HospitalInspections.org

Based on medical record review and staff interview, it was determined that the hospital failed to provide 2 of 2 Medicare beneficiary patients (Patient #'s 6 and 7) in the sample, with "An Important Message from Medicare" prior to discharge. Findings included:

Medical record review revealed no evidence to support that Patient #'s 6 and 7, who were Medicare beneficiaries, were provided a copy of "An Important Message from Medicare" prior to discharge:

A. Patient #6
- admitted 12/12/18
- discharged 12/18/18

B. Patient #7
- admitted 1/11/19
- discharged 1/21/19

Interview with Performance Improvement/Risk Director A on 9/5/19 between 4:41 PM and 5:15 PM confirmed these findings.

Based on medical record review, policy review, document review and staff interview, it was determined that for 40 of 40 inpatients on 9/5/19, the hospital failed to provide the patient/patient's representative with a telephone number and address of the State Agency as per their established grievance process. Findings included:

The hospital policy entitled "Complaint and Grievance Procedures" stated, "...the patient may lodge a grievance with the state agency...The telephone number and address for lodging these grievances are included in the patient handbook..."

A. During an interview on 9/5/19 at 12:30 PM, Performance Improvement/Risk Director A reported that patients were advised of their right to file a grievance with the State Agency in the documents included in the patient admission packet entitled:
"Adolescent Welcome Handbook, SUN Behavioral Delaware"
"Adult Welcome Handbook, SUN Behavioral Delaware"
"Patient Rights Guide for Residents of Private Psychiatric Facilities"

B. Review of the following documents revealed no evidence of the State Agency's telephone number and address:
"Adolescent Welcome Handbook, SUN Behavioral Delaware"
"Adult Welcome Handbook, SUN Behavioral Delaware"
"Patient Rights Guide for Residents of Private Psychiatric Facilities"

This finding was confirmed by Interim Director of Intake/Admissions on 9/5/19 at 2:25 PM.

Based on review of hospital policies, documents and staff interview, it was determined that the hospital's utilization review (UR) committee failed to carry out the UR function (refer to A 654); failed to review admissions (refer to A 655); and failed to review the professional services provided (refer to A 658). The cumulative effect of these deficient practices resulted in the hospital's inability to ensure the provision of quality care.

Based on review of hospital policies, documents and staff interview, it was determined that for 40 of 40 inpatients on 9/5/19, the utilization review (UR) committee failed to carry out the UR function. Findings included:

The facility policy entitled "Utilization Management Plan" stated, "...provide both quality patient care and effective utilization of available services through effective cooperation between hospital administration and the Medical Staff...Plan includes a review of services furnished by the hospital and the medical staff to patients...Utilization Management Committee shall meet as often as necessary...at least quarterly...Physician reviewer will be responsible for review of all cases referred by the Review Coordinator, making appropriate determination regarding the medical necessity for the patient's need...Committee will maintain written records of all its activities. Minutes of each committee meeting shall be documented...include...Worksheets used for Committee review function..."

A. The hospital opened in October 2018.

B. During an interview on 9/5/19 between 10:36 AM and 10:45 AM, Performance Improvement/Risk Director A reported:
- a UR meeting was scheduled12/6/18 to begin the UR plan process
- there was no evidence that the 12/6/18 meeting occurred

C. Review of the facility's UR documentation with CEO (chief executive officer) A and Performance Improvement/Risk Director A on 9/5/19 between 10:36 AM and 11:18 AM, revealed the following:

a. No evidence to support that the UR committee meeting occurred on 12/6/18.

b. No evidence that the UR committee met to carry out the UR function since the opening of the hospital.

These findings were confirmed by CEO A on 9/5/19 at 11:18 AM.

Based on review of hospital policies, documents and staff interview, it was determined that for 40 of 40 inpatients on 9/5/19, the utilization review (UR) committee failed to review admissions. Findings included:

The facility policy entitled "Utilization Management Plan" stated, "...provide both quality patient care and effective utilization of available services through effective cooperation between hospital administration and the Medical Staff...Plan includes a review of services furnished by the hospital and the medical staff to patients...Utilization Management Committee shall meet as often as necessary...at least quarterly...Physician reviewer will be responsible for review of all cases referred by the Review Coordinator, making appropriate determination regarding the medical necessity for the patient's need...Committee will maintain written records of all its activities. Minutes of each committee meeting shall be documented...include...Worksheets used for Committee review function..."

A. The hospital opened in October 2018.

B. Review of the facility's UR documentation with CEO (chief executive officer) A and Performance Improvement/Risk Director A on 9/5/19 between 10:36 AM and 11:18 AM, revealed the following:

a. No evidence to support that the UR committee reviewed the medical records of any patients admitted since the opening of the hospital.

b. No evidence that the UR committee met to carry out the UR function since the opening of the hospital.

These findings were confirmed by CEO A on 9/5/19 at 11:18 AM.

Based on review of hospital policies, documents and staff interview, it was determined that for 40 of 40 inpatients on 9/5/19, the utilization review (UR) committee failed to review the professional services provided. Findings included:

The facility policy entitled "Utilization Management Plan" stated, "...provide both quality patient care and effective utilization of available services through effective cooperation between hospital administration and the Medical Staff...Plan includes a review of services furnished by the hospital and the medical staff to patients...Utilization Management Committee shall meet as often as necessary...at least quarterly...Physician reviewer will be responsible for review of all cases referred by the Review Coordinator, making appropriate determination regarding the medical necessity for the patient's need...Committee will maintain written records of all its activities. Minutes of each committee meeting shall be documented...include...Worksheets used for Committee review function..."

A. The hospital opened in October 2018.

B. Review of the facility's UR documentation with CEO (chief executive officer) A and Performance Improvement/Risk Director A on 9/5/19 between 11:12 AM and 11:18 AM revealed the following:

a. No evidence that the UR committee reviewed the professional services provided since the opening of the hospital.

This finding was confirmed by CEO A on 9/5/19 at 11:18 AM.