Good Shepherd Specialty Hospital

“Facility ID# 53020100 Component 01 Main Building Based on an unannounced Medicare Recertification Survey completed on May 5, 2026, it was determined that Good Shepherd Specialty Hospital was in compliance with the requirements of the Life Safety Code for an existing acute care health care occupancy. Compliance with the National Fire Protection Association’s Life Safety Code is required by 42 CFR 482.41(b). This is a five story, Type II (222), fire resistive building, with a basement and miscellaneous rooftop mechanical spaces, that is partially sprinklered. The Good Shepherd Specialty Hospital is located at the third and fourth floor levels of the Muhlenberg Campus of the Lehigh Valley Hospital.”

“Facility ID# 53020100 Component 01 Main Building Based on an unannounced Medicare Recertification Survey completed on December 21, 2023, it was determined that Good Shepherd Specialty Hospital, was not in compliance with the requirements of the Life Safety Code for an existing acute care health care occupancy. Compliance with the National Fire Protection Association’s Life Safety Code is required by 42 CFR 482.41(b). This is a five story, Type II (222), fire resistive building, with a basement and miscellaneous rooftop mechanical spaces, that is partially sprinklered. The Good Shepherd Specialty Hospital is located on the third floor of the Muhlenberg Campus of the Lehigh Valley Hospital.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to monitor the use of power taps in one of two smoke compartments. Findings include: 1. Observation on December 21, 2023, at 11: 30 am, revealed various small appliances being powered by a power tap/surge protector in the staff lounge. Interview with the administrator and Lehigh Valley Health representative on December 21, 2023, at 11:30 am, confirmed the appliances were being powered by a multi-outlet power tap.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 19056 Based on the systemic nature of the standard level deficiencies related to Quality Assessment and Performance Improvement, the facility failed to substantially comply with this condition. Findings include: The following standards were cited and show a systemic nature of non-compliance with regards to Quality Assessment and Performance Improvement as follows: §482.21(a) Standard: Program Scope §482.21(d) Standard: Performance Improvement Projects.”

“RESPIRATORY CARE SERVICES CFR(s): 482.57 The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory care services. This Condition is not met as evidenced by: 19056 Based on the systemic nature of the standard level deficiencies related to Respiratory Services, the facility failed to substantially comply with this condition. Findings include: The following standards were cited and show a systemic nature of non-compliance with regards to Respiratory Services as follows: §482.57(a)(1) - There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly. The director may serve on either a full-time or part-time basis. §482.57(b) Standard: Delivery of Services §482.57(b)(4)- All respiratory care services orders must be documented in the patient ’ s medical record in accordance with the requirements at §482.24.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 19056 Based on review of facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure the program measured, analyzed, and tracked quality indicators for contracted services. Findings include: Review on December 13, 2023, of the facility’s “Performance Improvement Plan Qaulity Assessment & Performance Improvement (QAPI) plan” dated 2023, revealed “... Design & Scope ... 2. Scope: QAPI activities will be integrated across all the care and service areas of our organization ... 3. Objectives: ... All departments and services will be involved in Performance Improvement activities ... 4. Quality Assurance: We will have a committee that will review data from areas of the organization on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization ... Performance Improvement Projects (PIPs) 13. As part of our QAPI program, we will conduct Performance Improvement Projects ... We will document what projects are being conducted, the reason for conducting the projects and the measurable progress achieved on the projects ...” A request was made to EMP1 on December 13, 2023, for the facility’s contracted services quality indicators. None was provided. Interview with EMP1 on Decmeber 13, 2023, at 11:40 AM, confirmed there is no measuring, analyzing, and tracking of quality indicators for the following contracted service areas: laboratory, radiology, dietary services, pharmaceutical services, envionmental services and dialysis services.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 19056 Based on review of facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure it conducted performance improvement projects related to its contracted services. Findings include: Review on December 13, 2023, of the facility’s “Performance Improvement Plan Qaulity Assessment & Performance Improvement (QAPI) plan” dated 2023, revealed “... Design & Scope ... 2. Scope: QAPI activities will be integrated across all the care and service areas of our organization ... 3. Objectives: ... All departments and services will be involved in Performance Improvement activities ... 4. Quality Assurance: We will have a committee that will review data from areas of the organization on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization ... Performance Improvement Projects (PIPs) 13. As part of our QAPI program, we will conduct Performance Improvement Projects ... We will document what projects are being conducted, the reason for conducting the projects and the measurable progress achieved on the projects ...” A request was made to EMP1 on December 13, 2023, for the facility’s performance improvement projects related to its contracted services. None was provided. Interview with EMP1 on Decmeber 13, 2023, at 11:40 AM, confirmed there were no performance improvement projects conducted for the following contracted service areas: laboratory, radiology, dietary services, pharmaceutical services, envionmental services and dialysis services.”

