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Based on record review and staff interview, it was determined that the facility failed to implement a system for evaluation of the quality of its contracted services to ensure that each contracted service is provided in a safe and effective manner.

Findings include:

During course of the review of 3 contracts on all dates of the survey, it was identified that the facility did not have a formal mechanism to evaluate the quality of each contracted service provided.

Specifically, the facility failed to perform a documented quality evaluation for the following contracts reviewed:
-a. Sodexho Management Inc.
-b. SeniorCare Emergency Medical Services, Inc. (Ambulance)
-c. Visiting Nurse Service of New York Home Care II

No data was collected to assess the performance in 2 of 3 contracts reviewed.
There was no evidence documented of the specific criteria utilized by the facility to assess the
individual performance of 2 of these contracted services in accordance with the terms (deliverables) unique to each contract.

a. No information was collected to assess the quality of the Sodexho contract. Interview with staff #4 on 4/7/11 found that the hospital relies on data collected from an external patient satisfaction survey company to gauge complaints about food and dietetics. No other information is collected for analysis of the contract.

b. At interview with staff #3 on 4/6/11 it was stated that documents are collected from the SeniorCare ambulance company for assessment of the contract. While it was stated that visual inspection is performed of the cleanliness of ambulances and employees, the results of these inspections are not documented.

c. Review of quality assurance data collected from the Department of Patient Care Management on 4/5/11 and 4/8/11 determined that only numerical referral data is collected for the number of referrals made to the VNS Certified Home Care Agency. The hospital did not provide sufficient oversight of this contracted service.

Review of the clinical affiliation agreement between the hospital and Visiting Nurse Services of New York Home Care and related Exhibit B on 4/8/11 found that the hospital is supposed to receive data from the agency regarding performance and outcomes. The hospital did not comply with a requirement in the contract to monitor VNS performance and outcomes data. In fact the hospital instead relied on data collected by the preferred provider agency and did not provide sufficient evidence of active evaluation of this service.
Collection of data was limited to home care agency referral numbers.
In fact, the numerical referral data provided on 4/5/11 and 4/8/11 contained inconsistent numbers of home care referrals made to the VNS agency.
For example, in December 2010 the department reported 39 referrals placed and accepted by the agency whereas the data submitted on 4/8/11 reported 285 referrals and 162 admissions to VNS during 12/10. There was no written analysis of these numerical discrepancies.

Cross-refer to findings noted under tag #A843.

1. Based on review of records, procedures, and staff interviews, the hospital did not ensure the consistent distribution of required notices to patients or their representatives. Specific reference is made to the lack of consistent provision of the Important Message from Medicare (IM) notification forms upon admission and prior to discharge.

Findings include:

The hospital has not ensured compliance with federal CMS notification requirements to notify inpatient Medicare beneficiaries about hospital discharge appeal rights. CMS requirements include specific timeframes for the delivery of the Important Notice to Medicare inpatients (IM), which includes IM provision within 48 hours of admissions and requires that written follow-up notification be issued within 48 hours in advance of discharge (but not less than four hours prior to discharge).
The hospital has not complied with its procedures for "Important Message from Medicare, # 511", which describes the process for provision of this statutorily required notice.

Review of patient records on all dates of the survey also determined the hospital is utilizing an incorrect discharge notice which does not meet the CMS requirement for provision of the standardized notice, an OMB-approved form (CMS-R-193) referenced in 200.6.2.
This form cannot be altered from its original format. The hospital must display the "Department of Health & Human Services , Centers for Medicare & Medicaid Services" and the OMB number. Hospitals may not deviate from this format except as permitted in Section 200.6. The incorrect form utilized for discharge was titled "Discharge Notice", which included the name of the facility and contained the number "NSG-362A".

In 16 of 23 applicable records reviewed, there was no evidence that patients or their representatives received either the IM admission notice and/or the correct Medicare IM discharge notice within 48 hours of discharge. Refer to MR #s 9, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26.

While the hospital has conducted quality assurance analysis of the initial distribution of IM notices after admission, the hospital has not implemented an audit to assess compliance with distribution of follow-up IM notices to patients or their representatives prior to discharge. Interview with staff # 5 on 4/7/11 confirmed the department is only monitoring the provision of the initial IM notice upon admission.

2. Based on review of four applicable patient records, it was determined the hospital did not address the needs of patients with Limited English proficiency.

Findings include:

Review of four records for patients with Limited English Proficiency on 4/6/11 and 4/8/11 did not record plans to address the communication issues or informed consent, including, but not limited to, provision of interpreters where necessary. Records did not consistently identify the patient's language needs or did not evidence provision of translator services for consent in accordance with hospital procedures.Examples include:
MR #22: 75 year old female with history of dementia was admitted for lethargy and weakness. The history and physical noted the patient spoke Spanish and history was obtained from the patient's son. However, nursing and discharge planning notes indicated the patient spoke Italian.

MR # 26: 91 year old female admitted for shortness of breath and with noted history of dementia. Patient was noted to be Chinese-speaking, yet the patient admission history form indicated staff was unable to obtain data due to language barrier. Staff used patient's daughter for translation.

MR # 29: This patient was seen in the ED on 12/20/11 for rectal bleeding where it was noted by staff that they were unable to fully assess the patient who was non-English speaking. The ED note indicated the patient's primary language is Chinese. The patient was assessed by a psychiatrist who noted the patient was a Korean male transferred from a nearby psychiatric hospital where there was a request to assess need for one to one observation. The assessment indicated the patient stated he could not speak English despite note indicating the patient was in the US for 30 years. There was no evidence of interpretation provided.

MR #31: The record for this patient whose primary language was Chinese indicated that a cousin was used as an interpreter to explain a procedure. The use of the translator was not indicated on the patient consent, which is in violation for the hospital's written procedure for consents.

Based on record review and interview, it was evident that the facility did not formulate and implement a forensic policy that ensured the equal rights of patients who are prisoners.

