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Based on a review of the facility's policy, facility documents, personnel files (PF), and interview with staff (EMP), it was determined that the facility failed to ensure staff (EMP) completed the Annual Mandatory Education (AME) Course-Infection Prevention for eight of twelve personnel files reviewed (PF1, PF2, PF3, PF4, PF5, PF6, PF7 and PF8).
A review on July 11, 2016, of facility policy "Infection Control Plan FY 2016" last revised on October 2015 revealed "Educational programs. The Infection Prevention and Control Department assists in the development of infection control education for personnel. Mandatory infection control education is provided via Penn Knowledge Link and additional targeted education is provided by infection control tools, memos and in-services. Topics include, but are not limited to hand hygiene, prevention of Healthcare Acquired Infections (HAI's), prevention of MDRO's (Multi-Drug Resistant Organisms), isolation procedures, and employee and patient safety."
A review on July 14, 2016, of PF1, PF2, PF3, PF4, PF5, PF6, PF7and PF8 for facility documentation "Knowledge Link Course Report-AME-Infection Prevention course revealed the following:
PF1 for EMP33 had no documentation that the AME-Infection Prevention course was completed in the years 2015 and 2016. The AME-Infection Prevention course for PF1 was last completed on April 29, 2014.
PF2 for EMP29 had no documentation that the AME-Infection Prevention course was completed in the years 2013, 2014, and 2015.
PF3 for EMP30 had no documentation that the AME-Infection Prevention course was completed in the year 2015.
PF4 for EMP31 had no documentation that the AME-Infection Prevention course was completed in the year 2015.
PF5 for EMP32 had no documentation that the AME-Infection Prevention course was completed in the year 2015.
PF6 for EMP12 had no documentation that the AME-Infection Prevention course was completed in the years 2014 and 2015.
PF7 for EMP27 had no documentation that the AME-Infection Prevention course was completed in the year 2016. The Annual Mandatory Education-Infection Prevention course for PF7 was last completed on May 24, 2015.
PF8 for EMP28 had no documentation that the AME-Infection Prevention course was completed in the year 2016. The Annual Mandatory Education-Infection Prevention course for PF8 was last completed on June 4, 2015.
An interview conducted on July 14, 2016, at 3:30PM with EMP8 confirmed that EMP12, EMP27, EMP28, EMP29, EMP30, EMP31, EMP32 and EMP33 had not completed the AME-Infection Prevention course in the years 2013, 2014, 2015 and 2016 as detailed in the Knowledge Link Course Report for these employees. EMP1 stated "These employees did not follow our hospital's standard of practice for completing this course annually. I should have made sure that these employees completed the Infection Prevention course annually."
An interview conducted on July 14, 2016, at 4:05PM with EMP1 and EMP24 confirmed that the facility did not have a policy addressing the time frame for completing the AME-Infection Prevention course. EMP24 further stated "It is the responsibility of the nurse manager [EMP8] to ensure the Intensive Care Nursery (ICN) staff completed the AME-Infection Prevention course annually."
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Based on a review of facility policy, personnel files (PF) and interview with staff, it was determined the facility failed to ensure reference checks were completed for two of twelve personnel files reviewed (PF11 and PF12).
A review on July 26, 2016, of the facility's policy "Recruitment" last revised January 1, 2001, revealed "Purpose. The purpose of this policy is to standardize the recruitment process, to select the most qualified candidate and to ensure compliance with applicable HUP/CPUP/Shared Service guidelines and federal, state and local legal requirements (Equal Opportunity and Affirmative Action)...Implementation. Implementation of this policy is the responsibility of the Entity Senior Leadership, Department Directors/Business Administrators and monitored by Associate Vice President of Human Resources, Chief Human Resources Officers, Director of Staffing and the Director of Nurse Recruitment. The Staffing Specialist will contact the designated departmental interviewer named on the requisition to discuss a recruitment strategy. This may include:...h. verify references and employment eligibility in the U.S...3. All applicants who are interviewed must complete an employment application in the Staffing Department. The completed application is used in the employment interview and provides pertinent information. The employment history of every potential employee must be verified."
A review on July 26, 2016, of facility document "Crothall Recruiting, Offer and New Hire Procedure" lasted revised September 2013, revealed "Policy/Procedure. To provide an overview of the entire recruiting, offer and hiring process for hourly associates at unit locations. Offer of Employment. Hiring Manager makes offer of employment contingent upon passing Company criminal background check or hospital criminal background check. In some cases this is also contingent upon taking and passing drug test and or physical. This is specific to each hospital location and in all cases hiring manager is to follow hospital policies outlined on our contract to conduct business at the unit. Further review of the policy revealed no documentation that required reference verification of candidates prior to an offer of employment."
A review on July 26, 2016, of PF11, a contracted housekeeping employee revealed there was three documented references received on January 25, 2016, during the hiring process. The contracted employee's date of hire was March 7, 2016. There was no documentation in PF11 that the references were verified.
A review on July 26, 2016. of PF12, a contracted housekeeping employee revealed there was three documented references received on February 10, 2016, during the hiring process. The contracted employee's date of hire was May 26, 2016. There was no documentation in PF12 that the references were verified.
An interview conducted on July 26, 2016, at 2:30PM with EMP1, EMP20 and EMP21 confirmed that there was no documentation that the references were verified in PF11 and PF12. In addition, EMP1, EMP20 and EMP21 confirmed that "Crothall' the contracted company did not require verification of references as a condition of hire.

