The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| BRANDYWINE HOSPITAL | 201 REECEVILLE ROAD COATESVILLE, PA 19320 | May 7, 2018 |
| VIOLATION: CHIEF EXECUTIVE OFFICER | Tag No: A0057 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, medical records (MR), and interview with staff (EMP) it was determined that the Chief Executive Officer/President failed: to provide for compliance with applicable laws and regulations; and to carry out policies established by the hospital and the Board. Findings include: A review of the "Brandywine Hospital, LLC Operating Agreement" effective date July 13, 2017, revealed, "ARTICLE IV OFFICERS ... . 4.3 President and Chief Executive Officer. ... . The President shall be responsible for the management of the Company, subject in all cases to the policies and directions of the Board. The President shall also be responsible for establishing a procedure for implementing, disseminating and enforcing a Patient's Bill of Rights in compliance with applicable law. In exercising general management of the business of the Company, the President's duties shall include, but not limited to: (a) providing for compliance with applicable laws and regulations; (b) carrying out policies established by the Member and the Board and advising on the formation of such policies; ... . (f) developing and administering personnel policies and practices of the Company that adequately support sound patient care; ... . (h) working with other health care professionals to ensure that high quality care is rendered to patients; ... ." 1. The Child Protective Services Law (23 Ps.C.S. Chapter 61) 6311. Persons required to report suspected child abuse. (a) Mandated reporters. ... (3) An employee of a health care facility or provider licensed by the Department of Health, who is engaged in the admission, examination, care or treatment of individuals. ... (b) Basis to report. -- (1) A mandated reporter enumerated in subsection (a) shall make a report of suspected child abuse in accordance with section 6313 (relating to reporting procedure)... . (c) Staff members of institutions, etc. -- Whenever a person is required to report under subsection (b) in the capacity as a member of the staff of a medical or other public or private institution... , that person shall report immediately in accordance with section 6313 and shall immediately thereafter notify the person in charge of the institution, ... . 6313 Report by mandated reporter. -- (1) A mandated reporter shall immediately make an oral report of suspected child abuse to the department via the Statewide toll-free telephone number under section 6332 (relating to establishment of Statewide toll-free telephone number) or a written report using electronic technologies under section 6305 (relating to electronic reporting). (2) A mandated reporter making an oral report under paragraph (1) of suspected child abuse shall also make a written report, which may be submitted electronically, within 48 hours to the department or county agency assigned to the case in a manner and format prescribed by the department. ... ." A review on April 3, 2018, of facility policy "Suspected Patient Abuse/Neglect" last revised October 16, 2016, revealed, "As required by Section 6311 of the Pennsylvania Child Protection Services Law, all licensed physician, social workers, registered nursed, licensed practical nurses and other Hospital personnel engaged in the admission, examination, care or treatment of patients are required by law to report all cases of suspected child abuse/neglect to the Children and Youth Services Agency according to the procedures specified in the body of the policy. ... . Procedure: I. Child Abuse... 2. When suspected child abuse is identified, the individual identifying the problem must complete CY-47 (Report of Suspected Child Abuse form - Child Protective Service Law - Title 23 CSA Chapter 63) and notify immediately the House Supervisor on duty. ... . 4. In child abuse cases, the patient's medical record shall be completed as follows: ... c. The person identifying the injuries must complete state Form CY-47. A mandatory call to ChildLine 1-800-932-0313 must occur during their work shift. The CY-47 must be mailed within 48 hours. d. A copy of the Report of Suspected Child Abuse (State form CY-47) shall be maintained in the medical record. ... . CY-47 form can be completed on line at:... ." A review of MR1 revealed documentation that staff observed on camera the actions of a visitor touching MR1 (a minor) in an inappropriate manner on August 27, 2018. A progress note on August 30, 2017, at 3:43 PM by EMP5 revealed "Therapist called to make report for Childline 1-800-932-0313. Therapist made report to operator... ." A telephone interview conducted on April 3, 2018, at 2:45 PM with EMP16 revealed