Findings include:

Review of the policy titled "Patient Prisoner" Section EC #209 found that the policy authorized certain practices that violated the rights of patients in custody. Under Emergency Treatment Procedures it was stated in section 6 that the security officer " assists the arresting officers as necessary "without defining what is meant by "assisting."

Under Admitting Section #2, it was stated that the admitting department attempts to assign the patient/prisoner to a room which is conducive to security. It stated that the patient should be assigned to a private room, which is located on an upper floor at the end of a corridor. It made no reference to assignment based upon clinical needs.

Under Physician Section #3 it was stated that the treating physician determines the earliest date that it would be medically appropriate for transfer or discharge and announces this date at a security conference. Under Section #4 it stated that the treating physician discharges or transfers the patient/ prisoner to the appropriate municipal hospital prison unit as soon as it is medically appropriate. Transfer or discharge will not be delayed by elective procedures, which are not medically essential. This directive limits the patient's access to care and creates a separate standard of care for a prisoner patient.

Under NYPD it states that the Police Officer may use physical restraints on the prisoner in his room only in an emergency or with the permission of the treating MD. It did not specify the definition of "restraints".

Under Discharge, the section for NYPD states that the local precinct arranges appropriate transportation for the discharge or transfer of the patient/ prisoner. There is no reference to the hospital's accountability in securing the appropriate transportation to another facility and not delegating this task to law enforcement.

Based on observation, review of records, and staff interviews, it was determined the hospital's system for the form and structure of medical records system does not permit for effective interdisciplinary communication.
Specific reference is made to the finding that documentation maintained in an electronic recording system used to record discharge planning activities was not readily accessible to clinical staff outside of the Care Management Department.

Findings include:

During review of medical records and tours of patient care units (7 Uris, 9 Uris and 9 Wollman) on 4/4/11 and 4/5/11 it was observed that nursing and medical staff interviewed were not able to access the most recent electronic discharge planning notes in patient records. Staff interviewed (staff #s 6,7,8,9) confirmed that that nurses and social workers employed by the Care management department shall print out the electronic notes in this computerized "Canopy" system for inclusion into the paper record.

The lack of immediate access to the most up to date electronic data by clinical staff creates the potential for lapses in interdisciplinary coordination.

Based on observation and review of records and documents, it was determined the hospital did not ensure the confidentiality of patient medical records in that a representative from an outside ambulance company was observed to have unrestricted and unauthorized access to a patient record.

Findings include:

During tour of the inpatient unit 9 West on 4/5/11 at 1:20 PM, surveyors observed a paramedic employed by SeniorCare Ambulance company (staff #1) going through a patient medical record (patient referenced in MR #4) at the nursing station and was observed entering information from the medical record into a laptop computer. No hospital employees were nearby and this individual was observed independently reviewing the record. At interview with this staff #1, it was stated he is employed by an ambulance company having a contract with the hospital and that he was reviewing the record for a patient being discharged. He reported that he reviewed the record for orders and other data including medical information, insurance information, social security number, and medicine history. He acknowledged he enters into his company computer so that he knows what to do if the patient goes into distress while being transported.

At interview with the Social worker on the unit (staff#2) it was stated this happens all the time and that it is customary for the ambulance staff to access the patient data and this happens at other hospitals; she specifically referenced the name of a nearby hospital with the same practice.

Review of the hospital's contract with the ambulance company on 4/5/11 determined that while the SeniorCare staff may have access to specific areas of the record (i.e., medical necessity forms, transfer paperwork, insurance information, approval paperwork, chart copy, etc.) it did not specifically authorize the Senior care staff independent and unsupervised access to the entire medical record. Therefore the hospital did not ensure the confidentiality of patient records in that it does ensure access to the record by only individuals authorized to do so.

Based upon observations, interviews and review of the facility's policy and procedures and other facility documents, it was determined that the facility failed to be constructed, arranged and maintained to ensure the safety of patients. Therefore the accumulative effect of the Hospital Regulation standard level deficiencies as well as the Life Safety Code deficiencies is that the Condition of Participation for Physical Environment is not met as evidenced by:

1. Failing to maintain the physical plant to assure patient safety and well-being. ( See A 701).

2. Failing to meet LSC standards. ( See K20, K22, K25, K29, K31, K33, K36, K38, K42, K43, K50, K52, K62, K72, K75, K76, K77, K106,K130, K135, K136,K145,K147 and K 161).

Based on observations, record review, and interview during tours of the facility between 4/4/11 through 4/8/11 the hospital did not ensure that the condition of the physical plant and overall hospital environment was developed and maintained in a manner to ensure the safety and well being of patients.

Findings include:

During a tour of the Operating Room suite (OR) on 4/5/11 the following environmental deficiencies were identified:

1. Interview with facility staff indicated that the hospital uses the American Institute of Architects (AIA) industry standard for humidity and temperature control. For humidity that range is 20-60%. Review of the humidity readings recorded by nursing staff and review of the 4/5/11 printout from the building management system (BMS) showed a discrepancy between the two sets of numbers. The BMS reading was showing OR with humidity readings as low as 0% and 4 %. According to staff member # 13 this was because several humidistat sensors were valved off. Facility staff was asked take manual reading of the OR so it could be assured that the rooms were safe for surgery. This could not be done because a hygrometer was not available on site. An outside vendor was called in to take readings. It was determined that all readings were in a safe range. The hospital's vendor indicated that 10 humidistat sensors for the BMS system required replacement.

2. On 4/5/11 the air flow ORs # 4,5,6, 7 and 8 was tested and found to be negative rather than positive as required. This was confirmed by the facility's vendor.
Cross Refer to A 748

3. On the morning of 4/5/11 the airflow from the sterile side of the sterile processing department (SPD) was tested and found to be negative rather than positive. This indicates that the air from the corridor would pull into SPD from the corridor. This was confirmed by the facility's vendor.
Cross Refer to A 748

4. On the afternoon of 4/4/11 the housekeeping closet on the decontamination side of SPD was noted heavily soiled.

6. During a tour of the psychiatric unit on morning on 4/7/11 looping hazards were noted in patient rooms. The hinges on the toilet room doors and wardrobe, the metal pipe on the toilet and large gaps between the fins in the vents of the window heating units all pose a risk of suicide by looping.

