HospitalInspections.org

The facility failed to comply with the Pennsylvania ELDERLY IMMUNIZATION ACT - ENACTMENT Act of Jul. 15, 2004, P.L. 731, No. 85 ... Section 3. Vaccination offered to eligible persons. (a) General rule.--When an eligible person is admitted to a hospital for a period of more than 24 hours for a condition unrelated to the influenza virus or pneumococcal disease, he or she shall be informed that a vaccination for the influenza virus and pneumococcal disease is available and provided the opportunity to receive vaccination against the influenza virus and pneumococcal disease prior to discharge from the hospital.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to comply with the Commonwealth of Pennsylvania Act 85, known as the Elderly Immunization Act for five out of five medical records reviewed (MR20, MR21, MR22, MR23, and MR24).

Findings include:

Review of facility protocols revealed no written protocols were in place for the flu and pneumonia vaccines.
1. Review of MR20 revealed no documentation of a pneumonia screening, and an influenza screening resulting in initiation of influenza vaccine order. Further review of MR20 revealed no documentation that a flu or pneumonia vaccine was contraindicated or ordered.
2. Review of MR21 revealed no documentation of a pneumonia screening, and an influenza screening resulting in initiation of influenza vaccine order. Further review of MR21 revealed no documentation that a flu or pneumonia vaccine was contraindicated or ordered.
3. Review of MR22 revealed no documentation of a pneumonia screening, and an influenza screening resulting in initiation of influenza vaccine order. Further review of MR22 revealed no documentation that a flu or pneumonia vaccine was contraindicated or ordered.
4. Review of MR23 revealed no documentation of a pneumonia screening, and an influenza screening stating that the patient had already received the vaccine. Further review of MR23 revealed no documentation that the pneumonia vaccine was contraindicated or ordered.
5. Review of MR24 revealed no documentation of a pneumonia screening, and an influenza screening stating that the patient had already received the vaccine. Further review of MR24 revealed no documentation that the pneumonia vaccine was contraindicated or ordered.
6. Interview with EMP5, on January 10, 2016, at approximately 10:45 am confirmed the above findings and revealed, "We stopped giving the pneumonia vaccine about a year ago since it was no longer a core measure. ... I don't know why those flu vaccines weren't given."

Based on review of facility documentation and staff interviews (EMP), it was determined that the facility's governing board failed to specify the frequency and detail of data collection in the Quality Improvement Plan.


Findings include:


Review of facility "WHS (Washington Health System): Performance Improvement Plan ... Approved by Quality Council: ... 2/11/16" Further review revealed "F. Director, Quality Management and Director, performance Improvement: The Director of Quality Management and Director, Performance Improvement are responsible for the ongoing coordination integration and communication of performance improvement activities throughout health system: 1. Maintaining an inventory of performance improvement projects and required performance improvement measures. ... 3. Assuring communication of performance improvement/patient safety activities."

Interview with EMP6 on January 10, 2017, at approximate 11:00 AM confirmed the above findings. EMP6 stated, "it's not there," when asked about the frequency and detail of the specified data.

Based on a review of facility documentation and staff interview (EMP), it was determined that the governing body failed to ensure that the QAPI program reflects the complexity of the hospital's organization and services: involves all hospital departments and services including those services furnished under contracted services.


Findings inclued:


Review of facility WHS (Washington Health System): Performance Improvement Plan" approved February 11, 2016, revealed "G. Department Managers: Each clinical and non-clinical department manager makes performance improvement an integral part of the daily operation of their respective departments) and is responsible for: 1. Ensuring an ongoing and systematic process for: a. Measurement of the performance of patient care and/or hospital services ... VI. Documentation And Reporting A. Each hospital and medical staff department and committee maintains meeting minutes and proper documentation of measurement, assessment and improvement activities."


1. Review of "Southwest Regional Medical Center Patient Safety Committee meeting minutes" dated February 10, 2016, March 9, 2016, May 11, 2016, June 23, 2016, July 28, 2016, August 25, 2016, September 22, 2016, October 27, 2016, and December 22, 2016, revealed no documentation of performance improvement data collection for dietary, medical records, case management, anesthesia, emergency department, or contracted services.


Interview with EMP6 on January 10, 2017 at approximately 1:00 PM confirmed the above findings and revealed "Our quality is part of our safety meeting. You're correct, it does not include those areas. I don't look at contracted services."


Interview with EMP1 on January 10, 2017, at approximately 1:45 PM confirmed the above findings and revealed "I understand we're not including everything."

Based on a review of facility documentation and staff interview (EMP), it was determined the facilities governing body failed to ensure that an ongoing program for quality improvement was implemented.


Findings include:


Review of "WHS (Washington Health System): Performance Improvement Plan ... Approved by Quality Council: ... 2/11/16." on January 10, 2017, at approximately 11:00 AM revealed the governing body failed to approve the plan since February 11, 2016.

Interview with EMP1 on January 13, 2017 at approximately 11:00 AM when asked if the Governing Board approved the Performance Improvement Plan, EMP1 stated, "No it has not been approved by the Governing Body yet."

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure the Utilization Review committee consisted of two or more practioners to carry out the Utilization Review functions.


Findings include:


Review of facility documentation "Utilization Management Plan" reviewed/revised February 2016, revealed "4. Utilization Management Committee 4.1 organization 4.1.1. Physician members. The committee will be composed of two(2) or more physician members, appointed by the President of the Medical Staff, and assisted by other professional personnel."


1. Review of facility's "Utilization Committee" meeting minutes dated December 20, 2016, November 15, 2016, October 25, 2016, September 20, 2016, April 12, 2016, June 21, 2016, March 15, 2016, February 16, 2016, and January 19, 2016, revealed no documentation that a physician attended.

Interview with EMP4 on January 10, 2017, confiremd the above findings and revealed "They [physicians] are suppose to come."