Based on a review of the facility's policy, facility documents, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to follow its policy for resolution of a grievance for one of three medical records reviewed (MR1).

A review of the facility's policy "Response to Patient's and Family Members' Complaints and Grievances" last reviewed April 9, 2014, revealed "Purpose. The purpose of this policy is to provide a formal process as delegated by the UP Board of Trustees for : a) Investigating and responding to patient and family complaints or grievances in a timely, confidential, consistent, and effective manner;..SCOPE. This policy applies to all patients, patient's representatives and family members, who have complaints that cannot be handled directly by the caregiver and/or the immediate supervisor and all employees and staff of Hospital of the University of Pennsylvania (HUP),...operating under the HUP license. COMPLAINT/GRIEVANCE DEFINITION, INVESTIGATION, AND RESOLUTION. 2. A patient grievance, as defined by CMS is any complaint that meet the criteria listed below: a) A formal, informal, written, or verbal complaint made by a patient or their representative received by the UPHS (University of Pennsylvania Health Systems), OPA (Office of Patient Affairs) , HUP (Hospital of the University of Pennsylvania), PGR (Patient and Guest Relations), the Disability Access Officer, or the Office of the Executive Director, Nursing Administration, or Clinical Chiefs or Chairs. This includes faxes, emails, and letter or notes attached to any patient satisfaction survey other than general comments...c) A complaint referred to a HUP PGR representative by a member of hospital management or administration...b. The recipient of the grievance should attempt to provide a response to the grievant acknowledging receipt within two business days of the date when the grievance was received. Every attempt will be made to resolve the grievance within 7 days of the receipt. If the grievance is unable to be resolved within 7 days of receipt, a written notice informing the grievant that the investigation is ongoing and an anticipated timeframe for a response will be sent to the grievant...A grievance is considered resolved when the investigation has been completed and a written response has been provided to the grievant."

A review of facility documentation "Current Summary Multiple Issues Feedback" entry date June 22, 2016, by EMP23 revealed "Father of patient (MRN#XXXXXXXXX HUP) shared the following feedback with PGR pertaining to the care/treatment of his son in the Intensive Care Nursery. Classification: Grievance, Date of Notification June 21, 2016. Method of Notification: In Person. Department: Neonatology and Newborn Services. Location: Ravdin 8. Feedback Categories: Infection. Brief Factual Description"

A review of facility documentation "Email Notification" dated June 21, 2016, from EMP9 to EMP23 " Dear [EMP23], We have the family in Bay 1 who are currently very dissatisfied. We test all of our infants for MRSA on Sunday night and their baby's test came back MRSA today, There have been several conversations with various members of the team, but they continue to be upset about the care of their baby."

An interview conducted on July 23, 2016, at 1:55PM, with EMP1, EMP22, and EMP23, confirmed that EMP23 had generated the grievance form "Current Summary Multiple Issues Feedback" based on the patient's father contacting EMP23, the manager of Patient and Guest Relations. Further interview with EMP22 and EMP23 revealed that a written letter of resolution had not been generated to the patient's father to address his concerns. EMP23 stated "I thought that everything was resolved since the father never approached me again. I did not know we had to forward a written response to the patient's father" In addition, EMP22 and EMP23 could not confirm that the grievance investigation had been completed.

