HospitalInspections.org

Based on facility documents and staff interview it was determined that the facility failed to ensure fire drill policies were administered to ensure a safe environment for three of four satellites.

Review of Penn Highlands Elk policy entitled "Scheduled Fire Drills", dated July 2019, revealed "... A minimum of 12 fire drills will be held annually in each building at irregular intervals ... ."

1. During a review of a sample of fire drills on July 7, 2021, it was noted that no fire drills were documented for the past 12 months as occurring at Penn Highlands Elk Physical Therapy, Laboratory or Radiology, 416 North Broad Street, Emporium, PA.

2. It was confirmed by EMP1 on July 8, 2021 that there were no fire drills on record. It was also confirmed that these three satellites are separate areas at the 416 North Broad Street, Emporium location.

Based on a review of facility documents and interview with staff (EMP), it was determined that Penn Highlands Elk failed to follow their adopted policies and Quality Improvement Plan by failing to identify, monitor and analyze Anesthesia quality indicators and by failing to investigate Anesthesia incident/events.
Findings include:
"Penn Highlands Elk Quality Assessment Performance Improvement Plan FY 2022" dated June 2020, revealed, "A. Overview The Quality Assessment Performance Improvement Plan (QAPI) provides a framework for promoting and sustaining performance improvement at Penn Highlands Elk in order to achieve excellent care that is effective, safe, patient centered, timely, cost effective and equitable. ... This QAPI Plan has been designed as a mechanism to assure: ... Quality and patient safety standards are met through an efficient and outcomes-based accreditation program: the CMS Conditions of Participation and PA DOH regulations. A team approach is used to evaluate and improve patient care, The use of evidence based practices to improve health outcomes and prevent medical errors, Patient care is objectively and systematically monitored and evaluated in relation to current standards of care: ... Organization-wide education and communication of relevant performance improvement information, initiatives and outcomes. ... Identified problems are systematically investigated and resolved. B. Authority and Responsibility of the Quality Management System With Associated Structure ... Board of Directors: The Board of Directors has the ultimate responsibility for performance improvement and for assuring safe and high quality patient care. ... The Board of Directors ensures the following: That an ongoing program for quality improvement and patient safety including the reduction of medical errors is defined, implemented and maintained. That hospital-wide QAPI efforts address priorities for improved patient safety. That all improvement and corrective action plans are evaluated. ... The determination of the number of distinct improvement projects is conducted annually ... Organizational Excellence Council: The Organizational Excellence Council (OEC) has the role of oversight for the quality management system at Penn Highlands Elk OEC in collaboration with Executive Leadership, Quality, Safety and Service Excellence Steering Committees and BQOC is responsible for: ... 2. Recommending organization-wide QAPI priorities through the management review process. ... 5. Ensuring that the organization designs processes well and systematically monitors errors, analyzes, and improves key processes, functions and services through internal audits while sustaining performance to improve patient outcomes 6. Through reports from Safety and Quality Committees via the Patient Safety Plan, providing oversight in identifying trends through event reports, audits and regulatory compliance rounds with emphasis on improving patient safety processes and regulatory compliance efforts. 7. Overseeing the organization-wide Service Excellence initiatives with emphasis on improving the patient's perception of care and service delivery and achieving excellence in patient care processes, outcomes and providing patient centered care. ... Safety Excellence Steering Committee The Safety Excellence Committee is comprised of a multidisciplinary team with community and board representation and provides oversight, guidance and direction for the organization for patient safety, employee safety and environmental safety. This committee reviews event reports, serious events and infrastructure failures from PA PSRS reports, the Safety Excellence dashboard and specific safety reports based on Safety Excellence Reporting Matrix schedule. This committee promotes a culture of safety through employee surveys and feedback, makes recommendations for actions and evaluates ongoing progress in the high reliability journey. ... D. Performance Improvement Priorities ... During planning, the following are given priority consideration: ... Processes that have been or are likely to be problem-prone ... Other priorities would be around patient experience, staff engagement, physician engagement, clinical outcomes, safety and regulatory requirements. ... ."
Penn Highlands Elk ... Title: Performance/Quality Improvement ... Anesthesia policy and procedure dated October 2018. "Purpose: To examine the safety, quality and appropriateness of anesthesia care provided throughout the Health Center and to provide a framework for promoting performance improvement. ... Scope: This policy applies to all patients who receive general anesthesia, spinal, epidural, regional anesthesia or monitored anesthesia care (M.A.C.) or undergo a procedure by a credentialed provider of the Department of Anesthesiology. ... The Director, Department of Anesthesiology, will participate in the development of these practitioners' performance and quality plans, review of their results, and provide comments, suggestions, or continuing education to improve the quality of anesthesia care provided by these clinicians. Results of this monitoring will be documented in their departmental QI meeting minutes and forwarded to the Director, Department of Anesthesiology, who after review and comment, will provided [sic] results directly to the Core Quality Committee of the Health Center. Objectives: A.) To monitor accurate documentation of overall anesthesia care. B.) To provide a mechanism to review appropriateness of anesthesia care. C.) In addition to participation in Health Center performance improvement, patient, electrical, fire, and equipment safety and risk management programs, the Department of Anesthesiology will take additional departmental specific steps to monitor and insure patient safety to all patients receiving any type of anesthesia care throughout the Health Center. D.) At least 2 quality indicators to improve patient safety or the quality of anesthesia patient care provided will be identified and monitored for 1 year. Implementation: Performance improvement and the delivery of quality anesthetic care is the job of all members of the Department of Anesthesiology as well as all the other providers credentialed to provide anesthesia and/or analgesia care. As such, all anesthesia credentialed providers are expected to actively participate in the performance and quality improvement program as outlined in the policy. ... ." Attachments to this policy included: Addendum #1- "Department of Anesthesiology Quality Assurance Record Review Audit," Addendum #3- "Untoward and Sentinel Anesthetic Events," and Addendum #6-"Quality Management: Moderate/Deep Sedation Quality Assurance Audit."
Penn Highlands Elk ... Title: Patient Safety-Event Reporting ... Risk Management policy and procedure dated September 26, 2019, revealed, " Purpose: To enhance the quality of patient care. To promote a safe (risk-reduced) environment for that care ... To achieve consistency in the method of reporting. To serve as an information base for devising corrective measures to preclude reoccurrence. To target problem areas through effective trend analysis. To promote open channels of communication throughout all levels within the organization on an as needed basis. ... Procedure: ... II. Procedure for Reporting: A. Documentation of an unusual or significant event: 1. Any employee or physician who discovers, witnesses, or to whom an unusual or significant event is reported, is responsible for documenting the event. ... Department Directors review all reports. ... Notifications and measures taken are documented on the medical re. Review, Investigation, and follow-up of an unusual or significant event: ... 6. The director or designee of the department where the unusual or significant event, or near miss, occurred begins the investigation. All information obtained during the investigation is reported to Risk Management. The Department Director must sign off on all events that occurred on their units within 7 working days of the date the event report was submitted. ... Any events that are not signed off within those 7 days will be sent to the senior leader overseeing that department. 7. Data related to the unusual or significant events is aggregated and analyzed across the organization to identify patterns and trends. Results of the analysis are reported to, and acted upon by, the Patient Safety Committee. ... ."