7. On 4/7/11 the electrical outlets in the toilet rooms on the psychiatric unit were noted to be regular outlets rather than the tamper resistant type and thus pose a risk of suicide by electrocution.

8. On 4/7/11 it was observed that the panic button in the psychiatric patient rooms were not working.

Based on observation and interview it was determined that the facility failed to ensure a safe environment consistent with recognized infection control practices.

Findings are:

1. During a tour of the basement materials management storage room at the 77th Street campus on 4/5 /11 and the 64 th street campus on 4/8/11 it was noted that medical supplies that would come into direct contact with patients were not protected from contamination. Open boxes of sterile supplies were adjacent to cardboard shipping boxes. Many sterile items were loose on the shelf. Supplies included were not limited to cardio thoracic open heart chest sets, IV sets, autoclave sets, IV solutions, lancets, Vacutainer, open boxes of gloves, Foley tubes, etc. A few packages of Foley tubes were noted on the floor in front of the shelf. The floor and ceiling in the materials management rooms at both campuses were noted soiled. HVAC vents throughout dust laden. The blue plastic totes used to transport sterile supplies from an offsite contractor were noted dirty and dusty.
Interview with staff member #24 confirmed that supplies are taken from the shelves in the materials management rooms and brought to the nursing units and ORs.

2. On the morning of 4/5/11 the airflow from the sterile side of the sterile processing department (SPD) was tested and found to be negative rather than positive. This indicates that the air from the corridor would pull into SPD from the corridor. This was confirmed by the facility's vendor.

3. On the afternoon of 4/5/11 the air flow OR's 4,5,6, 7 and 8 was tested and found to be negative rather than positive as required. This was confirmed by the facility's vendor.

4. Grout between tiles on the walls of 8/16 were noted grimy. Grout on OR walls is not appropriate surface in a sterile environment as the cracks and crevices may retain dirt and dust.

5. No water was available at one of two faucets at the scrub sink between ORs 1 and 2. Only cold water was provided at one of three faucets at the scrub sink between OR's 4 and 5.

6. On the afternoon of 4/7/11 during a tour of the ambulatory surgical suite at the 77th Street campus cold water was noted at several scrub sinks. The temperature was noted to be 67 degrees Fahrenheit at 2 of 4 faucets of the scrub sink outside OR 21, one of 2 faucets outside OR 25 and the faucet at the scrub sink adjacent to OR 24.

Based on review of documents and staff interviews, it was determined the hospital staff, in the course of formulating discharge plans, did not implement a consistent system for sufficient patient notification about available options for the selection of home health care agencies.

Findings include:

1. The hospital has not implemented a consistent system to ensure compliance with the requirement for patient notification of options in the selection of home care agencies, where feasible. The hospital's practices for home care referrals did not ensure objectivity in patient selection of home care provider and did not fully comply with the requirement prohibiting the limitation or specification of home care choices.
2. Review of the procedure titled, "Non-Discrimination in Post-Hospital referrals to Home Health Agencies" on 4/5/11 finds that the hospital notes that patients shall have the right to choose a home health provider and that hospital staff will generate a list of agencies available in the area in which the patient receives services. This policy also notes that the list shall not constitute an endorsement of any particular agency. The written policy itself did not specifically identify the staff responsible for the distribution of this options list nor describe a detailed procedure for its distribution.

This written policy also did not include the description or presence or role of on-site staff from a certified home health agency contracted by the hospital, in which the contract deemed the agency as a "preferred provider" (VNSNY II). The policy lacked mention of this on-site agency preferred provider, VNS, and did not describe the responsibilities of this agency's home health intake coordinators, who were involved in the intake process.
In addition, a flowchart was subsequently provided that graphically depicted a home care algorithm for patient choice. Review of this referral algorithm reveals the hospital's structure and process for CHHA home care agency referrals directs patients choosing agencies within the geographic area to be screened by VNS staff after receiving "choice" from hospital discharge planning staff.
Review of this form titled, "Home Care Algorithm for Patient Choice, Out of Area, NSLIJ HC, and VNSNY referrals" shows that while choice is given to patients by hospital staff, the actual home care referral must first be made to VNS (preferred provider) for intake when a patient chooses a certified home health care agency (CHHA) that is "NOT out of area". VNS agency staff would then forward the referral to the selected agency before this agency staff is able to come on-site.
Persons choosing agencies "out of area" are first directed to Payer Specialist/Discharge Planners- from Home Care ("PSDP's), who process referrals for the system-owned and affiliated home care agency, North-Shore LIJ Home Care. Therefore, this process requires that any person choosing an agency that is located within the area network must first be referred and processed by on-site staff from VNSNY. Consequently, direct referrals are not made by hospital staff to alternative home care agencies without first being processed by the "preferred provider" on-site nurse from VNSNY or by a Home Care nurse (PSDP) primarily responsible for referrals to the network-affiliated agency.

