By Walter F. Roche Jr.
A rehabilitation facility affiliated with Penn Medicine has been cited by the Pennsylvania Health Department for failure to immediately report multiple patient complaints of improper touching.
The citation, based on complaints and a January on-site inspection, found that Good Shepherd Penn Partners failed to immediately report "situations that could seriously compromise the the quality of care and/or patient safety."
According to the report the initial complaints came from two clients who reported the improper touching occurred in November and December of 2015.
Good Shepherd, which calls itself "the official therapy provider for Penn Medicine," did not respond to requests for comment. It operates from facilities in Philadelphia and Bala Cynwyd.
State inspectors, responding to a complaint, visited the facility on Jan. 8.
According to the report, the initial complaint alleging improper touching was registered by a client on Nov. 8. A second client registered a similar complaint against the same employee on Dec. 18.
The report states that two Good Shepherd employees confirmed to the inspectors that the complaints had been registered and that they had not been reported to the state Health Department.
Although reports were filed with the state Patient Safety Authority, they were not entered properly, the report states.
They were re-entered properly at a later date.
According to the inspectors a third allegation of improper touching by the same employee was registered during a patient satisfaction survey conducted by telephone in January.
In a plan of correction filed by Good Shepherd, administrators promised to report any future complaints to the state health agency promptly and "with sufficient detail."
They also promised to implement retraining and monitoring programs to ensure future compliance.
The report does not identify the employee, identified only as "Employee 1," or what if any action was taken as a result of the complaints.
GOOD SHEPHERD PENN PARTNERS
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This report is the result of an unannounced, onsite complaint investigation [PSA16A59L (32540729) and PSA16A60L (32540863)] conducted on January 8, 2016, and completed on January 11, 2016, at Good Shepherd Penn Partners Penn Therapy & Fitness. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
51.3 (f) LICENSURE
Name - Component - 00
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Based on a review of facility policy, the Pennsylvania Department of Health (DOH), Pennsylvania Patient Safety Authority Reporting System (PA-PSRS) and staff interviews (EMP), it was determined that the facility failed to notify the Department of Health immediately of situations which could seriously compromise quality of care and/or patient safety.
A review on January 11, 2016, of the facility's Patient Safety Plan 2015 dated February 17, 2015, revealed "...II. Scope and Components. ..Leadership guides the specific components of our patient safety program: education, reporting, analysis, and disclosure. ...Reporting...External. Depending on the severity of the event or incident, the appropriate authorities will be notified utilizing their specific required reporting format within the required time frame. Examples of external agencies may include, but are not limited to, the Pennsylvania Patient Safety Authority, Pennsylvania Department of Health...."
A review on January 11, 2016, of the facility's Patient Safety Plan 2015 dated February 17, 2015, revealed "IV. Patient Safety Committee...Structure and Reporting Relationships. The Specialty Hospital at Rittenhouse Patient Safety Committee is a separate committee that reports directly to the Professional Relations and Quality Oversight Committee, a subcommittee of the Board of Directors, and will address safety issues within each facility. It is the designated patient safety committee for The Specialty Hospital at Rittenhouse, Penn Therapy and Fitness..." The Specialty Hospital at Rittenouse Patient Safety Plan and designated patient Safety Officer shall govern patient safety matters at these sites so as to ensure a uniform standard of care at each."
A review on January 11, 2016, of PA-PSRS report 32540863 revealed patient allegations of "inappropriate touching " by EMP1 at Penn Therapy and Fitness, Bala Cynwyd. Patient #1 reported the allegations to the facility on November 8, 2015.
A review on January 11, 2016, of the PA-PSRS report 32540729 revealed patient allegations of "inappropriate touching" by EMP1 at Penn Therapy and Fitness, Bala Cynwyd. Patient #2 reported the allegations to the facility on December 18, 2015.
An interview conducted on January 11, 2016, at 2:55PM with EMP3 and EMP4 confirmed patient event 32540863 was reported to the facility on November 8, 2015, by Patient #1 and patient event 32540729 was reported to the facility on December 18, 2015, by Patient #2 to the facility. EMP3 and EMP4 also confirmed patient events 32540729 and 32540863 were not reported to DOH. Further interview with EMP3 and EMP4 revealed the patient events were entered into the Pennsylvania Patient Safety Authority Reporting System as incidents.
An interview conducted on January 11, 2016, at 3:05PM with EMP2 revealed that EMP2 received notification from the Pennsylvania Patient Safety Authority informing the facility that it had failed to enter patient events 32540729 and 32540863 appropriately into the PA-PSRS. EMP2 confirmed that the patient events were re-entered into PA-PSRS on January 5, 2016, as Infrastructure Failures.
An interview conducted on January 15, 2016, at 1:05PM with EMP2 confirmed that 21 patient satisfaction calls were placed to the patients of EMP1 on January 14, 2016, and January 15, 2016 by the facility. EMP2 stated that during the patient satisfaction call process a patient alleged that she had been "inappropriately touched" by EMP1. EMP2 also confirmed that an addendum to event 32540863 was added on January 18, 2016 to include this new event.
Plan of Correction:Effective January 28, 2016, the following action items were established for Good Shepherd Penn Partners Specialty Hospital at Rittenhouse, including its inpatient facility and outpatient sites ("Good Shepherd Penn Partner"):
* If Good Shepherd Penn Partners is aware of a situation or the occurrence of an event at its health care facility or any site which could seriously compromise quality assurance or patient safety, the facility will immediately notify the Department of Health in writing in accordance with the Medical Care Availability and Reduction of Error Act, 40 P.S. 1303.313 and 1303.314. The notification shall include sufficient detail and information to alert the Department of Health as to the reason for its occurrence, to the extent then known, and the steps which the health care facility shall take to rectify the situation.
* Events which potentially could seriously compromise patient care and/or patient safety will result in immediate notification to and/or consultation with the Department of Health.
-- The Corporate Patient Safety Officer will audit all incidents, Serious Events and Infrastructure Failures from January 1st, 2015 to present by February 19th, 2016 as a secondary validation that the proper event type and taxonomy, reporting and disclosure occurred. Any events that were not assigned the proper event type and taxonomy will be revised by February 19th, 2016.
-- On a monthly basis at each Patient Safety Committee ("Committee")meeting beginning in February, the events for the period will be reviewed with Committee members for the next six (6)months. The minutes will reflect that the events were reviewed and if event type and taxonomy were validated. Any events that are not thought to be assigned the proper event type will be noted in the meeting minutes and revised by the Patient Safety Officer.
* Any Good Shepherd Penn Partner employee who has the responsibility of reporting events to DOH through PA-PSRS will receive education and training for identification, timeframe, and reporting through the Pennsylvania Patient Safety Authority when next offered. This will include, but not be limited to PA-PSRS event types and taxonomy, reporting and disclosure.
-- The Corporate Patient Safety Officer has received all of the training and will serve as the Patient Safety Officer for Good Shepherd Penn Partners.
-- The Administrator of Good Shepherd Penn Partner will receive basic training from a representative of PA-PSRS by February 5th, 2016.
* Patient Safety Plan will be enhanced to reference alignment with 28 Pa Code 51.3 with regard to external reporting of events, as well as notification to and consultation with Department of Health germane to event; to be completed on or before March 30th, 2016. The enhancement will be communicated to employees and managers as well as mandatory training conducted by April 15th, 2016. To memorialize participation in the training, each employee will sign the participation roster and we will audit the participation roster to make sure all employees that require the training have participated.