HospitalInspections.org

Based on a review of facility documents, and medical records (MR), it was determined the Medical Executive Committee failed to implement policies of the Medical Staff, by failing to ensure that History and Physicals were reviewed and approved by the Supervising Physician within 24 hours of being performed and prior to discharge, by a physician for one of four medical records reviewed (MR7) by failing to ensure that Admission Orders were initiated by a physician in four of five medical records reviewed (MR7, MR8, MR33, MR38), by failing to ensure Discharge Orders were initiated by a physician in five of five medical records reviewed (MR7, MR8, MR33, MR37, MR38), by failing to ensure progress notes were co-signed by a physician in five of five medical records reviewed (MR7, MR8, MR33, MR37, MR38), by failing to ensure Discharge Summaries were authenticated by an attending physician in four of five medical records reviewed. (MR7, MR8, MR33, MR37).

Findings include:

Review of "Penn Highlands Brookville Medical Staff Rules & Regulations", dated January 21, 2020, revealed "... In-Patient Admissions. 1. Physician members of the Medical Staff may admit patients only to the Department to which they have been appointed. 2. A patient may be admitted to the Hospital only by a physician member of the Medical Staff with admitting privileges. Each patient shall be the responsibility of a designated appointee to the Medical Staff.in (sic) the case of a group practice, unless the admission sheet clearly shows the admitting physician, the first name listed on the admission sheet in any group practice description shall be considered the responsible, designated Medical Staff appointee. Such appointee shall be responsible for the medical care and treatment, including daily rounds on the patient and documented finding in a daily progress note, for the prompt completeness and accuracy of the medical record, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring appointee and to relative of the patient. The requirement for daily rounds can be met an APP (Advanced Practice Professional-Nurse Practitioner or Physician Assistant) who is acting under direction and supervision of the admitting physician or their designee who must be on the PHC (sic) medical staff. The admitting physician must also have made arrangements for physician back-up as required for urgent and emergent conditions that the exceed the APP's scope of practice ... Except in and emergency, no patient shall be admitted to the Hospital until a provisional or admitting diagnosis has been provided by the admitting physician ... A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of each medical record ... Observation/Rapid Treatment Patients. 1. Physicians or designated appointee must accomplish the following actions when admitting a patient to this category: (A) A physician must write an admission order to admit a patient to this category. (B) A physician must write a relevant history and physical or an extensive progress note which indicates the reasons for observation. (C) A physician must write a discharge order to discharge a patient from this category. (D) A physician must issue appropriate instructions to a patient upon discharge ... Swing Bed Patients ... The attending physician must visit a Swing Bed patient within twenty-four (24) hours initially and then at least once every seven (7) days ... Health Information Management. 1. General Rules. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient under his/her care. Its contents shall be pertinent and current. A single attending physician shall be identified in the medical record as being responsible for the patient at any given time. A physician's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, but must dated and signed by the attending physician ... History and Physical (a) A complete history and physical examination must be documented in the medical record within 24 hours of admission or registration ... Progress Notes. Progress Notes made by the Medical Staff should give a pertinent chronological Report of the patient's course in the hospital ... (a) Progress notes shall be written at least daily on acute care patients. Pertinent progress notes shall also be made by others, such as house staff, individuals who have been granted clinical privileges, and specified professional personnel ... Discharge Summaries. (a) A clinical discharge summary shall be included in the medical records of all patients requiring hospitalization. (b) The discharge summary shall include the reason for hospitalization; the significant findings; any complications; the procedures performed and treatment rendered; the condition of the patient on discharge; and any specific instructions given to the patient or family, as pertinent. The condition of the patient on discharge should be stated in terms that permit a specific measurable comparison with the condition on admission. When preprinted instructions are given to the patient or family, the record shall so indicate and a copy of the instruction sheet used should be on file in the Health Information Management Department. All summaries shall be authenticated by the attending physician ... General Care of Patients ... Patients shall be discharged only on a documented order of the attending physician. The attending physical shall include discharge instructions including follow-up care, medications, diet and activity level ... Physician Assistants/Certified Nurse Practitioners. 1. Physician Assistants and Nurse Practitioners who desire to see patients in the Hospital shall be credentialed as an Allied Health Professional under the Medical Staff Bylaws. Their clinical privileges shall be limited by duties and responsibilities noted in their privileges which are approved by their supervising physician and by the parameters of their State approved agreement. 2. Physician Assistants and Nurse Practitioners may perform and initial assessment of patients in the Hospital and dictate same. The initial evaluation must be reviewd and approved by the Supervising physician within twenty-four (24) hours of being performed and prior to discharge ... 3. Medical record entries by Physician Assistants and Nurse Practitioners shall be countersigned and approved by their supervising physician within a reasonable time not to exceed ten (10) days ... Telemedicine. 1. Telemedicine in which medical information is exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services. 2. All LIPs who are responsible for the patient's care, treatment, and services via telemedicine link are credentialed and privileged under the Medical Staff protocol for credentialing and privileging ... 4. The medical staffs at both the originating and distant sites recommend the clinical services to be provided by licensed independent practitioners through a telemedicine link at their respective sites ... The medical staff recommends which clinical services are appropriately deliverd by LIPs through this medium ... ."

