UPMC Greene

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 50030 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of fifteen smoke compartments. Findings include: 1. Observation on April 1, 2025, revealed the following automatic sprinkler system deficiencies: a) 9:30 a.m., there was a gap greater than 1/8 inch in the ceiling tile surrounding a dryer exhaust line in Room 503, which could affect operation of the automatic sprinkler system; b) 9:47 a.m., there was a gap greater than 1/8 inch in the ceiling tile surrounding a dryer exhaust line in Room 433. Interview with the Director of Facilities and Facilities Coordinator on April 1, 2025, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 44386 Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, for one out of over 30 doors tested. Findings include: 1. Observation on April 1, 2025, at 9:15 a.m., revealed the door to resident room 505 failed to latch when tested. Interview with the Director of Facilities and Facilities Coordinator on April 1, 2025, at 2:00 p.m., confirmed the corridor door deficiency.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, and staff interview (EMP), it was determined the governing body failed to ensure the services of a registered dietician via the Master Services Agreement dated October 1, 2024. Findings include: On March 19, 2025, a review of the Master Services Agreement (dated October 1, 2024) between UPMC Washington and UPMC Greene was reviewed and revealed: “1. Provision of Services 1.1 UPMC Washington agrees to provide to UPMC Greene the services and personnel described in the attached Appendices pursuant to the terms and conditions of this agreement.” On March 19, 2025, a review of “Appendix B” of the Master Services Agreement- “UPMC Washington Services/Employees Provided to UPMC Greene Under This Agreement was completed and revealed the following services are provided to UPMC Greene from UPMC Washington:1. Nursing; 2. PT/OT/ST; 3. Medical Director; 4. Medical Office Staff; 5. Human Resources; 6. Employee Health; 7. Radiology; 8. Laboratory; 9. Infection Control; 10. Marketing; 11. Foundation/Volunteers; 12. Patient Experience; 13. Cardiac Diagnostics; 14. Administration; 15. Registration; 16. Information Technology; 17. Respiratory Care; 18. Case Management; 19. Medical Records; 20. Quality/Performance Improvement; 21. Materials Management; 22. Pharmacy; 23. Emergency Preparedness; 24. Police (as of 1/15/2024).” On March 19, 2025, at 3:11 PM, EMP1 confirmed that the dietician was not included in the Master Services Agreement; however, may be included in the Cura Hospitality, LLC contract (executed July 27, 2020). A review of the Cura Hospitality Agreement was completed and revealed in “ Section 10.4 “ that all employees have an “ Independent Contractor Relationship: Employees of the Company (Cura) are not, nor shall they be deemed to be, employees of the client (Washington Health System). Employees of the client are not, nor shall they be deemed to be, employees of Company.” On March 18, 2025, at 10:00 AM, EMP9 stated that EMP9 “could not recall the last time EMP9 had been to UPMC Greene.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to document the ongoing assessment of the patient in restraints every two hours in one of four restraint medical records (MR11). Findings include: On March 17, 2025, a review of Restraint and Seclusion Policy (Last Approved: 04/08/2024) was completed and revealed the following: “Monitoring: C. At a minimum, the following parameters are assessed and documented as indicated: Non Violent and Non Self Destructive Restraint: Hygiene needs- Every two hours; Food/fluid needs- Every two hours; Skin condition/skin care/circulation- Every two hours; Reassessed: Restraints continued as ordered- Every two hours; Removed restraints- Every two hours; Mental Status- Every two hours; Cognitive functioning- Every two hours.” On March 17, 2024, a review of MR11 was completed. On January 25, 2025, MR1 was placed in non violent- non self-destructive wrist restraints. Orders were written by the LIP on January 25, 2025 at 11:00 PM; January 26, 2025 at 2:00 PM; and January 27, 2025 at 12:11PM when MR11 was placed in a canopy bed. There is no evidence of the required two hour documentation from January 26, 2025 at 6:00 PM until MR11 discharged on January 27, 2024 at 2:20 PM. Thus, MR1 was not re-assessed for 20 hours while in nonviolent restraints. There is no evidence in the medical record that the restraint was discontinued. On March 17, 2025, at approximately 1:15 PM, EMP6 confirmed that a canopy bed was considered a restraint in the facility. In addition, EMP6 confirmed that there was no evidence of the required every two hour reassessments from January 26, 2025 at 6:00 PM until January 27, 2025 at 2:20 PM.