HospitalInspections.org

Based on review of facility policy and procedure, observation tour, and interview with staff (EMP), it was determined the facility failed to maintain the patient's right to the confidentiality of his or her clinical records.

Findings include:

Review of the facility's policy "Confidentiality of Medical Center Information," dated last reviewed March 26, 2012, revealed "Policy ... It is the policy of Pocono Health System to expect its employees to observe a strict code of ethics regarding the use of any information considered confidential by the Health System. Information considered confidential includes but is not limited to the following: Patient medical information; patient financial and demographic information ... Patient Medical Information ... Information between physician and patient is confidential, as required by law and by the medical code of ethics. The confidential nature of the medical relationship extends to an employee observation and knowledge of the patient's medical diagnoses and treatments."

Review of the facility's policy "Confidentiality of Protected Health Information," dated last reviewed June 21, 2011, revealed "1.0 Purpose: To ensure that protected health information is protected so that all individuals are not afraid to seek health care or to disclose sensitive information to health professionals, and also to ensure that protected health information is protected during its collection, use, disclosure, storage, and destruction by or on behalf of Pocono Medical Center and all healthcare facilities within the Pocono Health System (collectively "PHS") in accordance with the provisions of applicable state and federal regulations. 2.0 Definitions: 2.1 Protected health information means all information, recorded or exchanged verbally, about an identifiable individual that relates to 2.1.1 The individual's health care history, including genetic information about the individual or the individual's family. ... 3.0 Policy: 3.1 All PHS employees and persons associated with PHS are responsible for protecting the privacy and security of all protected health information (oral or recorded in any form) that is obtained, handled, learned, heard, or viewed in the course of his/her work or association within PHS. 3.2 Protected health information shall be protected during it's collection, use, disclosure, storage and destruction by or on behalf of PHS."

An observation tour conducted on May 10, 2012, at approximately 11:30 AM revealed a cleaned patient room, with no occupant. A sputum culture report with patient identifying information was observed to be taped to the sharps disposal box in that patient room.

Interview with EMP2 confirmed this patient room was unoccupied and was cleaned and prepared for the next admission. EMP2 further confirmed the lab report was taped to the sharps disposal box in the unoccupied patient room.

Based on review of the facility Performance Improvement Plan, facility documents, and interview with staff (EMP), it was determined the facility failed to develop a measurement to analyze, and track quality indicators for all contracted services of the hospital.

Findings include:

Review of the facility's "Performance Improvement Plan for Pocono Medical Center," dated approved November 30, 2011, revealed "... Objectives: To provide a planned, systematic organization-wide approach to process design and performance measurement, analysis and improvement. ... To provide a systematic process for the collection of data necessary to establish baselines, assess dimensions of performance relative to processes and outcomes, measure performance and identify opportunities for potential performance improvement, and determine whether improvements have been sustained. ... To provide a mechanism for the ongoing aggregation, analysis and display of data utilizing appropriate statistical techniques and comparing its performance over time with comparative databases."

1) Review of the facility's performance improvement plan revealed no methodology in place for monitoring contracted services, such as waste management, environmental services, linen, and dietary services.

2) Review of the Governing Body Meeting Minutes and Quality Management Meeting Minutes for 2011 and 2012 revealed no documentation of a quality assessment of the contracted services.

3) Interview with EMP1 on May 7 2012, at approximately 10:30 AM confirmed the contracted services were not reported through quality and to the governing body.

Based on review of facility policy and procedures, facility documents, and interview with facility staff (EMP), it was determined the facility failed to maintain written evidence of regular fire drill inspections conducted quarterly for three of three outpatient satellite clinics.
Findings include:

Review of the facility's policy "Fire Safety," dated reviewed January 8, 2009, revealed "... Quarterly Fire Drills will be conducted in accordance with EC.02.03.03 (NFPA guidelines (National Fire Protection Association).

1) Review of the facility's "Fire Drill Evaluation Form" revealed a fire drill was conducted at the at the 447 Plaza site on April 7, 2011, and April 13, 2012. There was no documentation that fire drills were conducted for the first, third, and fourth quarters of 2011 and the first quarter of 2012.

2) Review of the facility's "Fire Drill Evaluation Form" revealed a fire drill was conducted at the at the Mountain Health Care sites in July 2011 and on May 8, 2012. There was no documentation fire drills were conducted for the first, third and fourth quarters of 2011 and the first quarter of 2012.

3) Review of facility's "Fire Drill Evaluation Form" revealed a fire drill was conducted at the at the 175 East Brown site on May 26, 2011. There was no documentation fire drills were conducted for the first, third and fourth quarters of 2011 and the first quarter of 2012.

4) Interview with EMP3 on May 9, 2012, at approximately 2:00 PM confirmed fire drills were not conducted quarterly for all of the outpatient satellite sites.