Review of "Penn Highlands Brookville Medical Staff Rules & Regulations", dated November 2020, revealed "... In-Patient Admissions. 1. Physician members of the Medical Staff may admit patients only to the Department to which they have been appointed ... A patient may be admitted to the Hospital only by a physician member of the Medical Staff with admitting privileges or designee appointment. Each patient shall be the responsibility of a designated appointee to the Medical Staff. In the case of a group practice, unless the admission sheet clearly shows the admitting physician, the first name listed on the admission sheet in any group practice description shall be considered the responsible, designated Medical Staff appointee. Such appointee shall be responsible for the medical care and treatment, including daily rounds on the patient and documented findings in a daily progress note, for the prompt completeness and accuracy of the medical record, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring appointee and to relative of the patient. The requirement for daily rounds can be met by an APP (Advanced Practice Professional-Nurse Practitioner or Physician Assistant) who is acting under direction and supervision of the admitting physician or their designee who must be on the PHB medical staff. The admitting physician must also have made arrangements for physician back-up as required for urgent and emergent conditions that exceed the APP's scope of practice ... Except in an emergency, no patient shall be admitted to the Hospital until a provisional or admitting diagnosis has been provided by the admitting physician ... A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of each medical record, for necessary instructions to other health care professionals and to patients and for transmitting reports of the patient's condition to the referring physician where applicable, and to the patient's family ... Observation/Rapid Treatment Patients. 1. Physicians or designated appointee must accomplish the following actions when admitting a patient to this category: (A) Must write an admission order to admit a patient to this category. (B) Must write a relevant history and physical or an extensive progress note which indicates the reasons for observation. (C) Must write a discharge order to discharge a patient from this category. (D) Must issue appropriate instructions to a patient upon discharge ... Swing Bed Patients ... 2. The attending physician must visit a Swing Bed patient within twenty-four (24) hours initially and then at least once every seven (7) days ... Health Information Management. 1. General Rules. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient under his/her care. Its contents shall be pertinent and current. A single attending physician shall be identified in the medical record as being responsible for the patient at any given time. A physician's routine orders when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, but must be dated and signed by the attending physician ... History and Physical. (a) A complete history and physical examination must be documented in the medical record within 24 hours of admission or registration ... Progress Notes. Progress notes made by the Medical Staff should give a pertinent chronological Report of the patient's course in the hospital. Progress notes shall be legible, recorded and dated at the time of observation, and shall contain sufficient content to insure continuity of care if the patient is transferred ... (a) Progress notes shall be written at least daily on acute care patients. Pertinent progress notes shall also be made by others, such as house staff, individuals who have been granted clinical privileges, and specified professional personnel ... Discharge Summaries. (a) A clinical discharge summary shall be included in the medical records of all patients requiring hospitalization. (b) The discharge summary shall include the reason for hospitalization; the significant findings; any complications; the procedures performed and treatment rendered; the condition of the patient on discharge; and any specific instructions given to the patient or family, as pertinent. The condition of the patient on discharge should be stated in terms that permit a specific measurable comparison with the condition on admission. When preprinted instructions are given to the patient or family, the record shall so indicate and a copy of the instruction sheet used should be on file in the Health Information Management Department. All summaries shall be authenticated by the attending physician ... General Care of Patients ... Patients shall be discharged only on a documented order of the attending physician. The attending physician shall include discharge instructions including follow-up care, medications, diet and activity level ... Medical Department. 1. All patients will be admitted to the hospitalist or appropriate specialist upon acceptance from the specialist ... Physician Assistants/Certified Nurse Practitioners. 1. Physician Assistants and Nurse Practitioners who desire to see patients in the Hospital shall be credentialed as an Advanced Practice Professional under the Medical Staff Bylaws. Their clinical privileges shall be limited by duties and responsibilities noted in their privileges which are approved by their supervising physician and by the parameters of their State approved agreement. 2. Physician Assistants and Nurse Practitioners may perform an initial assessment of patients in the Hospital and dictate same. The initial evaluation must be reviewed and approved by the Supervising physician within twenty four (24) hours of being performed and prior to discharge ... 3. Medical record entries by Physician Assistants and Nurse Practitioners shall be countersigned and approved by their supervising physician within a reasonable time not to exceed ten (10) days ... Telemedicine. 1. Telemedicine is which medical information is exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services. 2. All LIPs who are responsible for the patient's care, treatment, and services via telemedicine link are credentialed and privileged under the Medical Staff protocol for credentialing and privileging ... 4. The medical staffs at both the originating and distant sites recommend the clinical services to be provided by licensed independent practitioners through a telemedicine link at their respective sites ... The medical staff recommends which clinical services are appropriately delivered by LIPs through this medium ... ."

