 3 Thompson Observation and Extended Stay Unit. The facility did not have occupancy approval for the space from the "Department".
An interview conducted on January 31, 2024, with EMP2 at 2:50 PM confirmed the above findings. Further interview on January 31, 2024, with EMP3 at 3:00 PM confirmed the facility was not compliant with the State of Pennsylvania Regulations for Hospitals-Chapter 51.3 and the applicable Guidelines for Design and Construction of Hospitals for 3 Thompson Observation and Extended Stay Unit and 3 Main Observation/Extended Recovery Unit.
The facility confirmed that the "Department" had conducted on-site occupancy survey visits at the request of the facility for the inpatient spaces listed and had not received occupancy approval from the "Department" to occupy the spaces due to patient safety concerns. The facility also confirmed that "Department" representatives had communicated to facility representatives the need to close the spaces or bring the spaces into compliance to comply with the State of Pennsylvania Regulations for Hospitals-Chapter 51.3 and the applicable Guidelines for Design and Construction of Hospitals. As of Janaury 31, 2024, the facility continues to be noncompliant with the State of Pennsylvania Regulations for Hospitals-Chapter 51.3 and the applicable Guidelines for Design and Construction of Hospitals.
Plan of Correction:In response to the citation, the Thomas Jefferson University Hospital (TJUH) Chief Operating Officer, Chief Medical Officer, Senior Vice President of Operations, Chief Nursing Officer, Director of Nursing and Patients Care Services, Nurse Manager, Department Chair of Emergency Medicine, Vice Chair Department of Emergency Medicine/Vice Chair of Clinical Operations Department of Emergency Medicine, Interim Medical Director of the Emergency Department, Director of Accreditation & Regulatory Affairs, Accreditation Program Manager, and the Central Region Chief Clinical Officer developed a plan to safely move patients out of the unauthorized/unapproved spaces and to reallocate staff and resources.
By 3/16, all rooms on 3 Thompson, 3 Main, 7 Southeast-Gibbon Building, and Kaiserman Conference Room-D-side Emergency Department Overflow were closed completely, following the "Opening/Closing Nursing Unit Policy". The Senior Vice President of Operations verified the closures. All patients were redistributed to other appropriately licensed patient care units.
To prevent patients from being placed in unauthorized/unapproved units, changes were made to electronic medical record, prohibiting bed assignments in these areas. Unit leadership as well as the Bed Management team, part of the Center for Operational Resource Efficiency, were notified of the closures. Per diem registered nursing staff use was discontinued in the affected areas. Full-time staff were educated on the closures during a 3/16 emergency staff meeting and were reallocated to other appropriate assignments. A record of the emergency staff meeting is available for surveyor review upon request.
The Nursing Administrative Supervisor will attest to the continued closure of the unauthorized beds daily, by signing an attestation log. The attestation log will be reviewed weekly by the Chief Nursing Officer or designee for 3 months, and then monthly for 3 months. Any noncompliance will be reported to the Chief Operating Officer and the Pennsylvania Department of Health. Beginning April 2024, compliance with the log will be reviewed monthly at the Patient Safety Committee, the Executive Quality-Safety-Experience Steering Committee, and the Clinician Affairs Committee of the TJUH Board of Trustees.
To ensure that TJUH provides a safe environment of care for patients, the Director of the Center for Operational Resource Efficiency and the Senior Vice President of Operations will verify the receipt of the Pennsylvania Department of Health space occupancy approval prior to the activation of any new beds, or the reactivation of any unlicensed patient beds.
The TJUH Senior Vice President of Operations will be accountable for the execution of this plan of correction.
The TJUH Chief Medical Officer will review the incident that led to the citation and the subsequent action plan at the April Clinician Affairs Committee of the TJUH Board of Trustees. The Chief Medical Officer will reinforce the need to comply with the Pennsylvania Department of Health's Rules and Regulations for Hospitals to ensure the provision of a safe environment of care for patients.
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