3. Review of the VNS contract on 4/8/11 determined the hospital had entered since 2003 a "preferred provider" agreement with VNS , which included on-site liaison Home health care staff. Interview with the Care Coordination Director on 4/4/11 found that VNS is planning to terminate the agreement at the end of April 2011. It was reported that there has been a change in the VNS on-site role since the transition made by the hospital to the North Shore LIJ network. In October of 2010 North Shore -LIJ had acquired another hospital's home care agency and it was reported that there was some discomfort at that time with the on-site presence and role of VNS agency staff in the hospital. It was stated that at that time three additional hospital staff were hired to perform home care intakes.4. Staff interview on 4/7/11 found that in the department of Psychiatry, staff will make a referral to VNS or North Shore -LIJ Home Care through a computer system and then VNS staff will come up to the unit to follow up. This information about the home care referral process was at variance from that revealed during interview of staff # 6 on 4/5/11, during which it was stated that only staff employed by the hospital will refer patients to the on-site home care agency staff only after a list of choices is provided.
5. The hospital has not consistently promoted the availability of patient choice in home care. For example, review of the list of multiple certified home health care providers given to patients and their representatives finds that this list designates that Visiting Nurse Service of New York is a Lenox Hill "preferred provider" . Home care listings for each borough were listed in bold and large print and prominently displayed on top of each page is the name of the Home care agency that is owned and operated by the North Shore-LIJ Health system. The form indicates that the hospital is a member of the same system.

The listing of the agency system- affiliated home care provider along with the contracted "preferred provider" has the potential effect of influencing and limiting patient choice in selection of home care provider. The manner in which the form was written can be construed as an endorsement of two agencies and has the potential to imply advice or guidance for the reader's decision.
6. The hospital has not consistently documented evidence in records that patients or their representatives have received written provision of lists of available certified home health care agencies. 9/10 applicable records did not include sufficient documentation of the provision of home care agency option listings and/or noted only the final outcome recording the selection of a specific agency. Despite sporadic evidence of listings provided, the majority of records reviewed had limited referrals to either the VNS (preferred provider) or the network system agency (North-Shore -LIJ Homecare).

Examples:

MR #s 4: Patient's plan changed from placement to home care for wound care. The record noted a referral was made to VNS for wound care. No evidence of options was noted.

MR #13: 78 year old patient hospitalized for worsening pulmonary symptoms and noted history of bronchiectasis. Patient had PICC line inserted on 3/16/11 for IV antibiotic therapy at home. The patient was referred to a "Advanced care" high tech infusion on 3/16/11. The hospital planner noted that "at this time region does not cover Manhattan". Case Manager made aware." There was no follow up validation of the home care referral during chart review of 4/5/11. No evidence of agency options provided was noted.
On 4/6/11 the hospital provided an additional electronic document to surveyors from discharge planning that indicated the patient had been referred for home infusion which started on 3/18/11 but this was not evident in the original record reviewed.

MR #15: This 89 year old patient was hospitalized for upper back pain and the record noted on 4/1/11 that she did not wish referral to VNS. On 4/4/11 the patient requested homecare for physical therapy and the record noted "she decided now on North Shore -LIJ Home Care". No evidence of provision of alternate options was apparent.

MR #18: 94 year old patient was referred to VNS for skilled PT , RN, and Home health aide visits. No evidence of choice was evident.

MR #24: 88 year old female admitted for ICH following fall. The record noted the daughter is considering sub-acute rehabilitation or home with home care. The agency of choice was noted as the network system agency (North Shore LIJ Home Care). However, there was no evidence noted to validate the actual provision of the agency options listing.

MR#25: 74 year old male who underwent ORIF surgery for a fractured humerus was referred to the hospital's network agency (North Shore-LIJ Homecare ) on 3/10/11. No evidence of home care choice was recorded. The patient refused services.

MR #26: 91 year old patient hospitalized for pneumonia. Documentation on 3/10/11 indicates "home care choice provided and the son in law prefers NS-LIJ Homecare". The plan changed to sub-acute rehabilitation and was again changed on 3/17/11 for home care. The North Shore agency refused to accept the patient due to physical needs and aggressive behavior. It was noted another agency (VNS) could be attempted and again it was noted the family agreed to VNS. No other options were recorded.

MR #27: No evidence of choice was provided other than a note indicating the patient's daughter requested VNS for the patient.

MR #32: 51 year old patient who required PICC line for long-term antibiotics. The chart noted the patient " was referred to VNS by a vascular PA as the patient is known to VNS and NS- LIJ Homecare does not do infusion cases in New York City". No evidence of choice was indicated and the presence of this documentation in the record implies a justification was made by hospital staff for not referring this case to the hospital's network-affiliated home care agency.

Based on review of records and staff interview, it was determined that there was inconsistent documentation of safe discharge planning referrals implemented for identified needs.

Findings include:

10/30 applicable records reviewed on all dates of the survey did not contain sufficient evidence of discharge planning disposition or did not ensure that post discharge plans addressed safety needs.

Examples include:

MR #13: This record reviewed on 4/5/11 lacked validation of arrangements and acceptance for home IV infusion therapy. This 78 year old patient with bronchchiectasis with pseudomonas had required IV antibiotics via PICC line, which was inserted on 3/16/11. Discharge planning notes were not updated since 3/16/11, which it was noted the plan was to refer to a specific agency for IV infusion and that the discharge planner was notified because " the region " did not cover Manhattan. There was no validation of home care acceptance on the record during initial review on 4/5/11. The patient was discharged on 3/18/11 with no evidence of acceptance by the home care agency nor validation the services were arranged and in place.

Follow up discussion with the facility staff on 4/6/11 found there were notes printed from the computerized record for discharge planning , which were not on the record reviewed originally. An additional note indicated that the patient was discharged "last night" for home IV infusion of primaxin and that the worker had contacted a payer specialist about discharge. Attached was an e-mail from the case manager dated 4/7/11 in which it was noted that the patient was started on home infusion on 3/18/11.

MR #15: This record for an 89 year old female who was scheduled for discharge on 4/4/11 lacked evidence of validation of home care acceptance. The patient was admitted for back pain and noted to have history of osteoporosis. Patient had acute and sub acute vertebral compression fractures. The discharge order was written at 8:31 AM on 4/4/11 and the social work note at 11:53 AM documented discussion with the hospital nursing staff to refer to home care for nursing and physical therapy. No validation of home care acceptance was evident by 1:05 PM on 4/4/11.