Review of "Penn Highlands Brookville Medical Staff Rules & Regulations", dated March 2021, revealed "... In-Patient Admissions. 1. Physician members of the Medical Staff may admit patients only to the Department to which they have been appointed. 2. A patient may be admitted to the Hospital only by a physician member of the Medical Staff with admitting privileges or designee appointment. Each patient shall be the responsibility of a designated appointee to the Medical Staff. In the case of a group practice, unless the admission sheet clearly shows the admitting physician, the first name listed on the admission of the sheet in any group practice description shall be considered the responsible, designated Medical Staff appointee. Such appointee shall be responsible for the medical care and treatment, including daily rounds on the patient and documented findings in a daily progress note, for the prompt completeness and accuracy of the medical record, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring appointee and to relative of the patient. The requirement for daily rounds can be met an APP (Advanced Practice Professional-Nurse Practitioner or Physician Assistant) who is acting under direction and supervision of the admitting physician or their designee who must be on the PHB medical staff. The admitting physician must also have made arrangements for physician back-up as required for urgent and emergent conditions that exceed the APP's scope of practice ... Except in an emergency, no patient shall be admitted to the Hospital until a provisional or admitting diagnosis has been provided by the admitting physician ... A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of each medical record ... Swing Bed Patients ... The attending physician must visit a Swing Bed patient within seven (7) days initially and then at least once every seven (7) days ... Health Information Management. 1. General Rules. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient under his/her care ... A single attending physician shall be identified in the medical record as being responsible for the patient at any given time ... Progress Notes. Progress notes made by the Medical Staff should give an pertinent chronological Report of the patient's course in the hospital. Progress notes shall be legible, recorded and dated at the time of observation, and shall contain sufficient content to insure continuity of care if the patient is transferred. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment. (a) Progress notes shall be written at least daily on acute care patients. Pertinent progress notes shall also be made by others, such as house staff, individuals who have been granted clinical privileges, and specified professional personnel ... Discharge Summaries. (a) A clinical discharge summary shall be included in the medical records of all patients requiring hospitalization. (b) The discharge summary shall include the reason for hospitalization; the significant findings; any complications; the procedures performed and treatment rendered; the condition of the patient on discharge; and an specific instructions given to the patient or family, as pertinent. The condition of the patient on discharge should be stated in terms that permit a specific measurable comparison with the condition on admission. When preprinted instructions are given to the patient or family, the record shall so indicate and a copy of the instruction sheet used should be on file in the Health Information Management Department. All summaries shall be authenticated by the attending physician ... General Care of Patients ... Patients shall be discharged only on a documented order of the attending physician. The attending physician shall include discharge instructions including follow-up care, medications, diet and activity level ... Medical Department. 1. All patients will be admitted to the hospitalist or appropriate specialist upon acceptance from the specialist ... Physician Assistants/Certified Nurse Practitioners. 1. Physician Assistants and Nurse Practitioners who desire to see patients in the Hospital shall be credentialed as an Advanced Practice Professional under the Medical Staff Bylaws. Their clinical privileges shall be limited by duties and responsibilities noted in their privileges which are approved by their supervising physician and by the parameters of their State approved agreement. 2. Physician Assistants and Nurse Practitioners may perform an initial assessment of patients in the Hospital and dictate same. The initial evaluation must be reviewed and approved by the Supervising physician within twenty-four (24) hours of being performed and prior to discharge ... 3. Medical record entries by Physician Assistants and Nurse Practitioners shall be countersigned and approved by their supervising physician within a reasonable time not to exceed ten (10) days ... 6. The initial evaluation must be reviewed and approved by the supervising physician within twenty-four (24) hours of being performed and prior to discharge ... Telemedicine. 1. Telemedicine in which medical information is exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services. 2. All LIPs who are responsible for the patient's care, treatment, and services via telemedicine link are credentialed and privileged under the Medical Staff protocol for credentialing and privileging. 3. The originating site retains responsibility for overseeing the safety and quality of services offered to its patients. The distant site will provide care, treatment and/or services to Brookville Hospital. 4. The medical staffs at both the originating and distant sites recommend the clinical services to be provided by licensed independent practitioners through a telemedicine link at their respective sites ... The medical staff recommends which clinical services are appropriately delivered by LIPs through this medium ... ."

