HospitalInspections.org

Based on document review and interview, the facility failed to provide the patient/client with a written notice of its decision following the filing of a grievance with the facility (Client #4).

Findings Include:
A. Review of the policy Client Records/Client Rights, Customer Grievances and Resolution of Client Dissatisfaction with Services, procedure number V - 512 (R 06), last approved on 3/9/10, indicated on page 3 under section 4.9.1 that The Performance Improvement Specialist or designee shall follow-up with the customer by telephone, letter or interview concerning the resolution of the grievance and follow-up on improvements made.

B. Review of the log of complaints between 7/1/15 and 12/29/15 indicated Client #4 had filed four complaints during that time frame.

C. At 10:10 AM on 12/30/15, interview with staff member #51, the Vice President of services, confirmed that:
1. Complaints and grievances are considered the same for this facility, there is no differentiation between the two.
2. No written notices were provided to client #4 in response to their four complaints filed with the facility.
3. The facility currently does not provide written responses to customer complaints.

Based on document review and interview, the facility failed to ensure that group and individual therapy notes were completed within 72 hours of the day of service, as per policy, for 7 of 10 clients (Clients #1, #2, #4, #7, #8, #9 and #10).

Findings Include:
A. Review of the policy Fiscal/Data Management, Superbills, Supernotes, procedure number II - 509 (R 06), last approved 10/8/09, indicated under Procedures: 4.3 that The Clinician shall complete his/her notes in accordance with the instructions provided with each form...and in .1.1, that: Outpatient therapists who work in an office, seventy-two (72) hours from date of service.

B. Review of client medical records indicated:
1. Clients #1 and #2 attended a group session on 12/10/15 with the notes not submitted until 12/17/15, which was beyond the 72 hours required by policy.
2. Clients #4 and #8 attended a group session on 9/3/15 with group notes not submitted until 10/6/15 and no individual notes done, as required.
3. Client #7 attended a group session on 9/24/15 and had a group note submitted late on 10/6/15, and lacked an individual note for that date.
4. Clients #9 and #10 attended a group therapy session on 12/17/15 and had no group or individual notes submitted as of 12/30/15.

C. At 9:00 AM on 12/30/15, interview with staff member #51, the vice president of services, confirmed that:
1. Superbills and Supernotes are the same as group notes, now written on line, but previously on particular forms. The policy needs to be updated to reflect the changes.
2. There were no group or individual session notes for the 12/17/15 therapy session.
3. Staff member P2 has been deficient in following the policy related to time frames for documenting and submitting group and individual therapy session notes by not submitting them within the 72 hours policy requires.