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.

PENN HIGHLAND DUBOIS 100 HOSPITAL AVENUE DUBOIS, PA 15801 Aug. 3, 2018
VIOLATION: LABORATORY SERVICES Tag No: A0576
Based on the nature of the standard level deficiencies related to Laboratory Services, the facility failed to substantially comply with this Condition.


Finding include:

These following standards were cited and establish non-compliance with this Condition.

(482.27(a) Tag A-0582)
The information reviewed during the survey provided evidence that the facility failed to determine which services are provided directly by the facility and which are provided through contractual agreements.

(482.27(a)(2) Tag A-0584)
The information reviewed during the survey provided evidence that the facility failed to ensure accurate description of services relative to the mixing/intermingling of two distinct facilities Laboratory and Radiology staff.

(482.27(a)(3) Tag A-0585)
The information reviewed during the survey provided evidence that the facility failed to ensure the proper receipt and reporting of specimens.

Cross Reference with:
482.27(a) Adequacy of Laboratory Services
482.27(a)(2) A written description of services must be available to the medical staff
482.27(a)(3) The Laboratory must make provision for the proper receipt and reporting of tissue specimens.
VIOLATION: ADEQUACY OF LABORATORY SERVICES Tag No: A0582
Based on a review of facility documents, observation, medical records (MR), and interview with staff (EMP), it was determined the facility failed to determine which services are provided directly by the facility and which are provided through contractual agreements.


Finding include:


A telephone interview was conducted with EMP2, on June 12, 2018, and revealed that the lab draw station at Saint Marys Community Building is using Elk's CCN (CMS Certification Number) number and treating this lab draw as Penn Highlands Elk. EMP2 also confirmed on June 19, 2018, that on January 20, 2017, this lab draw location closed under Penn Highlands DuBois and on January 23, 2017 was placed under Penn Highlands Elk. EMP2 confirmed that nothing was completed by either faciilty to formalize this change, and neither Penn Highlands DuBois or Penn Highlands Elk requested approval by the Department prior to their changing providers CCN. Subsequently, EMP2 stated that they were advised by Compliance personnel that labs drawn under DuBois cannot go to Penn Highlands Elk lab for processing, and that the Saint Marys Community Building is listed as a whole as Penn Highlands DuBois for CMS 855 purposes.


Review of photographs of the signage at the Saint Marys Community Medical Building, were received by EMP2 June 21, 2018. The entrance of the building was noted to state Penn Highlands Healthcare, Imaging and Lab Services. Other pictures of interior signage was reviewed related to the Imaging and Lab Services area, which included view of the Registration desk, and a photo of the Lab window. No signage was noted that indicated Penn Highlands Elk was providing the outpatient Lab services, or that Penn Highlands DuBois was providing Imaging Services.


Review of MR1, revealed a demographic page which indicated the medical service to be Laboratory, and listed the facility as Penn Highlands Elk, on March 21, 2018. A review of the consent signed by the patient, on March 21, 2018, revealed " ... I present myself to Penn Highlands Elk for medical care, I consent to diagnostic procedures, telehealth/telemedicine and /or treatments as prescribed by the attending physician or his designees as needed ... I furthermore authorize payment directly to Penn Highlands Elk ... ." Review of other documentation relative to MR1 revealed that the patient had chemistry lab work (PSA) specimen collected again on March 28, 2018.


A telephone interview with EMP9, on June 19, 2018, at approximately 2:30PM, revealed "The patient presented to the Saint Marys Community Building Lab. EMP4 entered the order for the blood work. (They are) a phlebotomist, but the Rad Tech drew the patient's blood. The results went to the wrong patient, because they went by the name only, didn't use two identifiers. Sometimes they come over from Radiology to help. I got involved because EMP4 is a DuBois employee. (They are) leased by Elk. Sometimes Elk covers the lab. This change (from DuBois to Elk) ... was January 2017."