Review of "Penn Highlands Brookville; Clearfield; DuBois, Elk; DuBois Surgery Center; DuBois Endoscopy Center, Elk Surgery Center Medical Staff Bylaws", dated June 2019, revealed "... Section 1.2 Certain Defined Terms ... "Advanced Practice Professionals" (APPs") means individuals other than Medical Staff members who are authorized by law and by the Hospital to provide patient care services. APPs function only under the direction of, or in collaboration with, a Sponsoring member of the Medical Staff, pursuant to a written supervision agreement and consistent with the scope of practice granted ... "Medical Staff" means all physicians, dentists, oral surgeons, podiatrists, who have been appointed to the Medical Staff by the Board ... Medical Staff Membership ... Each staff member must provide appropriate, timely, and continuous care of his/her patients ... Medical Records. a. Consistent with the Medical Staff Rules and Regulations and medical records policies, the attending physician shall be held responsible for preparation of a complete and legible medical record of each patient. This record shall include identification data, complaint, personal history, family history, history of present illness, physical examination, special reports such as medical and surgical treatment, operative report, pathological findings, progress notes, condition on discharge, discharge summary or note which must include activity, diet, medications, and followup, and autopsy when performed ... b. A complete history and physical examination shall, in all cases, be completed/documented within 24 hours after admission of the patient. A history and physical report (H&P) shall be performed by any Licensed Independent Practitioner (LIP) who is licensed in the state of Pennsylvania ... c. As permitted by state law and policy individuals who are not LIPs may perform part or all of a patient's medical history and physical examination under the supervision of, or through the appropriate deligation (sic) by, a specific physician who is accountable for the patient's medical history and physical examination. The medical history and physical examination report by an individual who is not a LIP must be validated and countersigned by an LIP with appropriate privileges ... ."