MR #16: The plan for a patient returned to a psychiatric facility lacked effective coordination for wound care needs resulting in multiple hospital returns (2). This 75 year old patient with dementia was transferred on 3/21/11 from a nearby psychiatric hospital for lower extremity recurrent cellulites superimposed on chronic venous stasis ulcers. The patient also had sacral pressure ulcer and stage II ischial ulcers. The patient was discharged back to the psychiatric facility via ambulance at approximately 3 PM on 4/1/11 and was returned to the hospital the same day. Patient admission history dated 4/1/11 at 7:30 PM indicated the patient was rejected from the psych facility after discharge but did not specify the reason. Staff interview and record review on 4/5/11 found discussion of need for wound care consult. Interview with staff # 6 on 4/4/11 determined that patients with wound care needs are returned from the psychiatric facility on a recurrent basis.

This patient was again discharged to the facility on 4/5/11 at 4:10 PM and was again returned to the hospital ED on 4/5/11 at 9:20 PM. It was noted the patient was not accepted at the psychiatric facility due to decubiti on back and bilateral heels. EMS had reported the psychiatric facility does not address decubiti and refused to admit this patient. Arrangements were made with the physician's intervention to return the patient to the psychiatric facility, to where he was again discharged at 2127 (9:27PM) on 4/5/11.

MR #19: The discharge plan for this 79 year old patient lacked evidence of direct patient participation. The patient had adenocarcinoma and was referred to a nursing home on 3/21/11, where the planning was conducted directly with the patient's daughter. The plan did not include a direct discussion with the patient, who was noted as alert and oriented, in order to assess her participation with and agreement with planning .

MR #20: The discharge plan for this 86 year old female who was admitted on 3/26/11 after a fall was insufficient and unsafe. The patient's history was significant for ESRD and CAD. The PA note dated 3/27/11 indicated the patient could not ambulate for more than 5 minutes and is unsafe for discharge as she lives alone. The patient also refused home care. The PT assessment on 3/28/11 indicated the patient would require outpatient physical therapy and 1 more session to assess ambulation and stair negotiation. Follow-up note by the PA on 3/28/11 indicated he discussed the case with the MD and that the patient was cleared for discharge and did not need home PT. Discharge planning noted the patient had Life alert system and that she refused home care. A message was left for the patient's son. The patient refused service. There was no assessment of patient capacity. The patient was discharged home on 3/28/11.

MR #22: The record for this 75 year old patient with dementia, hepatic /biliary slowing did not demonstrated evidence of referral despite recommendation for skilled physical therapy. The patient's assessment indicated she received two rotating 24 hour home attendants which would be reinstated from the agency and scheduled for the day following discharge on 3/16/11. The PT consultation dated 3/15/11 indicated the patient would benefit from skilled PT and that the recommendation was short term rehabilitation or home with 24 hour care. The discharge plan did not incorporate the physical therapy recommendations.

MR #25: 74 year old male admitted on 3/9/11 following a fall where he sustained a right humeral fracture. The patient underwent ORIF. The patient was referred for home care but refused. It was noted he lived alone and required a one-person assist in transfers/ personal care on 3/14/11. The patient was started on lovenox injections but did not have drug coverage. It was noted on 3/15/11 the patient could be discharged to home when these barriers to discharge were resolved. There was no evidence on the record of a final discharge planning note and outcome. The patient was discharged on 3/15/11 without evidence of a safe plan nor assessment of the patient's decisional capacity. The lovenox SQ injection was crossed off the patient's discharge plan form.

MR #26: Inconsistent notes were evident regarding the patient's discharge disposition. This 91 year old patient with dementia and arthritis was admitted 3/9/11 with shortness of breath and treated for pneumonia. The patient was rejected by the first home care agency attempted due to physical needs and agressive behavior. An attempt was made to place the patient at a specific short term rehabilitation facility. The social worker noted on 3/17/11 a plan to refer to VNS in accordance with the family's change in decision, but noted that remaining decisions could include placement or not receiving home care (which could render the family's plan to take the patient home as unsafe). Psychiatry placed the patient on one to one observation due to unpredictable behavior. PT recommended short term rehabiliation upon discharge on 3/18/11. Nursing indicated on 3/18/11 the patient was discharged to rehabilitation but the placement was not identified. There was no final discharge planning/social work note present in the record to explain the outcome. In addition the discharge instruction form indicated that the patient was discharged home, which was in direct contradiction to the progress notes that noted the patient was discharged to rehabilitation.

MR #28: The discharge plan for this child referred to ACS did not demonstrate clearance by ACS before discharge. This child was witnessed being slapped in the face by her mother's boyfriend while in the ED and the child was subsequently assessed for contusion. The child's mother was being treated in the ER when the witnessed incident had occurred. The social worker assessed the case and reported the incident to Child protective authorities. It was noted the alleged suspect did not live with the child and the mother. However, the child was discharged without evidence of any prior authorization by ACS.

MR #30: Concurrent review of the discharge planning for this patient on 4/5/11 at 12:45 PM determined that the patient did not receive psychiatric assessment for evident needs. This 81 year old patient with ESRD was admitted 3/31/11 with altered mental status , exhibiting increased confusion and disorientation. The patient was noted to express a wish to end dialysis and his life. He was assessed by Renal who suggested the need for palliative care evaluation and consideration of subsequent psychiatric assessment. CT of the head was + for brain atrophy and neurology consult indicated transient global amnesia due to vascular disease. Discharge planning assessment indicated the patient lives alone in a Single room occupancy (SRO) and had received home attendant services. The patient was seen by Ethics on 4/4/11 who recommended a psychiatric consult in light of his hopelessness and need to assess the current regimen of intermittent use of antidepressants. A psychiatric follow up referral was also suggested. During review of the record on 4/5/11 the discharge plan and medication reconciliation form had been completed in advance and no psychiatric consult was yet ordered.
Per interview with the nurse on the unit it was stated the patient was ready to go but was pending a final plan from the social worker. Social work notes were limited to reinstatement of home care. Interview with the social worker on the unit revealed they were awaiting a palliative care consult and it was reported that if the patient was accepted, this service could not be provided in the setting of the patient's living situation.