that EMP16 and EMP4 were at the nursing station on August 27, 2017, and they observed on camera a visitor with MR1 massage, touch and kiss the patient inappropriately. EMP16 stated that EMP16 had directed the staff to make a report to EMP3 and expected the staff would report to the CHILDLINE number. A telephone interview conducted on April 3, 2018, at 3:00 PM with EMP5 revealed that, on August 30, 2017, EMP5 viewed the DVD of the visitor's inappropriate behavior on August 27, 2017, towards MR1. EMP5 confirmed that EMP5 reported the suspected child abuse incident to CHILDLINE# on August 30, 2017, when EMP5 determined that no staff had reported the incident. EMP5 stated that EMP5 was not aware that a written report on a CY-47 needed to be completed within 48 hours of the verbal report and no such report was completed. A telephone interview conducted on April 3, 2018, at 3:30 PM with EMP4 revealed that EMP4 and EMP16 had observed the inappropriate behavior of a visitor with MR1 on camera on August 27, 2017. EMP4 revealed that EMP4's understanding on August 27, 2017, was that EMP16 would report the suspected child abuse incident and therefore EMP4 did not need to report. EMP4 stated that EMP4 was not aware of the facility policy for reporting suspected patient abuse or the specifics for the reporting process. Further interview confirmed that EMP4 had completed the facility's 2017 annual mandatory training that included reporting of Child Abuse. A review of an email received April 3, 2018, from EMP1 revealed, "PA Law and Brandywine Hospital policy: Suspected Patient Abuse / Neglect, states that "The person identifying the injuries must complete state Form CY-47. A mandatory call to ChildLine 1-800-932-0313 must occur during their work shift. The CY-47 must be mailed within 48 hours." The staff member that observed the behavior did not fulfill (their) legal mandate, to report reasonable cause to suspect that a child is being abused." A telephone interview conducted on April 5, 2018, at 2:00 PM with EMP1 confirmed that the facility had failed to follow the requirements of the Child Protective Services Law and their policy for reporting suspected child abuse for the incident that occurred on August 27, 2017, at the facility. 2. A review of policy "Discharge Planning and Continuity of Care" effective date March 2017 revealed, "1. Discharge Criteria: ... . c. The social worker/designee has primary responsibility for documenting in the patient's record all activities and their status regarding the process of discharge planning of the patient,... ." A review of policy "Withdrawal from Treatment" last revised March 2017 revealed, "When a patient requests to leave treatment, the following procedures will be followed: ... 6. Following this notice, contact will be made by the Social Worker or designee with the patient's outpatient therapist or treatment provider." A review of MR1 on March 27, 2018, revealed the patient was admitted [DATE], to the Eating Disorder Unit (EDU) and an initial treatment plan was started August 23, 2017, that included, "Social Worker/Therapist: ... Coordinate discharge placement, aftercare, and community resources;... ." The patient signed the Withdrawal from Treatment form on August 30, 2017, and the Informed Consent for Refusal and Release of Liability on September 2, 2017, and left Against Medical Advice (AMA) on September 2, 2017. No documentation was found that the initial discharge plan was implemented or that the patient's outpatient therapist or treatment provider was contacted. A review of MR2 on March 27, 2018, revealed the patient was admitted [DATE], to the EDU and an initial treatment plan was started March 27, 2018. The patient signed the Withdrawal from Treatment form on February 23, 2018, and the Informed Consent for Refusal and Release of Liability on February 25, 2018. The patient left AMA on February 25, 2018. No documentation was found that the initial discharge plan was implemented or that the patient's outpatient therapist or treatment provider was contacted. A review of MR3 on March 27, 2018, revealed the patient was admitted [DATE], to the EDU and an initial treatment plan was started . The patient signed the Withdrawal from Treatment form on November 2, 2017, and the Informed Consent for Refusal and Release of Liability on November 6, 2017. The patient left AMA on November 6, 2017. No documentation was found that the initial discharge plan was implemented or that the patient's outpatient therapist or treatment provider was contacted. An interview conducted on March 27, 2018, at 3:40 PM with EMP1 and EMP2 confirmed that the staff did not follow their policies for discharge planning and for patients leaving AMA for MR1, MR2 and MR3. EMP2 confirmed that no evidence was found that the initial discharge plans were implemented or that the patient's outpatient therapist or treatment provider was contacted. A telephone interview conducted on April 3, 2018, at 3:00 PM with EMP5 revealed that EMP5 did not understand that, when a patient signed out AMA, discharge planning still needed to continue. EMP5 confirmed that they had not contacted MR1's outpatient therapist or treatment provider as required by policy. |