Based on a review of facility documents, medical record (MR), and interview with staff (EMP), it was determined that the facility failed to develop a plan of care for Contact Isolation Precautions for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5, and MR6).

A review on July 26, 2016, of facility policy "General Documentation" effective February 28, 2011, revealed "Policy. Documentation is to be pertinent, accurate and concise. It includes: significant assessment findings, the patient's status, nursing interventions/care and the patient's response to care. Procedure. B. The Nursing Plan of Care is completed on all patients and is based on the patient's goal and the time frames, settings, and services required to meet those goals. Based on the goals established in the patient's plan of care, staff evaluates the patient's progress and revises the plan of care accordingly."

A review on July 26, 2016, of the facility's policy "Nurse's role in Plan Care-4A-03-04" effective February 26, 2010, revealed "Planning for nursing care is individualized to meet the patient's unique needs. These needs are identified through assessment, reassessment and the results of diagnostic testing. The written plan of care is based on the patient's goals and the time frames and services required to meet those goals. This plan is documented on the Nursing Plan of Care (NPOC) and is initiated within twenty four hours of admission on all patients. The patient's progress is evaluated based on the goals established in the plan of care. Plans and goals for care, treatment and services are revised based on the patient's needs. Unit-specific NPOC developed with patient needs and goals commonly seen on speciality units are acceptable."


A review on July 26, 2016, of the facility's documentation "Methicillin Resistant Staphylococcus Screen (MRSA) Evaluation Form" revealed MR1, a positive MRSA Culture dated June 20, 2016. A review of MR2, a positive MRSA Culture dated June 12, 2016. A review of MR3, a positive MRSA Culture dated June 20, 2016. A review of MR4, a positive MRSA Culture dated June 6, 2016. A review of MR5, a positive MRSA Culture dated June 20, 2016. A review of MR6, a positive MRSA Culture dated June 6, 2016.

A review on July 26, 2016, of MR1 "Interdisciplinary Plan of Care (For Intensive Care Nursery Patients)" revealed no documentation of Contact Isolation Precautions for MRSA colonization. The date of the positive MRSA Screen was on June 20, 2016. A review on July 26, 2016, of MR2 "Interdisciplinary Plan of Care (For Intensive Care Nursery Patients)" revealed no documentation of Contact Isolation Precautions for MRSA colonization. The date of the positive MRSA Screen was on June 12, 2016. A review on July 26, 2016, of MR3 "Interdisciplinary Plan of Care (For Intensive Care Nursery Patients)" revealed no documentation of Contact Isolation Precautions for MRSA colonization. The date of the positive MRSA Screen was on June 20, 2016. A review on July 26, 2016, of MR4 "Interdisciplinary Plan of Care (For Intensive Care Nursery Patient)" revealed no documentation of Contact Isolation Precautions for MRSA colonization. The date of the positive MRSA Screen was on June 6, 2016. A review on July 26, 2016, of MR5 "Interdisciplinary Plan of Care (For Intensive Care Nursery Patient)" revealed no documentation of Contact Isolation Precautions for MRSA colonization. The date of the positive MRSA Screen was on June 20, 2016. A review on July 26, 2016, of MR6 "Interdisciplinary Plan of Care (For Intensive Care Nursery Patient)" revealed no documentation of Contact isolation Precautions for MRSA colonization. The date of the positive MRSA Screen was on June 6, 2016.

An interview conducted on July 26, 2016, at 2:30PM with EMP5 confirmed a positive MRSA Culture for MR1 on June 20, 2016, a positive MRSA Culture for MR2 on June 12, 2016, a positive MRSA Culture for MR3 on June 20, 2016, a positive MRSA Culture for MR4 on June 6, 2016, a positive MRSA Culture for MR5 on June 20, 2016 and a positive MRSA Culture for MR6 on June 6, 2016.

An interview conducted on July 26, 2016, at 2:55PM with EMP1 and EMP8 confirmed that there was no documentation for Contact Isolation Precautions in the Interdisciplinary Plan of Care for Methicillin Resistant Staphylococcus Aureus colonization in MR1, MR2, MR3, MR4, MR5, and MR6.