A telephone interview with EMP10 on June 21, 2018, at 10:00AM, with EMP1 revealed "We received a call from the patient stating their lab results had not gone to their doctor. EMP3 took care of getting the patient to come back. They notified me of the incident. I did report it. I spoke to Penn Highlands DuBois Laboratory Supervisor and the Assistant VP of Lab." When asked about the DOE (Department Order Entry) process, EMP10 stated that this is a Penn Highlands DuBois process, and that this Lab draw location uses the Penn Highlands DuBois DOE (Departmental Order Entry) process. EMP10 stated that EMP4 informed them of what happened and that Penn Highlands DuBois followed up with EMP4. EMP10 stated that EMP4 placed the order and that on March 21st, the patient was registered by Penn Highlands DuBois Registration personnel. EMP10 continued by stating that the Rad Techs help with phlebotomy when it is busy, and stated that Radiology is a service of Penn Highlands DuBois. When asked about the process for placing an order, EMP10 stated that you are to look at the patient's account, name, birth date and financial number and that at least two items are to be verified when placing the order, and stated that patient identification is what broke in the process. EMP10 stated that they didn't know how the lab draw was set up, and stated that they do not supervise that area.


A telephone interview with EMP3 with EMP1 on June 21, 2018, at 11:00AM, revealed "I was initially contacted by the patient, they were concerned that their doctor hadn't received their PSA results ... I have no oversight over the Community Medical Building ... The patient called me, that is why I got involved."


A telephone interview with EMP12 with EMP2, on June 21, 2018, at approximately 2:45PM, regarding the registration process at Saint Marys Community Medical Building, revealed "First the patient takes a number, and they are called to office one or two. I'll call the Lab and then the Lab staff gets them. We do the registration and get the consent signed." When asked about consents, EMP12 stated that for lab it is the Penn Highlands Elk consent and, for Radiology, EKG, and Ultrasound it is Penn Highlands DuBois consent. EMP12 stated they had education when hired, but nothing with Elk. EMP12 stated that they utilized DuBois policies and patient rights handouts are all DuBois.


A telephone interview with EMP4 with EMP8, on June 22, 2018, at approximately 8:45AM, revealed "A patient came in the day before with a similar name, with just one letter short. The patient was in the day before, andthe results went under them ... To the best of my knowledge, I used identifiers, but I must not have. It is a Penn Highlands DuBois policy, because we're DuBois staff, most of us." When asked about any policies related to Elk, EMP4 stated "They have a little policy but is very vague. It was recent, after this event ... I go by what I've done for DuBois ... We're sending labs to Elk. They lease me and reimburse DuBois for me. On my days off, it's Elk staff ... ."


A telephone interview with EMP11 with EMP8, on June 22, 2018, revealed "I don't remember this very well. I'm one of five Radiology techs that rotate. We help out when the Lab is busy. When Saint Marys took over the Lab, they had their own system, so they learned a whole new way of ordering... ." When asked, if there is a policy to describing the process, EMP11 stated it was a Penn Highlands DuBois Protocol, Outpatient.


Cross Reference:
482.27 Laboratory Services
VIOLATION: WRITTEN DESCRIPTION OF SERVICES Tag No: A0584
Based on a review of facility documents, observation, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure accurate description of services relative to the mixing/intermingling of two distinct facilities Laboratory and Radiology staff.


Finding include:

Penn Highlands DuBois policy entitled "Outpatient Phlebotomy", dated February 2018, revealed, "Purpose: Procedure for out patient phlebotomy. ... 2. Patients will ring the bell and give the lab personnel their orders and have a seat. Courteously bring patients into the drawing area. Identify patient by their name and DOB ... ."


Penn Highlands DuBois policy entitled "Outpatient Services", dated February 2018, revealed, "Purpose: To provide a convenient and efficient protocol to receive, register, draw and bill all out patients. Policy: No out patient will be received without proper orders from the physician. All out patients must be properly registered. Procedure: All patients identification will be confirmed by asking the patient their name and birthdate. The orders for the out patient are either given to the patient on a doctors order slip to bring to the hospital with them or ... A Doctor must request all laboratory procedures. The report is given to the Doctor who requested the tests. The result may be given to patient if we have been instructed to by the Doctor. A release form must be signed by the patient. ... ."

A telephone interview was conducted with EMP2, on June 12, 2018, and revealed that the lab draw station at Saint Marys Community Building is using Elk's CCN (CMS Certification Number) number and treating this lab draw as Penn Highlands Elk. EMP2 also confirmed on June 19, 2018, that on January 20, 2017, this lab draw location closed under Penn Highlands DuBois and on January 23, 2017 was placed under Penn Highlands Elk. EMP2 confirmed that nothing was completed by either faciilty to formalize this change, and neither Penn Highlands DuBois or Penn Highlands Elk requested approval by the Department prior to their changing providers CCN. Subsequently, EMP2 stated that they were advised by Compliance personnel that labs drawn under DuBois cannot go to Penn Highlands Elk lab for processing, and that the Saint Marys Community Building is listed as a whole as Penn Highlands DuBois for CMS 855 purposes.


