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READING, PA 19601

PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES

Tag No.: A0120

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Haven Behavioral Hospital failed to ensure an effective grievance process for referral of concerns regarding the quality of care for one of one patient.

Findings include:

On December 14, 2021 review of facility policy "Grievance Patient" last approved November 2, 2021 revealed, "Policy: The facility will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients. All patients and their families should have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by facility or medical staff ... Procedure 1. Staff present who receive a grievance/concern from a patient/patient's legal representative will take the following steps: Staff acknowledge receipt of the grievance/concern. Staff attempt to resolve the issue at the time of receipt. Staff member completes the Grievance Concern Process Communication Tool form. If the staff member is unable to resolve or satisfy the grievance/concern the supervisor or Administrator On-Call (AOC) is notified. Grievance Concern Process Communication Tool form is forwarded to the Patient Advocate for timely follow up and resolution."

On December 14, 2021 review of facility policy "Patient Rights Pennsylvania" last approved February 2020 revealed "1. Grievance Procedure. (a) Any patient, or those helping him, may initiate a complaint orally or in writing, concerning the exercise of these rights or the quality of services and treatment at the facility. The complaint shall be presented as soon as possible to the treatment team leader or other appropriate person. (b) Every patient shall have the right to the assistance of an independent person and witnesses in presenting his complaint."
On December 14, 2021 review of MR1 revealed Social Services Note dated November 15, 2021 noted by EMP5, "0925-SW(Social Worker) called Pt's family member who filed a complaint, to inquire about Pt's admission. Complainant interrupted SW and stated that complainant wanted to file several grievances about how Pt is treated ... Complainant expressed they wanted a form that they did not receive with pt's admission paperwork. SW asked what form and complainant replied it was an ROI. SW stated they would have to check on this and reach out to the Supervisor. Complainant then asked for SW Supervisor's name and number. SW provided this information. SW also provided Patient Advocate's name and phone number for complainant's grievances. Complainant had requested to make an appointment in person with SW to discuss pt's care. SW stated that they do not have in person appointments with family and primarily conduct phone calls for family meetings, if requested."

Interview with EMP5 conducted on December 14, 2021. EMP5 confirmed complainant had requested to file a grievance and provided complaintant with EMP6 information. EMP5 confirmed they did not attempt to resolve issue nor did they complete the Grievance Concern Process Communication Tool form.

Interview with EMP6 on December 16, 2021 EMP6 confirmed a voicemail was left on phone from complainant requesting to file a grievance, and that two attempts were made to return call to complainant with no answer. EMP6 denies documenting the date and times the two phone calls were made to complainant. EMP6 stated they told EMP4 to address the grievance issue since they had a good rapport with the complainant.

Interview with EMP4 was conducted on December 14, 2021. EMP4 confirmed a discussion about complainant paperwork was received regarding POA / Legal Rep., but did not have a discussion regarding any grievances.

On December 14, 2021 review of facility Grievance Log dated October 1, 2021- December 14, 2021 was completed and failed to reveal any greivance was completed or processed for the complainant.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Haven Behavioral Hospital failed to ensure the Patient's Representative was provided the right to make informed decisions regarding care with the practitioner.


Findings include:

On December 14, 2021 review of facility policy Patient Rights Pennsylvania, last approved February 2020 revealed " ... (a) Every patient shall have the right to the assistance of an independent person not a member of his treatment team to resolve a problem raised by the patient ... (c) Every patient has the right to participate to the extent feasible in the development of his treatment plan. ... ."

On December 15, 2021, a review of Social Services Coordinator, Job Description revealed, "Customer Service Work collaboratively with all treatment team members to create a treatment environment that supports the facility's mission to provide exemplary
treatment and customer service. ... ."

MR1 Social Services Note dated November 15, 2021 noted by EMP5 revealed "0925 ... Complaintant asked to speak with Psychiatrist; SW informed complainant that they were the point of contact for the Treatment Team.

Interview with EMP5 on December 14, 2021, confirmed that the complaintant requested to speak to the doctor, but they would relay any messages to the doctor and let the complainant know what the physician said, but the complainant would not be speaking directly to the doctor. EMP5 confirmed there is a process to provide the physician with a family members phone number to call them, but EMP5 did not do that in this case.