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, credential files (CF) and staff interview (EMP), it was determined that the facility failed to adhere to the Medical Staff Bylaws during the credential process in assigning the appropriate Medical Staff category for nine of nineteen credential files reviewed (CF11, CF12, CF13, CF14, CF15, CF16, CF17, CF18, and CF19). Findings include: On March 18, 2025, a review of the Medical Staff Bylaws (Last Approved: December 12, 2023) was completed and revealed the following: “Credentials Policy: 2.A Active Staff; 2.A.1: Qualifications: The active staff shall consist of Medical Staff Members who meet the General Qualifications for Membership as established by these bylaws. 2.B. Associate Staff; 2. B.1. Qualifications: The Associate Staff shall consist of members who are in the process of becoming eligible for appointment to the Active Staff and who meet all other qualifications of Active Staff appointment. Upon completing one year on the Associate Staff, individuals who meet all the Active Staff qualifications shall be automatically transferred to Active Staff. 2.C. Courtesy Staff; 2.D. Coverage Staff; 2.D.2. Prerogatives and Responsibilities: (a) shall assume all functions and responsibilities to provide coverage for the other members of their coverage group, including ...emergency services and consultations ...2F Affiliate Staff; 2G Honorary Staff...”. On March 18, 2025, a review of CF11 was completed and revealed, in a letter dated January 15, 2025, ...”approved by the board on December 12, 2024 for the ‘Moonlighting’ category.” On March 18, 2025, a review of CF12 was completed and revealed, in a letter dated January 3, 2025, ... “approved by the board on December 12, 2024 for the ‘Moonlighter Staff’ category in the Department of Medicine.” On March 18, 2025, a review of CF13 was completed and revealed, in a letter dated January 3, 2025, ... “approved by the board on December 12, 2024 for the ‘Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, a review of CF14 was completed and revealed, in a letter dated January 3, 2025, ...”approved by the board on December 12, 2024 for the ‘Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, a review of CF15 was completed and revealed, in a letter dated January 3, 2025, ... “approved by the board on December 12, 2024 for the ‘Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, a review of CF16 was completed and revealed, in a letter dated January 3, 2025, ... “approved by the board on December 12, 2024 for the ‘Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, a review of CF17 was completed and revealed, in a letter dated January 3, 2025, ...”approved by the board on December 12, 2024 for the ’ Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, a review of CF18 was completed and revealed, in a letter dated January 3, 2025, ... “approved by the board on December 12, 2024 for the ’ Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, a review of CF19 was completed and revealed, in a letter dated January 3, 2025, ... “approved by the board on December 12, 2024 for the ’ Moonlighter Staff ’ category in the Department of Medicine.” On March 18, 2025, at approximately 10:30 AM, EMP11 acknowledged that the “Moonlighter Staff” category was not defined in the Medical Staff Bylaws.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 50899 Based on a facililty tour, document review, and staff interview (EMP), it was determined that the facility failed to ensure unauthorized access, and maintain condition of the walls in the dry food storage closet of the Nutritional Food Services Department. Findings include: On March 17, 2025, at 10:00 AM, a tour of the first floor therapy pool room revealed a fire exit door that was ajar and would not latch when properly closed. A review of facility policy “Door Wedge Policy”, last revised and approved on October 7, 2024, states “... B. Doors to stairwells, fire exits, smoke doors, and hazardous locations such as soiled utility rooms shall remain closed and latched at all times, unless equipped with hold-open magnets that release the door upon fire alarm activations ...” An interview with EMP5 on March 17, 2025, at 10:05 AM, confirmed the unsecured entrance. On March 17, 2025, at 10:05 AM, a tour of the Nutritional Services Department revealed areas in the dry food storage closet where paint was lifting away from the cement block, creating bubbles and large paint chips hanging from the walls. Observation occurred at approximately 11:15 AM, during tour of the food preparation area with EMP3, EMP7, and EMP15.”