Review of photographs of the signage at the Saint Marys Community Medical Building, were received by EMP2 June 21, 2018. The entrance of the building was noted to state Penn Highlands Healthcare, Imaging and Lab Services. Other pictures of interior signage was reviewed related to the Imaging and Lab Services area, which included view of the Registration desk, and a photo of the Lab window. No signage was noted that indicated Penn Highlands Elk was providing the outpatient Lab services, or that Penn Highlands DuBois was providing Imaging Services.


Review of MR1 revealed a demographic page which indicated the medical service to be Laboratory, and listed the facility as Penn Highlands Elk, on March 21, 2018. A review of the consent signed by the patient, on March 21, 2018, revealed " ... I present myself to Penn Highlands Elk for medical care, I consent to diagnostic procedures, telehealth/telemedicine and /or treatments as prescribed by the attending physician or his designees as needed ... I furthermore authorize payment directly to Penn Highlands Elk ... ." Review of other documentation relative to MR1 revealed that the patient had chemistry lab work (PSA) specimen collected again on March 28, 2018.



A telephone interview with EMP10 on June 21, 2018, at 10:00AM, with EMP1 revealed "We received a call from the patient stating their lab results had not gone to their doctor. EMP3 took care of getting the patient to come back. They notified me of the incident. I did report it. I spoke to Penn Highlands DuBois Laboratory Supervisor and the Assistant VP of Lab." When asked about the DOE (Department Order Entry) process, EMP10 stated that this is a Penn Highlands DuBois process, and that this Lab draw location uses the Penn Highlands DuBois DOE (Departmental Order Entry) process. EMP10 stated that EMP4 informed them of what happened and that Penn Highlands DuBois followed up with EMP4. EMP10 stated that EMP4 placed the order and that on March 21st, the patient was registered by Penn Highlands DuBois Registration personnel. EMP10 continued by stating that the Rad Techs help with phlebotomy when it is busy, and stated that Radiology is a service of Penn Highlands DuBois.



A telephone interview with EMP12 with EMP2, on June 21, 2018, at approximately 2:45PM, regarding the registration process at Saint Marys Community Medical Building, revealed "First the patient takes a number, and they are called to office one or two. I'll call the Lab and then the Lab staff gets them. We do the registration and get the consent signed." When asked about consents, EMP12 stated that for lab it is the Penn Highlands Elk consent and, for Radiology, EKG, and Ultrasound it is Penn Highlands DuBois consent. EMP12 stated they had education when hired, but nothing with Elk. EMP12 stated that they utilized DuBois policies and patient rights handouts are all DuBois.



A telephone interview with EMP11 with EMP8, on June 22, 2018, revealed "I don't remember this very well. I'm one of five Radiology techs that rotate. We help out when the Lab is busy. When Saint Marys took over the Lab, they had their own system, so they learned a whole new way of ordering... ." When asked, if there is a policy to describing the process, EMP11 stated it was a Penn Highlands DuBois Protocol, Outpatient.

Cross Reference:
482.27 Laboratory Services
VIOLATION: WRITTEN PROTOCOL FOR TISSUE SPECIMENS Tag No: A0585
Based on a review of facility documents, observation, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the proper receipt and reporting of specimens.


Finding include:

Penn Highlands DuBois policy entitled "Outpatient Services", dated February 2018, revealed, "Purpose: To provide a convenient and efficient protocol to receive, register, draw and bill all out patients. Policy: No out patient will be received without proper orders from the physician. All out patients must be properly registered. Procedure: All patients identification will be confirmed by asking the patient their name and birthdate. The orders for the out patient are either given to the patient on a doctors order slip to bring to the hospital with them or ... A Doctor must request all laboratory procedures. The report is given to the Doctor who requested the tests. The result may be given to patient if we have been instructed to by the Doctor. A release form must be signed by the patient. ... ."


Review of medical record documents for MR2, revealed that the PSA test result from March 21, 2018, for MR1, was reported relative to the patient associated with MR2. It was noted that the patient relevant to MR2 was sent for a Urology Consult as a result of this testing, at which time biopsy was discussed.


