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Based on staff interview and record review, the hospital failed to establish a clearly explained grievence procedure for patients to utilize when submitting a grievance. Findings include:

Per review on 10/12/10, the hospital's procedure for a patient or the patient's representative to submit a written or verbal grievance was not clearly stated and required the complainant to make multiple contacts to obtain a resolution to a grievance. The procedure, given to patients upon admission, directs the patient or the patient's representative to contact a member of the treatment team with their grievance. If not resolved, the patient is directed to notify their attending psychiatrist (who is a member of the treatment team). If the grievance is still not resolved the grievance would be referred to the unit Clinical Manager. If still not resolved the patient was then expected to contact the Patient Advocate. Once the Patient Advocate has provided the patient or the patient's representative with a written response, an appeal can be made in writing regarding the unresolved concerns to the Vice President of Medical Affairs. The procedure then states a Grievance Committee would then become involved and provide a written notice to the complainant after the committee conducts their review.

Per interview on the morning of 10/13/10 the Director of Quality and Regulatory Services confirmed the hospital's Grievance Procedure (last reviewed 7/18/08) was confusing and layered with multiple contacts, making the grievance process difficult for a patient or patient's representative to achieve resolution.

Based on record review and interview, the hospital failed to develop a grievance process
that reviewed, investigated and resolved a patient's grievance within a reasonable time frame. Findings include:

Per review on 10/12/10 of the hospital's Grievance Procedure, time frames for resolution of a grievance were prolonged. If a grievance was referred to the Patient Advocate a written response was provided within 14 days. If an appeal is made to the Vice President of Medical Affairs, the hospital was allowing 30 days for review of the grievance and if the Grievance Committee reviewed the grievance an additional 10 days was added for a response and decision regarding the grievance.

Per interview on the morning of 10/13/10, the Director of Quality and Regulatory Services confirmed the Grievance Procedure lacked the average resonable time frame of 7 days for the provision of the response to a grievance.

Based on interview and record review, the hospital failed to ensure sufficient safeguards were incorporated when maintaining the confidentiality of patient clinical records for 2 applicable patients. (Patient #1, 2) Findings include:

1. Per record review on 10/13/10, Patient #1 was admitted to the hospital on 8/5/10 as a voluntary admission for alcohol dependence. During the course of the patient's hospitalization h/she was asked to sign "Authorization to use or Disclose Protected Health Information" for the purpose of exchanging health information during the patient's treatment with the patient's Primary Care Physician (PCP) and a Clinical Case Manager. After discharged the patient stated h/she had informed hospital staff h/she did not want specific records released. The authorization to release health information was signed by the patient but not dated. Per interviews on 10/12/10 and 10/13/10 with the attending psychiatrist, Social Worker, admission APRN and program assistant, no one was aware when the releases were signed and whether information was released prior to obtaining authorization. In addition, a fax was sent from the hospital to Patient #1's PCP. The fax face sheet was stamped with "faxed" , however no date, time or initials of the person who faxed the information was documented. The fax transmittal contained 9 pages. There was no listing of what was faxed and staff on the unit where Patient #1 received treatment were unable to confirm what information was sent. Per interview on 10/13/10 at 11:10 AM the Program Assistant stated when a fax is sent, the stamped "faxed" on the fax face sheet should be signed/initialed and time noted when documents were faxed. There was no specific policy which determines what information would be sent on the day a patient is discharged. The Program Assistant stated presently, the information fax consisted of AfterCare Plan, lab results, MD orders and the discharged medication list, however the hospital had not developed what specific records that should or can be sent.

2. Patient #2 was admitted to the hospital on 10/6/10 and discharged 10/13/10. At the time of admission, hospital admission staff who conducted the Comprehensive Intake Evaluation determined the patient was incompetent to sign health information release forms due to being intoxicated. At some point during the patient's admission, the patient signed the "Authorization to use or Disclose Protected Health Information" forms. Per review of the forms on 10/13/10 at 1:30 PM and interview with the Social Worker, confirmed although the patient did eventually sign the consents the authorization was not dated and it could not be determined whether releases were signed before or after health information was shared.