Review of "Penn Highlands Brookville; Clearfield; DuBois, Elk; Huntingdon; DuBois Surgery Center; DuBois Endoscopy Center Medical Staff Bylaws", dated June 2020, revealed "... Section 1.2 Certain Defined Terms ... "Advanced Practice Professionals" (APPs") means individuals other than Medical Staff members who are authorized by law and by the Hospital to provide patient care services. APPs function only under the direction of, or in collaboration with, a Sponsoring member of the Medical Staff, pursuant to a written supervision agreement and consistent with the scope of practice granted ... "Medical Staff" means all physicians, dentists, oral surgeons, podiatrists, who have been appointed to the Medical Staff by the Board ... Medical Staff Membership ... Each staff member must provide appropriate, timely, and continuous care of his/her patients ... Medical Records. a. Consistent with the Medical Staff Rules and Regulations and medical records policies, the attending physician shall be held responsible for preparation of a complete and legible medical record of each patient. This record shall include identification data, complaint, personal history, family history, history of present illness, physical examination, special reports such as medical and surgical treatment, operative report, pathological findings, progress notes, condition on discharge, discharge summary or note which must include activity, diet, medications, and followup, and autopsy when performed ... b. A complete history and physical examination shall, in all cases, be completed/documented within 24 hours after admission of the patient. A history and physical report (H&P) shall be performed by any Licensed Independent Practitioner (LIP) who is licensed in the state of Pennsylvania ... c. As permitted by state law and policy individuals who are not LIPs may perform part or all of a patient's medical history and physical examination under the supervision of, or through the appropriate deligation (sic) by, a specific physician who is accountable for the patient's medical history and physical examination. The medical history and physical examination report by an individual who is not a LIP must be validated and countersigned by an LIP with appropriate privileges ... ."

1. Review of MR7, revealed an observation order initiated by a hospitalist CRNP with the CRNP listed as the responsible provider on January 13, 2021, at 17:33. The order was not co-signed by a physician until 17:35. An admission order was initiated by the CRNP, with the CRNP listed as the responsible provider on January 14, 2021, at 08:21. The order was not co-signed by a physician until January 15, 2021, at 08:59.

A discharge order was initiated by the CRNP on January 16, 2021, at 07:19 and the order was was not co-signed by a physician until 08:58.

Review of the History and Physical was noted to be completed by a CRNP, and there was no documentation that it was co-signed by a supervising physician.

Progress note completed by a CRNP dated January 15, 2021, did not reflect documentation that the supervising physician co-signed the progress note.

Discharge Summary Report completed by a CRNP, dated January 16, 2021, revealed no documentation that it was authenticated by the supervising physician.

2. Review of MR8 revealed an admission order initiated by a CRNP, dated December 27, 2020, at 16:57, with CRNP as responsible provider. The order was not co-signed by a physician until 17:26.

Review of Discharge Order, was noted to be initiated by a CRNP, dated January 5, 2021, at 12:07. The order was not co-signed by a physician until 12:18.

Progress Notes completed by a CRNP dated December 28, 2020-January 4, 2021, revealed that none reflected documentation that the supervising physician co-signed the progress notes

Review of Discharge Summary report completed by a CRNP, dated January 5, 2021, revealed no documentation that it was authenticated by the supervising physician.

3. Review of MR33 revealed an admission order initiated by a CRNP, dated December 15, 2020, at 15:52, with CRNP as responsible provider. The order was not co-signed by a physician at until 18:07.

Discharge Order initiated by a CRNP on December 24, 2020, at 08:30. The order was not co-signed by a physician until 11:23.