A telephone interview with EMP9, on June 19, 2018, at approximately 2:30PM, revealed "The patient presented to the Saint Marys Community Building Lab. EMP4 entered the order for the blood work. (They are) a phlebotomist, but the Rad Tech drew the patient's blood. The results went to the wrong patient, because they went by the name only, didn't use two identifiers. Sometimes they come over from Radiology to help. I got involved because EMP4 is a DuBois employee. (They are) leased by Elk. Sometimes Elk covers the lab. This change (from DuBois to Elk) ... was January 2017."


A telephone interview with EMP10 on June 21, 2018, at 10:00AM, with EMP1 revealed "We received a call from the patient stating their lab results had not gone to their doctor. EMP3 took care of getting the patient to come back. They notified me of the incident. I did report it. I spoke to Penn Highlands DuBois Laboratory Supervisor and the Assistant VP of Lab." When asked about the DOE (Department Order Entry) process, EMP10 stated that this is a Penn Highlands DuBois process, and that this Lab draw location uses the Penn Highlands DuBois DOE (Departmental Order Entry) process. EMP10 stated that EMP4 informed them of what happened and that Penn Highlands DuBois followed up with EMP4. EMP10 stated that EMP4 placed the order and that on March 21st, the patient was registered by Penn Highlands DuBois Registration personnel. EMP10 continued by stating that the Rad Techs help with phlebotomy when it is busy, and stated that Radiology is a service of Penn Highlands DuBois. When asked about the process for placing an order, EMP10 stated that you are to look at the patient's account, name, birth date and financial number and that at least two items are to be verified when placing the order, and stated that patient identification is what broke in the process. EMP10 stated that they didn't know how the lab draw was set up, and stated that they do not supervise that area.



A telephone interview with EMP3 with EMP1 on June 21, 2018, at 11:00AM, revealed "I was initially contacted by the patient, they were concerned that their doctor hadn't received their PSA results ... I have no oversight over the Community Medical Building ... The patient called me, that is why I got involved."



A telephone interview with EMP4 with EMP8, on June 22, 2018, at approximately 8:45AM, revealed "A patient came in the day before with a similar name, with just one letter short. The patient was in the day before, andthe results went under them ... To the best of my knowledge, I used identifiers, but I must not have. It is a Penn Highlands DuBois policy, because we're DuBois staff, most of us." When asked about any policies related to Elk, EMP4 stated "They have a little policy but is very vague. It was recent, after this event ... I go by what I've done for DuBois ... We're sending labs to Elk. They lease me and reimburse DuBois for me. On my days off, it's Elk staff ... ."



Cross Reference:
482.27 Laboratory Services
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on the nature of the standard level deficiencies related to Medical Records Services, the facility failed to substantially comply with this Condition.

Findings include:

These following standards were cited and demonstrate non-compliance with Medical Record Services as follows:

(482.24(b) Tag A-0438)
The information reviewed during the survey provided evidence that the facility failed to maintain an accurate medical record for one of one medical records reviewed (MR2)

(482.24(b)(3) Tag A-0441)
The information reviewed during the survey provided evidence that the facility failed to ensure access to medical records was limited to the distinct entity that was providing services.


Cross Reference:
482.24(b) Form and Retention of Record
482.24(b)(3) The facility must have a procedure for ensuring the confidentiality of patient records.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to maintain an accurate medical record for one of one medical records reviewed (MR2).

Findings:

Review of medical record documents for MR2, revealed that the PSA test result from March 21, 2018, for MR1, was reported relative to the patient associated with MR2.

A telephone interview with EMP9, on June 19, 2018, at approximately 2:30PM, revealed "The patient presented to the Saint Marys Community Building Lab ... all the results went to the wrong patient ... ."

A telephone interview with EMP4 on June 22, 2018, at approximately 8:45AM, revealed "A patient came in the day before with a similar name, just with one letter short. That patient was in the day before, and the results went under them ... When you bring up accounts, it shows whether the encounter was for Imaging, PT (Physical Therapy). The two hospitals are intermingled."

Cross Reference:
482.24 Medical Record Services
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure access to medical records was limited to the entity that was providing services.


Findings:

Review of medical record documents for MR2, revealed that the PSA test result from March 21, 2018, for MR1, was reported relative to the patient associated with MR2.

A telephone interview with EMP9, on June 19, 2018, at approximately 2:30PM, revealed "The patient presented to the Saint Marys Community Building Lab ... all the results went to the wrong patient ... ."

A telephone interview with EMP4 on June 22, 2018, at approximately 8:45AM, revealed "A patient came in the day before with a similar name, just with one letter short. That patient was in the day before, and the results went under them ... When you bring up accounts, it shows whether the encounter was for Imaging, PT (Physical Therapy). The two hospitals are intermingled."


