The state health department issued some failing grades for Bradford Regional Medical Center earlier this year, but a spokesman said corrective measures are underway or, in some cases, completed.
Pennsylvania Department of Health reports, available online, detail nearly a dozen ways in which BRMC was not in compliance during site visits, surveys and reviews.
Some of the non-compliance was pointed out in August 2022 in a prior round of violations from the Board of Health, with plans of correction issued by BRMC — yet the problems remained.
“Our team has been working diligently on the corrective action plans on the findings from the surveys conducted by the Pennsylvania Department of Health,” said spokesman Joseph Fuglewicz. “The areas of concern have been addressed through corrective action plans that have been submitted and accepted by the PA DOH.”
Several of the issues seem to have arisen from the state line between Olean General Hospital and BRMC, and meeting requirements within Pennsylvania.
“We have implemented the resolutions as we continue to work collaboratively with the PA DOH to ensure we’re meeting all regulatory requirements while providing our patients with quality care,” Fuglewicz said.
According to the state reports, physicians who were on-call to care for inpatients at BRMC were not always present at the hospital. In one instance, a review of schedules showed a three-month period in which one physician for inpatient care was scheduled on-call 24 hours a day, seven days a week.
The report noted this has been corrected.
“As a corrective measure, the facility initiated in-house, 24/7, hospitalist-credentialed inpatient physician coverage for the facility on March 27.”
Fuglewicz said, “Unlike other hospitals in the region, we have a board-certified physician onsite 24/7 inside the facility covering all patients, where other facilities use telemedicine and are staffed by advanced practice providers such as physician assistants or nurse practitioners.”
The health department also noted that not all physicians who had been practicing in the hospital, including telemedicine for psychiatry and out-of-state providers, had the proper privileges. It was noted, too, that emergency room doctors had been called in some instances to provide care for inpatients when no doctor was available, without the appropriate privileges. At the same time, the health department had never been contacted for approval of a telemedicine program for psychiatry, the reports noted.
All of that has been addressed, Fuglewicz said.
“All our positions have the appropriate privileges that are congruent with the care that they provide to our patients and services that are permitted to use telemedicine, such as psychiatry, now have the appropriate state approval,” he explained.
“Olean General Hospital and Bradford Regional Medical Center are merged as one hospital with two campuses,” he continued. The health department stated that it hadn’t been notified of, nor seen a contract for, services being performed at BRMC’s sterile processing department for both campuses.
Fuglewicz said, “This was completed as requested and submitted as part of our approved plan of correction.”
The health department noted other areas where it hadn’t received notification, like when BRMC reduced the hours of the pharmacy, ceased a teletriage pilot program in the emergency department, and failed to follow a prior plan of correction from August 2022 for letters of notification on telemedicine, sterile processing, reduction of pharmacy hours and the reduction of one bed on the dual diagnosis unit.
Again, Fuglewicz said, “All required notifications have been submitted to the DOH in regards to the following areas hours of the pharmacy, teletriage program in ER, inpatient telemedicine program as well as the reduction of one bed in dual diagnosis unit — an issue with the actual bed — which was resolved in less than one week’s time and the unit is back to full capacity.”
Some other matters identified were also related to the hospital’s two-campus system.
In the August 2022 report, the health department said a chief administrative officer must be devoted full-time to BRMC, part of the organization’s board meeting must be devoted to BRMC and notes must be kept at BRMC. All contracted services must have a specific reference to the Pennsylvania campus as well.
“We have had a chief administrative officer since it was made a requirement in 2018 and have policies and processes to ensure that all appropriate notifications are sent out in the required timeframe,” Fuglewicz explained. “David Monroe, MBA, BSN, is the current chief administrative officer at BRMC and has been in this position since July 2022 where he’s devoted full-time.”
The health department noted job descriptions must be kept for BRMC, as well as performance evaluations. Again, Fuglewicz noted, the issue stems from the two-campus system.
“Since BRMC and OGH are one organization with two campuses, some employees have dual roles at both sites. The job descriptions for these positions laid out the job roles and responsibilities for the entire organization and were not site-specific. Descriptions, evaluations, and HR files now mirror one another and have one for each campus for these dual roles.”