Based on review of documents and staff interviews, it was determined that the facility did not fully reassess significant elements of the hospital's discharge planning process.

Findings include:

It was determined the hospital's discharge planning quality improvement process did not include:
- formal activities to monitor the provision of home care referrals by the network home care agency and the performance of the on-site "preferred provider" of home care;
-lack of evidence of qualitative reviews for cases referred for suspected child abuse and neglect.

a. Review of statistical data and QAPI reports submitted by the Department of Care Management on 4/5 and 4/8/11 revealed that the majority of patient referrals were made to only two of at least 27 additional available agencies listed within the five boroughs.

Three different sets of data were provided to the surveyor for the quantity of discharge planning referrals made to and accepted by certified home health care agencies (CHHA's).

Examples include:

- In one set of reports for Home Care referral statistics provided on 4/5/11 it was revealed that of 813 accepted referrals to certified home health agencies, 448 were accepted by North Shore LIJ (the same network as the hospital) and 269 were placed (accepted) by VNS of New York (a preferred provider) between the period of September 2010 and March 2011. The means that 88.19% of referrals were placed to only two agencies, one of which is a system agency of the hospital (NSLIJ) and the second a designated "preferred provider" (VNSNY). Staff #6 reported this data represented cases that were placed (accepted by the agency and closed).

The CHHA placement detail reports contains data as noted:
30 referrals were placed (accepted) to VNSNY in October 2010 ;
23 referrals were placed to VNSNY in November 2010;
39 referrals were placed to VNSNY in December 2010
This information was contrary to subsequent data provided by the hospital on 4/8/11 regarding VNS admissions, which revealed:
192 referrals were admissions to VNSNY in October 2010 ;
179 referrals were admissions to VNSNY in November 2010;
162 referrals were admissions to VNSNY in December 2010.

In another report, titled "ECIN data: Provider placed and open or closed", of 1171 referrals placed by home care agencies for the same time period from September 2010 through March 2011, 677 were placed with VNSNY (preferred provider) and 462 were placed with NS-LIJ Home care (the system affiliated agency). It was reported this data represented cases accepted by home care providers but that might not have been closed out in the computerized referral system (ECIN). This represents that 97.26% of home care agency referrals are placed (accepted) by only two agencies; each of which is system-owned or designated as a "preferred provider".

It was stated during interview with staff #6 on 4/6/11 that it was not possible to consistently track all of the home care referrals made to various home care agencies because the computerized system did not clearly identify cases that were accepted and closed out in the system. The staff was therefore unable to differentiate between active and closed cases in the electronic referral system. In addition the reports had difficulty quantifying the number of cases at each phase of the referral process from the points of referral initiation to acceptance. Consequently, the numbers of referrals made and accepted by agencies were not fully consistent. No formal quality assurance was conducted on home care referrals. The Director had stated the numbers are eyeballed for imbalances but that no formal quality assurance was conducted.
Cross-refer to related findings under tag #s A809 and A084.

b. Review of Care management quality reports and interview with staff #5 on 4/7/11 found that there was no qualitative reviews for cases referred for suspected child abuse and neglect.

Based on review of documents and interview, it was determined that the hospital did not formulate and implement a policy and procedure to ensure that all surgical staff practice within specific guidelines and do not exceed the scope of practice.

Findings include:

Review of both the job description and training on 4/4/11 for endoscopy technicians found that certain documents authorized unlicensed personnel to perform certain tasks during the course of polypectomies that involved exceeded the scope of practice.

Specific reference is made to a course given 12/7/10 in which it was stated that the operator (technician or RN ) introduces the sheath and retracted snare into the endoscope accessory channel amd that the device is to be advanced in small increments until endoscopically viewed exiting endoscope. It also directed the operator to "proceed with polypectomy." The course was given by US Endoscopy to RN's and endoscopy technicians.

At interview with the Nurse Manager of Endoscopy on 4/7/11, it was stated that the technicians perform this function only if there is no RN in the room. Also, she stated that the operators practice use of the snare on chickens to learn to feel for the characteristics of a polyp so that they can elevate it successfully.

At interview with Nursing Administration on 4/7/11, it was stated that the function of the technicians was not properly described in the course and that the endoscopist is more technically involved in the procedure than the course describes.

Based on review of records, it was determined the hospital's procedures for site verification were incomplete. Specifically site verification forms in medical records were missing vital information necessary to ensure safety and time out prior to surgery.
Review of 13 applicable records found site verification forms did not denote laterality, date , time, and/ or the specific operative procedure. Refer to MR #s 1,2,3,4,5,6,7,8,9,10,11,12,25.

Based on review of records and staff interview, it was determined that there was inconsistent documentation of safe discharge planning referrals implemented for identified needs.

Findings include:

10/30 applicable records reviewed on all dates of the survey did not contain sufficient evidence of discharge planning disposition or did not ensure that post discharge plans addressed safety needs.

Examples include:

MR #13: This record reviewed on 4/5/11 lacked validation of arrangements and acceptance for home IV infusion therapy. This 78 year old patient with bronchchiectasis with pseudomonas had required IV antibiotics via PICC line, which was inserted on 3/16/11. Discharge planning notes were not updated since 3/16/11, which it was noted the plan was to refer to a specific agency for IV infusion and that the discharge planner was notified because " the region " did not cover Manhattan. There was no validation of home care acceptance on the record during initial review on 4/5/11. The patient was discharged on 3/18/11 with no evidence of acceptance by the home care agency nor validation the services were arranged and in place.