Cross Reference:
482.24 Medical Record Services
VIOLATION: GOVERNING BODY Tag No: A0043
Based on the nature of the standard level deficiencies related to Governing Body, the facility failed to substantially comply with this Condition

Findings include:

These following standards were cited and establish non-compliance with this Condition.

(482.12(a) Tag A-0047)
The information reviewed during the survey provided evidence that the Governing Body failed to ensure that space/services utilized for the Imaging Services at the off-site location at the Saint Marys Community Medical Building was limited to said provider (distinct entity requirements), by failing to ensure that the Governing Body approved Medical Staff Bylaws and rules and regulations address the mixing/intermingling of Laboratory and Radiology staff with another distinct facility's staff.

(482.12(a)(5) Tag A-0049)
The information reviewed during the survey provided evidence that the Governing Body failed to ensure quality of care by the mixing/intermingling of two distinct facilties Laboratory and Radiology staff.

(482.12(a)(10) Tag A-0053)
The information reviewed during the survey provided evidence that the Governing Body failed to ensure direct consultation with the medical staff related to quality care as it relates to the mixing/intermingling of two distinct facilties Laboratory and Radiology staff.

Cross Reference:
482.12(a) Standard: Medical Staff. The governing body must
482.12(a)(5) Ensure that the Medical Staff is accountable to the governing body for the quality of care provided to patients.
482.12(a)(10) The governing body must
482.27 Laboratory Services
482.24 Medical Record Services
VIOLATION: MEDICAL STAFF - BYLAWS Tag No: A0047
Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that space/services utilized for the Imaging Services at the off-site location at the Saint Marys Community Medical Building was limited to said provider (distinct entity requirements), by failing to ensure that the Governing Body approved medical staff bylaws and rules and regulations which address the mixing/intermingling of Laboratory and Radiology staff with another facility's staff.

Findings:

On approximately April 17, 2018, a telephone call was placed to EMP1 (Penn Highlands Elk). EMP1 stated that the patient (MR1) only had blood processed at their facility in the Lab. EMP1 stated that a DuBois employee drew the blood at the draw site in the Saint Marys Community Medical Building. EMP1 stated that the error involved two patients, and that the blood was mislabeled at the Medical Office Building. EMP1 stated that this is a DuBois lab draw station.

A telephone interview with EMP2, on May 31, 2018, revealed that the lab draw station at the Community Building is not on Penn Highlands DuBois 855. EMP2 stated that it is being billed under Penn Highlands Elk.

A telephone interview was conducted with EMP2, on June 12, 2018, and revealed that the lab draw station at Saint Marys Community Building is using Elk's CCN (CMS Certification Number) number and treating this lab draw as Penn Highlands Elk satellite. EMP2 also confirmed on June 19, 2018, that on January 20, 2017, this lab draw location closed under Penn Highlands DuBois and on January 23, 2017 was placed under Penn Highlands Elk. EMP2 confirmed that nothing was completed by either faciilty to formalize this change, and neither Penn Highlands DuBois or Penn Highlands Elk requested approval by the Department prior to their changing providers CCN. Subsequently, EMP2 stated that they were advised by Compliance personnel that labs drawn under DuBois cannot go to Penn Highlands Elk lab for processing, and that the Saint Marys Community Building is listed as a whole as Penn Highlands DuBois for CMS 855 purposes.

A telephone interview with EMP2 on June 19, 2018, related to the Saint Marys Community Medical Building, revealed that the lab draw closed on January 20, 2017, under DuBois, and that the lab is not listed on the 855 for CMS purposes for Penn Highlands Elk. EMP2 stated that Penn Highlands Elk employs the phlebotomist. EMP2 continued by stating that all services for Saint Marys Community Medical Building are listed under Penn Highlands DuBois 855 for CMS purposes.

Cross reference:
482.12 Governing Body
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure quality of care by the mixing/intermingling of two distinct facilties Laboratory and Radiology staff.

Findings:

A telephone interview with EMP9, on June 19, 2018, at approximately 2:30PM, revealed "The patient presented to the Saint Marys Community Building Lab. EMP4 entered the order for the blood work. EMP4 is a phlebotomist, but the Rad Tech drew the patient. Everything went to the wrong patient. They went by the name only. Sometimes staff come over from Radiology to help. I got involved because EMP4 is a DuBois employee. EMP4 is leased by Elk. Sometimes Elk covers the lab. This change (from DuBois to Elk) occurred January 2017." EMP9 confirmed that registration is shared between Radiology and Lab area.

