HospitalInspections.org

Bringing transparency to federal inspections

145 NORTH 6TH STREET

READING, PA 19601

PATIENT RIGHTS: GRIEVANCES

Tag No.: A0118

Based on a review of facility policy, documentation and interview with staff (EMP), it was determined that the facility failed to follow their grievance policy for one of one medical record reviewed (MR1).

Findings include:

A review on August 5, 2016 of the facility "Grievance Patient Policy, last approved 10/20/2015," revealed "...The facility will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and services to our patients...The Governing Board has appointed the Patient Advocate the responsibility to execute the grievance program, in conjunction with the Grievance Committee...Procedure: 1. Staff present who receive a grievance/concern from a patient/patient's legal representative will take the following steps. Acknowledge receipt of the grievance/concern by documenting the time and date of the grievance on the Patient Concern Notification form. Attempt to resolve the issue at the time. Document actions taken, on the Patient Concern Notification form. Forward Patient Concern Notification form to the Patient Advocate..."

An interview conducted on August 4, 2016, at 10:30 AM with EMP3 revealed staff of the Area of Aging called and yelled about the discharge plan and that the patient had been readmitted to an acute care hospital the day after discharge. Further interview revealed that the matter was discussed a team meeting but was not reported to the Patient Advocate.

An interview conducted on August 4, 2016, at 2:35 PM with EMP2 confirmed the matter should have been handled per the grievance policy. Further interview confirmed the event was a grievance per the grievance policy.

IMPLEMENTATION OF A DISCHARGE PLAN

Tag No.: A0820

Based on review of facility policies, medical record (MR), and interview with staff (EMP), it was determined the facility did not properly implement the discharge plan, by failing to provide education and list the changes from the patient's pre-admission medications the patients should be taking at discharge, for four of five discharge medical records (MR) reviewed (MR2, MR4, MR5 and MR6).

Findings include:

A review of the Haven Behavioral Healthcare policy , "Discharge/Aftercare Plan", last reviewed July 2016 revealed, " ... The discharge/aftercare plan is a multidisciplinary form ... Specific efforts to educate ... regarding the patient's treatment interventions ... medication ... "

A review of MR2, MR4 and MR6 on August 4, 2016, revealed there was no documentation of medication education. Further review revealed there was no clear distinction of changes from the patient's pre-admission medications and the medication the patient should be taking at discharge.

A review of MR5 on August 4, 2016, revealed there was no clear distinction of changes from the patient's pre-admission medications and the medication the patient should be taking at discharge.

An interview conducted with EMP 1 on August 5, 2016, at 11:00 AM confirmed that education was not documented in the medical record for MR2, MR4 and MR6 and there was no clear distinction of changes from the patient's pre-admission medications and the medication the patient should be taking at discharge for MR 2, MR4, MR5 and MR6. Further interview confirmed there was no policy that required a medication reconciliation with clear distinction of changes from the patient's pre-admission medications and the medication the patient should be taking at discharge.


.

REASSESSMENT OF DISCHARGE PLANNING PROCESS

Tag No.: A0843

Based on a review of facility documents, medical records and staff interview (EMP), it was determined that the facility failed to evaluate the reason for readmission for patients readmitted within 30 days of discharge (MR13).

Findings include:

A review on August 5, 2016, of the Utilization Management minutes for April 20, 2016, May 18, 2016 and June 15, 2016, revealed there was no documentation of an evaluation of patients who were readmitted within 30 days of discharge.

A review of MR1 revealed the patient was admitted on April 24, 2016 and discharged on May 13, 2016. MR1 was re-admitted within 30 days on May 24, 2016, and discharged on June 2, 2016.

A review of MR3 revealed the patient was admitted on July 12, 2016, then transferred to an acute care hospital. MR3 was re-admitted to Haven Behavioral Hospital on August 2, 2016.

An interview on August 5, 2016, with EMP1 confirmed that there was no documentation of an evaluation of whether readmissions were due to a problem in discharge planning in the Utilization Management minutes or in MR1 and MR3.