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| VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN | Tag No: A0820 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, medical records (MR) and interview with staff (EMP), it was determined the facility failed to follow their policies to arrange for the initial implementation of the patient's discharge plan. Findings include: 1. A review of policy "Discharge Planning and Continuity of Care" effective date March 2017 revealed, "2. Development and Implementation of the Discharge Plan a. Development and implementation of the discharge plan is coordinated by, but not, limited to the Social Worker/designee with input from their team members along with relying upon input from the patient for initial and ongoing assessments of the patient. b. The patient, family and significant other are encouraged to participate in discharge planning. e. Should the patient require continuing treatment with the identified provider following discharge from inpatient care, the patient will be referred by the Social Worker/designee to that provider through contact with appropriate liaison or case manager. 3. Discharge Process: ... . c. The social worker/designee has primary responsibility for documenting in the patient's record all activities and their status regarding the process of discharge planning of the patient,... ." A review of policy "Withdrawal from Treatment" last revised March 2017 revealed, "When a patient requests to leave treatment, the following procedures will be followed: ... 6. Following this notice, contact will be made by the Social Worker or designee with the patient's outpatient therapist or treatment provider." A review of MR1 on March 27, 2018, revealed the patient was admitted [DATE], to the Eating Disorder Unit (EDU) and an initial treatment plan was started August 23, 2017, that included, "Social Worker/Therapist: ... Coordinate discharge placement, aftercare, and community resources;... ." The patient signed the Withdrawal from Treatment form on August 30, 2017, and the Informed Consent for Refusal and Release of Liability on September 2, 2017, and left Against Medical Advice (AMA) on September 2, 2017. No documentation was found that the initial discharge plan was implemented, the patient's outpatient therapist or treatment provider was contacted or that the initial discharge plan was discussed with the parents when they left with the patient AMA. A review of MR2 on March 27, 2018, revealed the patient was admitted [DATE], to the EDU and an initial treatment plan was started March 27, 2017, that included, "Social Worker/Therapist: ... Coordinate discharge placement, aftercare, and community resources;... ." The patient signed the Withdrawal from Treatment form on February 23, 2018, and the Informed Consent for Refusal and Release of Liability on February 25, 2018. The patient left AMA on February 25, 2018. No documentation was found that the initial discharge plan was implemented, the patient's outpatient therapist or treatment provider was contacted or that the initial discharge plan was discussed with the parents when they left with the patient AMA. A review of MR3 on March 27, 2018, revealed the patient was admitted [DATE], to the EDU and an initial treatment plan was started November 3, 2017, that included, "Social Worker/Therapist: ... Coordinate discharge placement, aftercare, and community resources;... ." The patient signed the Withdrawal from Treatment form on November 2, 2017, and the Informed Consent for Refusal and Release of Liability on November 6, 2017. The patient left AMA on November 6, 2017. No documentation was found that the initial discharge plan was implemented, the patient's outpatient therapist or treatment provider was contacted or that the initial discharge plan was discussed with the parents when they left with the patient AMA. An interview conducted on March 27, 2018, at 3:40 PM with EMP1 and EMP2 confirmed that the staff did not follow their policies for discharge planning and for patients leaving AMA for MR1, MR2 and MR3. EMP2 confirmed that no evidence was found that the initial discharge plans were implemented, the patient's outpatient therapist or treatment provider was contacted or that the initial discharge plan was discussed with the parents when they left with the patient AMA. |
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