A telephone interview with EMP10, on June 21, 2018, at 10:00AM, with EMP1, revealed "We received a call from the patient stating their lab results had not gone to their doctor. EMP3 took care of getting the patient to come back. EMP3 notified me of the incident. I did report it. I spoke to Penn Highlands DuBois Laboratory supervisor and the Assistant VP of Lab." When asked about the DOE (Departmental Order Entry) process, EMP10 stated that this is a Penn Highlands DuBois process, and that this lab draw uses the Penn Highlands DuBois DOE (Departmental Order Entry) process. EMP10 stated that EMP4 informed them of what happened and that Penn Highlands DuBois followed up with EMP4. EMP10 stated that the registration staff are Penn Highlands DuBois employees. EMP10 stated that EMP4 placed the order and that on March 21st, the patient was registered by Penn Highlands DuBois registration personnel. EMP10 stated that they did not think the error occurred at registration, and stated that (they are) doing the audits because (they are) the closest. EMP10 continued by stating that the Rad Techs help with phlebotomy when it is busy, and stated that Radiology is a service of Penn Highlands DuBois. EMP10 stated that they didn't know how the lab draw was set up, and stated that they do not supervise that area. EMP10 stated that phlebotomists from Penn Highlands Elk fill in at the Saint Mary's Community Medical Building when EMP4 is not there.

A telephone interview with EMP3 with EMP1, on June 21, 2018, at 11:00AM, revealed "I was initially contacted by the patient, they were concerned that their doctor hadn't gotten their PSA results ... I talked to EMP4 and they said they believed the patient's blood work had ended up on the account of another patient. I handed this over to EMP10. I knew they would know what direction to take. I have no oversight over the Community Medical Building ... The patient called me, that is why I got involved."

A telephone interview with EMP12, with EMP2 on June 21, 2018, at approximately 2:45PM, regarding the registration process at Saint Marys Community Medical Building, revealed "First the patient takes a number, and they are called to office one or two. I'll call the Lab and then the Lab staff gets them. We do the registration and get the consent signed." When asked about consents, EMP12 stated that for labs, it is the Penn Highlands Elk consent, and for Radiology, EKG, and Ultrasound, it is Penn Highlands DuBois consent. EMP12 stated that they utilize DuBois policies and Patient Rights handouts are all DuBois. EMP12 stated that there is one big Waiting Room and Registration area for both facilities.


Cross reference:
482.12 Governing Body
VIOLATION: CONSULTATION WITH MEDICAL STAFF Tag No: A0053
Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure direct consultation with the Medical Staff related to quality care as it relates to the mixing/intermingling of two distinct facilties Laboratory and Radiology staff.

Findings:


A telephone interview with EMP4 with EMP8, on June 22, 2018, at approximately 8:45AM, revealed "... I go by what I've done for DuBois for ... years. I make sure it's the right doctor, right account, patient and birth date. We're sending labs to Elk. They lease me and reimburse DuBois for me. On my days off, they use Elk staff. It's been a little under a year and a half ... When you bring up accounts, it shows whether the encounter was for Imaging, PT. The two hospitals are intermingled." EMP8 stated that the Waiting Room is shared.

A telephone interview with EMP 11 with EMP8, on June 22, 2018, revealed "I don't remember this very well. I'm one of five techs that rotate. We help out when the lab is busy. When Saint Marys took over the lab, they had their own system, so they learned a whole new way of ordering. Once we went back to Cerner, the Rad Tech can't order. I can only activate electronic orders. I brought the patient back, I had an order in hand. I asked patient their name and birthdate. Sometimes, I'll have stickers, and I'll label manually. I know I had the order. I don't remember if I drew or EMP4 drew the blood. It was the patient's order, under a different name. If I know we only have one or two tubes, I could do and label it the name and birthdate of the patient and put the stickers on later. ... ." When asked if there was a policy describing the process, EMP 11 stated it was a Penn Highlands DuBois Protocol, Outpatient.

A telephone interview with EMP1, on July 3, 2018, revealed that in addition to lab draws, the collection of urine and stool specimens, sputum specimens, throat and nasopharyngeal swabs, are all collected at this lab site, and all are subsequently sent to Penn Highlands Elk Hospital, for processing.


Cross reference:
482.12 Governing Body