Initial Comments:
This report is the result of a full state licensure survey completed on November 7, 8 and 9, 2022, at AHN Hempfield Neighborhood Hospital. The survey included all four hospitals, Hempfield, Harmar, McCandless and Brentwood. 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:
103.4 (3) LICENSURE
FUNCTIONS
Name - Component - 00
(3) Take all reasonable steps to
conform to all applicable Federal,
State, and local laws and
regulations.
Observations:
Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure compliance with all applicable state laws.
The facility was determined to be non-compliant with the following state law:
Medical Care Availability and Reduction of Error (MCARE) of March 20, 2022, stated, "Section 310. Patient safety committee. (a) Composition. -- (1) A hospital's patient safety committee shall be composed of the medical facility's patient safety officer and at least three health care workers of the medical facility and two residents of the community served by the medical facility who are not agents, employees, or contractors of the medical facility. No more than one member of the patient safety committee shall be a member of the medical facility's board of trustees. The committee shall include members of the medical facility ' s medical and nursing staff. The committee shall meet at least monthly.
Findings include:
A review of the facility's Patient Safety Plan, revised 4/27/2022, revealed, " ...Patient Safety Program: 9) Patient Safety Committee (PSC): a) Membership comprises of PSO, three health care workers of the facility, and two residents of the community. i) Community Member Requirement does not include agents, employees or contractors of the facilities....10) Patient Safety Committee duties include b) Meet monthly and maintain minutes to evaluate investigations and actions of PSO on all reports ...".
On November 9, 2022, at 11:45AM, a review of the facility's Patient Safety Committee Meeting minutes revealed that the facility did not have two residents of the community represented in their monthly committee meeting in September 2021, October 2021, November 2021, December 2021, and March 2022, as per policy.
During an interview on November 9, 2022, at 12:30PM, EMP1 confirmed the above.
Plan of Correction:AHN Hempfield Neighborhood Hospital
takes great pride in not only providing an excellent level of care to all our patients, but also in our compliance with requirements of community participation in our Patient Safety Committees.
Based on the review of the facility
documents and staff interview, it was
determined that the facility failed to
ensure compliance with the Medical
Care Availability and Reduction of Error
(MCARE) of March 20, 2022. As stated,
in Section 310, "A hospital's patient
safety committee shall be composed of
the medical facility's patient safety
officer and at least three health care
workers of the medical facility and two
residents of the community served by the
medical facility who are not agents,
employees, or contractors of the medical
facility. No more than one member of
the patient safety committee shall be a
member of medical facility's board of
trustees. The committee shall include
members of the medical facility's
medical and nursing staff. The
committee shall meet at least monthly".
On review of the facility's Patient Safety Committee Meeting minutes revealed that they facility did not have two residents of the community represented in their monthly committee meeting in September 2021, October 2021,
November 2021, December 2021, and
March 2022, as per policy.
As a result, we have taken immediate
action to address the finding with the plan of correction noted below.
- Per policy, there needs to be a
minimum of two community
members present during the patient
safety meeting. After the
conclusion of our last survey,
leaders came together to find ten
community members to attend our
monthly patient safety meetings.
- With ten active community
members now invited to our safety
meeting, this ensures great
community participation and
assures that our organization meets
the requirement of at least two
community members present on
the meeting thus preventing noncompliance moving forward.
- The Patient Safety Officer will
ensure attendance by monitoring
meeting minutes and monitoring
meeting attendance showing
appropriate community
representation.
- The date of this corrective action
will be completed on December
20th, 2022 at our next Patient
Safety Meeting.
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