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.
| DANVILLE STATE HOSPITAL | 50 KIRKBRIDE DRIVE DANVILLE, PA 17821 | Nov. 18, 2015 |
| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure problems identified in the Infection Control program were addressed in the hospital's Quality Assurance Performance Improvement program. Findings include: Review on April 9, 2015, of the facility's "Performance Improvement/Risk Management Program," last reviewed May 2012, revealed "Purpose: To ensure all Hospital employees are aware of, understand, and support the Hospital's Performance Improvement/Risk Management efforts. Policy: It is the goal of this Hospital to provide treatment and services at the highest possible level of excellence and that each employee be [sic] aware of, and strive to achieve this goal. To assist in accomplishing this objective, a Performance Improvement/Risk Management Program has been established. Policies and procedures governing the administration of the Performance Improvement/Risk Management Program are contained in the attached Performance Improvement/Risk management Program Plan." Review on April 9, 2015, of the facility's "Performance Improvement/Risk Management Program Plan," last reviewed May 2012, revealed "... 3. Organization and Responsibilities ... C. The following standing committees are an integral part of the hospital's Performance Improvement/Risk Management Program in that they report to the Executive Staff. Problems or potential problems, which are the concern of their respective committees, the actions taken for correction, and the outcome of the action; 1. Collaborative Practice Committee 2. Functional Safety and Management Committee 3. Human Rights Committee 4. Infection Control Committee 5. Information Management Committee 6. Pharmacy and Therapeutics Committee 7. Policy/Procedure Committee 8. Therapeutic Environment Committee 9. Treatment Planning Committee 10. Utilization Review Committee. ..." Review on April 9, 2015, of the facility's Quality Committee Meeting Minutes for January 16, 2014, February 10, 2014, April 14, 2014, June 9, 2014, July 14, 2014, August 11, 2014, September 8, 2014, November 10, 2014, December 8, 2014, January 12, 2015, and March 9, 2015, revealed no documentation infection control was represented at the Quality Committee Meetings. There was no documentation the problems identified in the Infection Control program were addressed in the hospital's Quality Committee meetings. Interview with EMP8 on April 9, 2015, at approximately 2:15 PM revealed the Infection Control officer did not attend the Quality Committee meetings or provide information for the Quality Committee meeting agenda. Interview with EMP7, EMP8 and EMP9 on April 10, 2015, at approximately 10:45 AM confirmed there was no Infection Control representation at the Quality Committee meetings on the above dates and that Infection Control was not part of the agenda. |
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| VIOLATION: DIRECTOR OF DIETARY SERVICES | Tag No: A0620 | |
| Based on review of facility documents, observation and staff interview (EMP) it was determined the dietary director failed to store food in a manner to protect it from contamination in the walk-in freezer. Findings include: Review on April 8, 2015, of facility policy "Receiving of Perishable Food," last reviewed March 20, 2015, revealed "1.0 Receiving of Frozen Food ... 1.5 Food packaging shall be inspected to ensure the box is sealed and was not tampered with. No damaged cases will be accepted. ... Policy/Procedure-Chilling, Storage, Reheating of Leftover Food Items 1.1 Leftover food items that are to be kept will be placed in the refrigerator immediately, covered and labeled with contents and the use by date. ..." Observation at 12:00 PM on April 7, 2015, of the walk-in freezer revealed open packages of chicken breast filets, chicken nuggets, fish filets and breaded fish patties. These packages of food were not re-sealed to prevent contamination. Interview of EMP5 and EMP6 at 12:00 PM on April 7, 2015, confirmed there were open packages of chicken breast filets, chicken nuggets, fish filets and breaded fish patties that were not re-sealed to prevent contamination. Further interview of EMP5 and EMP6 at 1:30 PM on April 8, 2015, revealed the facility had no policy regarding re-sealing frozen bags of food after opening them. |
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| VIOLATION: UTILIZATION REVIEW COMMITTEE | Tag No: A0654 | |
| Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure two physicians attended the Utilization Review Committee meetings for 10 of 10 meetings. Findings Include: Review on April 9, 2015, of the facility "Utilization Review Plan," last reviewed May 18, 2014, revealed "... 3. Organization The Utilization Review Committee is a multidisciplinary standing committee. The committee shall consist of at least two (2) physician representatives from the hospital, one of whom is knowledgeable or skilled in the diagnosis and treatment of psychiatric disorders. The Chief Executive Officer shall appoint physician members who have no financial interest in any hospital, and he/she shall designate one of these members as chairperson. The chairperson shall be a psychiatrist. ..." Review on April 9, 2015, of the facility's Utilization Review Committee meeting minutes revealed one physician attended the following meetings: March 17, 2015, February 17, 2015, January 20, 2015, December 16, 2014, October 21, 2014, September 16, 2014, August 19, 2014, July 15, 2014, June 17, 2014 and May 2, 2014. Interview of EMP3 and EMP4 at approximately 1:30 PM on April 9, 2015, confirmed that one physician attended the Utilization Review Committee meetings. EMP3 stated a second physician reviewed the information and provided a report. The second physician did not attend the meetings. |
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| VIOLATION: OPO AGREEMENT | Tag No: A0886 | |
| Based on review of facility documents, it was determined the facility failed to have a written agreement with an Organ Procurement Organization (OPO). Findings include: Review on March 10, 2015, of the facility's "Organ and Tissue Donations" policy, last reviewed May 2013, revealed "Purpose: To provide a procedure to staff on the methodologies to be instituted when a consumer has expressed the desire to be an organ and/or tissue donor upon death and for the procurement of organs and tissues for consumer deaths that occur at Danville State Hospital. ... Policy: It is the policy of Danville State Hospital to maintain compliance with all current accreditation/certification agency standards and conditions of participation. ... The Gift of Life Donor Program is the Organ Procurement Organization (OPO) designated and certified, pursuant to Federal Law, to serve as our regional procurement organization. The Gift of Life Program shall serve as the designated requester for organ and tissue procurement. A Memorandum of Agreement (MOA) with the OPO shall be kept on file in the Chief Executive Officer's (CEO) office at the hospital. A request was made of EMP1 on April 7, 2015, and of EMP2 on April 10, 2015, for the facility's written agreement with an Organ Procurement Organization. No agreement was provided. Cross reference 482.45(a)(5) Death Record Review |
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| VIOLATION: DEATH RECORD REVIEWS | Tag No: A0892 | |
| Based on review of facility documents and staff interview (EMP), it was determined the facility failed to complete a periodic review between the Organ Procurement Organization (OPO) and the hospital death records. Findings include: Review on March 10, 2015, of the facility's "Organ and Tissue Donations" policy, last reviewed May 2013, revealed "Purpose: To provide a procedure to staff on the methodologies to be instituted when a consumer has expressed the desire to be an organ and/or tissue donor upon death and for the procurement of organs and tissues for consumer deaths that occur at Danville State Hospital. ... Policy: It is the policy of Danville State Hospital to maintain compliance with all current accreditation/certification agency standards and conditions of participation. Identification of consumer donors and review of consumer deaths (that occur within the hospital) for potential organ and tissue donation shall be completed to meet the needs of the individual and existing regulation. Procedure: ... Consumer Deaths That Occur at Danville State Hospital: 1. All consumer deaths that occur at Danville State Hospital shall be reported to the Gift of Life Donor Program. The Gift of Life Donor Program is the Organ Procurement Organization (OPO) designated and certified, pursuant to Federal Law, to serve as our regional procurement organization. The Gift of Life Program shall serve as the designated requester for organ and tissue procurement. A Memorandum of Agreement (MOA) with the OPO shall be kept on file in the Chief Executive Officer's (CEO) office at the hospital. ..." Further review of this facility policy revealed no documentation of the frequency of periodic reviews of death records between the OPO and the hospital. Interview with EMP2 on March 10, 2015, at approximately 12:00 PM confirmed the facility did not obtain reports from the OPO for periodic review of death records between the OPO and the hospital to improve identification of potential donors. Cross reference 482.45(a)(1) OPO Agreement |
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