Hospitalist Progress Notes dated December 16, December 17, at 15:28, December 18, at 17:43, December 19-20, December 22, at 16:40, and December 23, 2020, revealed that none reflected documentation that the supervising physician co-signed the progress notes.

Review of Discharge Summary report completed by CRNP, dated December 24, 2021, revealed no documentation that it was authenticated by the supervising physician.

4. Review of MR37 revealed an admission order was initiated by a physican on May 29, 2020, at 18:53, however the responsible provider was noted to be a CRNP.

Discharge Order initiated by a CRNP, on June 2, 2020, at 08:03. The order was not co-signed by a physician until 10:33.

Hospitalist Progress Notes dated May 31, 2020-June 1, 2020, revealed that none reflected documentation that the supervising physician co-signed the progress notes.

Review of Discharge Summary report completed by CRNP, dated June 2, 2020, revealed no documentation that it was authenticated by the supervising physician.

5. Review of MR38 revealed an admission order initiated by a CRNP, dated March 12, 2021, 19:23, with CRNP as responsible provider. The order was not co-signed by a physician until March 17, 2021, at 09:06.

Discharge Order initiated by CRNP on March 15, 2021, 07:49. The order was not co-signed by a supervising physician until March 17, 2021, at 09:06.

Hospitalist Progress Notes dated March 13, 2021-March 14, 2021, revealed no documentation that the supervising physician co-signed the progress notes.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Penn Highlands Brookville failed to ensure that physicians are present for sufficient periods of time to provide medical direction, consultation, and supervision of medical services provided in the Hospital.

Findings include:

Review of "Penn Highlands Brookville; Clearfield; DuBois, Elk; DuBois Surgery Center; DuBois Endoscopy Center, Elk Surgery Center Medical Staff Bylaws", dated June 2019, revealed "... Section 1.2 Certain Defined Terms ... "Advanced Practice Professionals" (APPs") means individuals other than Medical Staff members who are authorized by law and by the Hospital to provide patient care services. APPs function only under the direction of, or in collaboration with, a Sponsoring member of the Medical Staff, pursuant to a written supervision agreement and consistent with the scope of practice granted ... "Medical Staff" means all physicians, dentists, oral surgeons, podiatrists, who have been appointed to the Medical Staff by the Board ... Medical Staff Membership ... Each staff member must provide appropriate, timely, and continuous care of his/her patients ... ."

Review of "Penn Highlands Brookville; Clearfield; DuBois, Elk; Huntingdon; DuBois Surgery Center; DuBois Endoscopy Center Medical Staff Bylaws", dated June 2020, revealed "... Section 1.2 Certain Defined Terms ... "Advanced Practice Professionals" (APPs") means individuals other than Medical Staff members who are authorized by law and by the Hospital to provide patient care services. APPs function only under the direction of, or in collaboration with, a Sponsoring member of the Medical Staff, pursuant to a written supervision agreement and consistent with the scope of practice granted ... "Medical Staff" means all physicians, dentists, oral surgeons, podiatrists, who have been appointed to the Medical Staff by the Board ... Medical Staff Membership ... Each staff member must provide appropriate, timely, and continuous care of his/her patients ... ."