“DIRECTOR OF RESPIRATORY SERVICES CFR(s): 482.57(a)(1) There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly. The director may serve on either a full-time or part-time basis. This Standard is not met as evidenced by: 44109 Based on review of facility documents, and interviews with staff (EMP), it was determined the facility failed to designate a director of respiratory care services who is a Doctor of Medicine or osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly. Review on December 13, 2023, of facility document “Good Shepherd Specialty Hospital Medical Staff Bylaws” revised June 22, 2021, revealed no designation of a director of respiratory care services. A request was made on December 13, 2023, at 10:30 AM to EMP3 for the job description of director of respiratory care services. None provided. Interview on December 13, 2023, at 11:36 AM with EMP3 confrimed the facility did not designate a director of respiratory services who is a Doctor of Medicine or osteopathy.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 44109 Based on review of medical records (MR), facility policy and procedures, and interviews with staff (EMP), it was determined the facility failed to adhere to its Respiratory Care Services established policies and procedures for two (2) out of five (5) respiratory medical records reviewed (MR12 and MR13). Review of MR12 on December 12, 2023, revealed tracheostomy care was documented as completed one time, at 2:10 AM, over two shifts on September 2, 2023. Review of MR13 on December 12, 2023, revealed tracheostomy care was documented as completed one time, at 3:20 AM, over two shifts on September 2, 2023. Review on December 13, 2023, of facility policy, “ Tracheostomy Care”, dated December 2022, revealed, “ ...C Changing Tracheostomy Tube Dressing...should be changed whenever soiled and/or every shift.” Interview on December 12, 2023, at 1:59 PM with EMP1 confirmed MR12 did not have progress note regarding omitted tracheostomy care on September 2, 2023. Interview on December 12, 2023, at 2:07 PM with EMP1 confirmed MR13 did not have progress note regarding omitted tracheostomy care on September 2, 2023 Interview on December 13, 2023, at 12:34 PM with EMP1 confirmed the Respiratory department staff work 12-hour shifts. Further interview with EMP1 confirmed that tracheostomy care should be completed and documented twice per 24-hour period.”

“RESPIRATORY SERVICES CFR(s): 482.57(b)(4) All respiratory care services orders must be documented in the patient’s medical record in accordance with the requirements at §482.24. This Standard is not met as evidenced by: 44109 Based on review of medical records (MR), facility policy and procedures, and interviews with staff (EMP), it was determined the facility failed to document in the medical record of two (2) out of five (5) respiratory medical records reviewed. (MR12 and MR14) Review of MR12 on December 12, 2023, revealed breathing treatments ordered by the physician on August 28, 2023, to be administered four times per 24-hour period. Further review revealed the breathing treatments were documented three times, at 7:07 AM, 10:55 AM, and 3:10 PM, over the 24-hour period of September 1, 2023. Review of MR14 on December 12, 2023, revealed cough assist was ordered by physician on October 17, 2023, to be completed four times per 24-hour period and as needed every two hours. Further review revealed cough assist was documented as completed three times, at 7:15 AM, 11:55 AM, and 9:00 PM, over the 24-hour period of October 19, 2023. Interview on December 12, 2023, at 1:59 PM with EMP1 confirmed when a treatment is not performed, there should be a progress note explaining why it was not performed. Further interview with EMP1 confirmed MR12 did not have a progress note regarding omitted breathing treatment for the 24-hour period of September 1, 2023. Interview on December 12, 2023, at 2:11 PM with EMP1 confirmed MR14 did not have progress note regarding omitted cough assist for the 24-hour period of September 2, 2023.”