Follow up discussion with the facility staff on 4/6/11 found there were notes printed from the computerized record for discharge planning , which were not on the record reviewed originally. An additional note indicated that the patient was discharged "last night" for home IV infusion of primaxin and that the worker had contacted a payer specialist about discharge. Attached was an e-mail from the case manager dated 4/7/11 in which it was noted that the patient was started on home infusion on 3/18/11.

MR #15: This record for an 89 year old female who was scheduled for discharge on 4/4/11 lacked evidence of validation of home care acceptance. The patient was admitted for back pain and noted to have history of osteoporosis. Patient had acute and sub acute vertebral compression fractures. The discharge order was written at 8:31 AM on 4/4/11 and the social work note at 11:53 AM documented discussion with the hospital nursing staff to refer to home care for nursing and physical therapy. No validation of home care acceptance was evident by 1:05 PM on 4/4/11.

MR #16: The plan for a patient returned to a psychiatric facility lacked effective coordination for wound care needs resulting in multiple hospital returns (2). This 75 year old patient with dementia was transferred on 3/21/11 from a nearby psychiatric hospital for lower extremity recurrent cellulites superimposed on chronic venous stasis ulcers. The patient also had sacral pressure ulcer and stage II ischial ulcers. The patient was discharged back to the psychiatric facility via ambulance at approximately 3 PM on 4/1/11 and was returned to the hospital the same day. Patient admission history dated 4/1/11 at 7:30 PM indicated the patient was rejected from the psych facility after discharge but did not specify the reason. Staff interview and record review on 4/5/11 found discussion of need for wound care consult. Interview with staff # 6 on 4/4/11 determined that patients with wound care needs are returned from the psychiatric facility on a recurrent basis.

This patient was again discharged to the facility on 4/5/11 at 4:10 PM and was again returned to the hospital ED on 4/5/11 at 9:20 PM. It was noted the patient was not accepted at the psychiatric facility due to decubiti on back and bilateral heels. EMS had reported the psychiatric facility does not address decubiti and refused to admit this patient. Arrangements were made with the physician's intervention to return the patient to the psychiatric facility, to where he was again discharged at 2127 (9:27PM) on 4/5/11.

MR #19: The discharge plan for this 79 year old patient lacked evidence of direct patient participation. The patient had adenocarcinoma and was referred to a nursing home on 3/21/11, where the planning was conducted directly with the patient's daughter. The plan did not include a direct discussion with the patient, who was noted as alert and oriented, in order to assess her participation with and agreement with planning .

MR #20: The discharge plan for this 86 year old female who was admitted on 3/26/11 after a fall was insufficient and unsafe. The patient's history was significant for ESRD and CAD. The PA note dated 3/27/11 indicated the patient could not ambulate for more than 5 minutes and is unsafe for discharge as she lives alone. The patient also refused home care. The PT assessment on 3/28/11 indicated the patient would require outpatient physical therapy and 1 more session to assess ambulation and stair negotiation. Follow-up note by the PA on 3/28/11 indicated he discussed the case with the MD and that the patient was cleared for discharge and did not need home PT. Discharge planning noted the patient had Life alert system and that she refused home care. A message was left for the patient's son. The patient refused service. There was no assessment of patient capacity. The patient was discharged home on 3/28/11.

MR #22: The record for this 75 year old patient with dementia, hepatic /biliary slowing did not demonstrated evidence of referral despite recommendation for skilled physical therapy. The patient's assessment indicated she received two rotating 24 hour home attendants which would be reinstated from the agency and scheduled for the day following discharge on 3/16/11. The PT consultation dated 3/15/11 indicated the patient would benefit from skilled PT and that the recommendation was short term rehabilitation or home with 24 hour care. The discharge plan did not incorporate the physical therapy recommendations.

MR #25: 74 year old male admitted on 3/9/11 following a fall where he sustained a right humeral fracture. The patient underwent ORIF. The patient was referred for home care but refused. It was noted he lived alone and required a one-person assist in transfers/ personal care on 3/14/11. The patient was started on lovenox injections but did not have drug coverage. It was noted on 3/15/11 the patient could be discharged to home when these barriers to discharge were resolved. There was no evidence on the record of a final discharge planning note and outcome. The patient was discharged on 3/15/11 without evidence of a safe plan nor assessment of the patient's decisional capacity. The lovenox SQ injection was crossed off the patient's discharge plan form.

MR #26: Inconsistent notes were evident regarding the patient's discharge disposition. This 91 year old patient with dementia and arthritis was admitted 3/9/11 with shortness of breath and treated for pneumonia. The patient was rejected by the first home care agency attempted due to physical needs and agressive behavior. An attempt was made to place the patient at a specific short term rehabilitation facility. The social worker noted on 3/17/11 a plan to refer to VNS in accordance with the family's change in decision, but noted that remaining decisions could include placement or not receiving home care (which could render the family's plan to take the patient home as unsafe). Psychiatry placed the patient on one to one observation due to unpredictable behavior. PT recommended short term rehabiliation upon discharge on 3/18/11. Nursing indicated on 3/18/11 the patient was discharged to rehabilitation but the placement was not identified. There was no final discharge planning/social work note present in the record to explain the outcome. In addition the discharge instruction form indicated that the patient was discharged home, which was in direct contradiction to the progress notes that noted the patient was discharged to rehabilitation.

MR #28: The discharge plan for this child referred to ACS did not demonstrate clearance by ACS before discharge. This child was witnessed being slapped in the face by her mother's boyfriend while in the ED and the child was subsequently assessed for contusion. The child's mother was being treated in the ER when the witnessed incident had occurred. The social worker assessed the case and reported the incident to Child protective authorities. It was noted the alleged suspect did not li

Based on review of documents and staff interviews, it was determined the hospital staff, in the course of formulating discharge plans, did not implement a consistent system for sufficient patient notification about available options for the selection of home health care agencies.