Review of policy entitled "Tele-Hospitalist", dated March 24, 2020, revealed "Policy: Tele-Hospitalist service for patients being followed by the Hospitalist providers. Procedure: A. Day Shift 7am-7pm (CRNP). 1. The CRNP will round on all assigned patients for the day at a frequency that is standard for the patient's level of care. For example, inpatients will be rounded on daily and as needed, swing bed patients every 2-3 days, unless there is an acute need. 2. Once rounding is complete, the CRNP will connect with the Telemedicine covering physician either via phone or video conferencing to discuss the plan of care for each patient. 3. The CRNP will document appropriately in the EMR which will be visible to the supervising physician for review and amendment as needed. 4. If there is a patient that the CRNP or physician feels uncomfortable with, a video visit will be scheduled for that patient using the Telemedicine cart and associated equipment assisted by the CRNP ... 5. The CRNP will complete the documentation with supporting physician documentation to reflect that the patient was seen by the supervising physician via Telemedicine visit. Process for Tele-Hospitalist Video visit (Day Shift 7am-7pm): 1. Decision for Tele-Hospitalist video visit is made between the CRNP and the Telemedicine covering physician. Scheduled time for video visit is established. 2. CRNP logs into the below client portal to schedule patient for the video visit ... 3. CRNP obtains the Telemedicine video workstation on wheels ... and has set up in patient's room prior to video connection appointment ... 5. Tele-Hospitalist video visit begins. The CRNP utilizes the peripheral device and stethoscope to assist with the exam ... 6 ... B. Night Shift Curbside Process: 7pm-7am (Bedside RN): 1. If the RN has any concerns regarding their patient contact the Hospitalist on call. The attending physician will place orders in EMR as indicated. It will be at the discretion of the attending physician if the patient needs transferred to Penn Highlands DuBois or another facility ... C. Provider Process for Telemedicine Video Visit: All providers will be trained and signed off on completing telemedicine video visits ... 1. The CRNP will call the Provider on call and make arrangements for the video visit. 2. The Provider will get a notification when a case is assigned to them and once the resident is checked in. 3. The Provider logs into the below client portal to view case ... 4. Select "View Case" to review resident information. 5. Once ready to see resident select "Join Video" 6. Telemedicine video visit begins. 7. Upon exam completion, end call, select complete case. 8. Place documentation and orders in EMR as needed ... E. Continuity of Care: Providers provide documentation for inclusion in the patient's medical record. All documentation clearly states that the service was provided via telemedicine and is entered into the Cerner electronic health record. Consulting physician reviews plan of care with provider. F. Patient Transfer: When clinically indicated the patient may be transferred to a facility capable of providing care to the patient ... ."

Review of "Penn Highlands Brookville Medical Staff Rules & Regulations", dated January 21, 2020, revealed "... Telemedicine. 1. Telemedicine in which medical information is exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services. 2. All LIPs who are responsible for the patient's care, treatment, and services via telemedicine link are credentialed and privileged under the Medical Staff protocol for credentialing and privileging ... 4. The medical staffs at both the originating and distant sites recommend the clinical services to be provided by licensed independent practitioners through a telemedicine link at their respective sites ... The medical staff recommends which clinical services are appropriately delivered by LIPs through this medium ... ."

Review of "Penn Highlands Brookville Medical Staff Rules & Regulations", dated November 2020, revealed "... Telemedicine. 1. Telemedicine is which medical information is exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services. 2. All LIPs who are responsible for the patient's care, treatment, and services via telemedicine link are credentialed and privileged under the Medical Staff protocol for credentialing and privileging ... 4. The medical staffs at both the originating and distant sites recommend the clinical services to be provided by licensed independent practitioners through a telemedicine link at their respective sites ... The medical staff recommends which clinical services are appropriately delivered by LIPs through this medium ... ."

Review of "Penn Highlands Brookville Medical Staff Rules & Regulations", dated March 2021, revealed ... Telemedicine. 1. Telemedicine in which medical information is exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services. 2. All LIPs who are responsible for the patient's care, treatment, and services via telemedicine link are credentialed and privileged under the Medical Staff protocol for credentialing and privileging. 3. The originating site retains responsibility for overseeing the safety and quality of services offered to its patients. The distant site will provide care, treatment and/or services to Brookville Hospital. 4. The medical staffs at both the originating and distant sites recommend the clinical services to be provided by licensed independent practitioners through a telemedicine link at their respective sites ... The medical staff recommends which clinical services are appropriately delivered by LIPs through this medium ... ."

1. Review of the Staffing Plan entitled "Penn Highlands DuBois Telemedicine Hospitalist program for Penn Highlands Brookville", revealed "... Hospitalist Service providers will be located at Penn Highlands DuBois Hospital, via the ... Hospitalist agreement with the patients receiving care located at the Penn Highlands Brookville Hospital ... Staffing have been increased in the PHD Hospitalist group to adequately cover the increased clinical demands to include: 2 Physician FTEs for the 7am/7pm shift to alternate every other week, (stationed at PHD), 2 Physician FTEs for the 7pm/7am shift to alternate every other week, (stationed at PHD), 4 Advanced Practice Provider FTEs to cover ... as well as PH Brookville for the 7am/7pm shifts to alternate every other week ... The ... hospitalist group will be covering PH Brookville via a hybrid Telemedicine/e Hospitalist program. A Hospitalist trained APP (CRNA or PA) will be physically present in the facility from 7 am to 7 pm. The APP will round on all the assigned patients for the day at a frequency that is standard for the patient's level of care. For example, inpatients will be rounded on daily and as needed, swing bed patients every 2-3 days unless there is an acute need. Once the daily rounding is complete, the APP will connect with the APP will connect with the Telemedicine covering physician either via phone or video conferencing to discuss the plan of care for each patient. The APP will document appropriately in the EMR which will be visible to the supervising physician for review and amendment as needed. If there is a patient that the APP or physician feels uncomfortable with, a video visit will be scheduled for that patient using the Telemedicine cart and associated equipment assisted by the APP. The APP will complete the documentation with supporting physician documentation to reflect that the patient was seen by the supervising physician via Telemedicine visit. The APP will also be responsible for admissions to the facility during their shift. They will accept admissions, evaluate the patients, write orders and discuss with the Telemedicine supervising physician. If the APP or physician feels uncomfortable with a patient's condition, he or she will request a Telemedicine physician visit in the same manner. If at any time, the supervising physician or APP has concerns about the deteriorating condition of a patient or if the patient becomes higher risk, arrangements will be made for immediate transfer to Penn Highlands DuBois or another facility (higher level of care if needed). Nocturnist coverage will be completed via Telemedicine from PH DuBois. The cart will be housed in the ED. Any patient that is referred for observation or admission will be evaluated via a Telemedicine vist in the ED with nursing assistance. The Telemedicine physician will place admission orders and complete the H&P in the EMR. In addition acute calls will be answered by the Telemedicine physician and in the circumstance that a patient needs to be seen acutely, the cart can be transported by nursing to the patient's room for an emergent Telemedicine visit ... In the event of technology failure or inability to transfer the patient in a timely manner, the Telemedicine physician will be located in the PH DuBois facility and can reach the PH Brookville facility in less than 30 minutes ... ."

2. Review of MR8, MR33, and MR37 revealed a History and Physical which indicated, an addendum that a telemedicine consultation by the supervision physician was completed, but it was noted that documentation did not reflect that this occurred between a Licensed Independent Practitioner to Licensed Independent Practitioner. Review of MR7 and MR38 revealed no documentation that either patient had a telemedicine consultation with a physician.

3. Review of MR7, MR8, MR33, MR37, MR38, revealed no documentation that the patients were ever seen on site by a hospitalist physician.

4. Interview with EMP1 on April 29, 2021, revealed that the Nurse Practitioner (CRNP) rounds on patients and then talks to PH DuBois hospitalist, whoever is on call, if patient needs seen, the telemedicine cart would be utilized, and the physician at DuBois would be able to share a screen video and dual monitors, so the physician can see the chart. EMP1
also stated that a physician hospitalist from Penn Highlands DuBois is only routinely on site to see swing bed patients every seven days, and that inpatients would only be seen routinely by a physician on swing bed rounding day, or the hospitalist would come to the hospital if needed, or if a patient requests to see a physician. It was also confirmed that inpatients may never be seen in person by a physician, as an onsite physician hospitalist is only routinely at the hospital every seven days.

5. During review of the facility's Tele-hospitalist policy and Staffing Plan, it was noted that the policy did not address the minimum amount of time or frequency of MD or DO presence on site.