Findings include:

1. The hospital has not implemented a consistent system to ensure compliance with the requirement for patient notification of options in the selection of home care agencies, where feasible. The hospital's practices for home care referrals did not ensure objectivity in patient selection of home care provider and did not fully comply with the requirement prohibiting the limitation or specification of home care choices.
2. Review of the procedure titled, "Non-Discrimination in Post-Hospital referrals to Home Health Agencies" on 4/5/11 finds that the hospital notes that patients shall have the right to choose a home health provider and that hospital staff will generate a list of agencies available in the area in which the patient receives services. This policy also notes that the list shall not constitute an endorsement of any particular agency. The written policy itself did not specifically identify the staff responsible for the distribution of this options list nor describe a detailed procedure for its distribution.

This written policy also did not include the description or presence or role of on-site staff from a certified home health agency contracted by the hospital, in which the contract deemed the agency as a "preferred provider" (VNSNY II). The policy lacked mention of this on-site agency preferred provider, VNS, and did not describe the responsibilities of this agency's home health intake coordinators, who were involved in the intake process.
In addition, a flowchart was subsequently provided that graphically depicted a home care algorithm for patient choice. Review of this referral algorithm reveals the hospital's structure and process for CHHA home care agency referrals directs patients choosing agencies within the geographic area to be screened by VNS staff after receiving "choice" from hospital discharge planning staff.
Review of this form titled, "Home Care Algorithm for Patient Choice, Out of Area, NSLIJ HC, and VNSNY referrals" shows that while choice is given to patients by hospital staff, the actual home care referral must first be made to VNS (preferred provider) for intake when a patient chooses a certified home health care agency (CHHA) that is "NOT out of area". VNS agency staff would then forward the referral to the selected agency before this agency staff is able to come on-site.
Persons choosing agencies "out of area" are first directed to Payer Specialist/Discharge Planners- from Home Care ("PSDP's), who process referrals for the system-owned and affiliated home care agency, North-Shore LIJ Home Care. Therefore, this process requires that any person choosing an agency that is located within the area network must first be referred and processed by on-site staff from VNSNY. Consequently, direct referrals are not made by hospital staff to alternative home care agencies without first being processed by the "preferred provider" on-site nurse from VNSNY or by a Home Care nurse (PSDP) primarily responsible for referrals to the network-affiliated agency.

3. Review of the VNS contract on 4/8/11 determined the hospital had entered since 2003 a "preferred provider" agreement with VNS , which included on-site liaison Home health care staff. Interview with the Care Coordination Director on 4/4/11 found that VNS is planning to terminate the agreement at the end of April 2011. It was reported that there has been a change in the VNS on-site role since the transition made by the hospital to the North Shore LIJ network. In October of 2010 North Shore -LIJ had acquired another hospital's home care agency and it was reported that there was some discomfort at that time with the on-site presence and role of VNS agency staff in the hospital. It was stated that at that time three additional hospital staff were hired to perform home care intakes.4. Staff interview on 4/7/11 found that in the department of Psychiatry, staff will make a referral to VNS or North Shore -LIJ Home Care through a computer system and then VNS staff will come up to the unit to follow up. This information about the home care referral process was at variance from that revealed during interview of staff # 6 on 4/5/11, during which it was stated that only staff employed by the hospital will refer patients to the on-site home care agency staff only after a list of choices is provided.
5. The hospital has not consistently promoted the availability of patient choice in home care. For example, review of the list of multiple certified home health care providers given to patients and their representatives finds that this list designates that Visiting Nurse Service of New York is a Lenox Hill "preferred provider" . Home care listings for each borough were listed in bold and large print and prominently displayed on top of each page is the name of the Home care agency that is owned and operated by the North Shore-LIJ Health system. The form indicates that the hospital is a member of the same system.

The listing of the agency system- affiliated home care provider along with the contracted "preferred provider" has the potential effect of influencing and limiting patient choice in selection of home care provider. The manner in which the form was written can be construed as an endorsement of two agencies and has the potential to imply advice or guidance for the reader's decision.
6. The hospital has not consistently documented evidence in records that patients or their representatives have received written provision of lists of available certified home health care agencies. 9/10 applicable records did not include sufficient documentation of the provision of home care agency option listings and/or noted only the final outcome recording the selection of a specific agency. Despite sporadic evidence of listings provided, the majority of records reviewed had limited referrals to either the VNS (preferred provider) or the network system agency (North-Shore -LIJ Homecare).

Examples:

MR #s 4: Patient's plan changed from placement to home care for wound care. The record noted a referral was made to VNS for wound care. No evidence of options was noted.

MR #13: 78 year old patient hospitalized for worsening pulmonary symptoms and noted history of bronchiectasis. Patient had PICC line inserted on 3/16/11 for IV antibiotic therapy at home. The patient was referred to a "Advanced care" high tech infusion on 3/16/11. The hospital planner noted that "at this time region does not cover Manhattan". Case Manager made aware." There was no follow up validation of the home care referral during chart review of 4/5/11. No evidence of agency options provided was noted.
On 4/6/11 the hospital provided an additional electronic document to surveyors from discharge planning that indicated the patient had been referred for home infusion which started on 3/18/11 but this was not evident in the original record reviewed.

MR #15: This 89 year old patient was hospitalized for upper back pain and the record noted on 4/1/11 that she did not wish referral to VNS. On 4/4/11 the patient requested homecare for physical therapy and the record noted "she decided now on North Shore -LIJ Home Care". No evidence of provision of alternate options was apparent.

MR #18: 94 year old patient was referred to VNS for skilled PT , RN, and Home health aide visits. No evidence of choice was evident.

MR #24: 88 year old female admitted for ICH following fall. The record noted the daughter is considering sub-acute rehabilitation or home with home care. The agency of choice was noted as the network system agency (North Shore LIJ Home Care). However, there was no evidence noted to validate the actual provision of the agency options listing.

MR#25: 74 year old male who underwent ORIF surgery for a fractured humerus was referred to the hospital's network agency (North Shore-LIJ Homecare ) on 3/10/11. No evidence of h