The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WESTCHESTER MEDICAL CENTER 100 WOODS RD VALHALLA, NY 10595 June 29, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview the facility failed to initiate an investigation of a grievance in a timely manner and in compliance with hospital policy for 1 of 9 patient complaints and grievance investigations reviewed by the Department of Health (DOH) survey team. Findings:

-During the Federal Allegation survey, DOH survey staff reviewed a sample of nine complaint and grievance investigations conducted by the hospital.

-The Director of Social Work and Community Reentry was interviewed during the morning of 6/29/2017 regarding the hospital's investigation of the index case. She stated on interview that she received, via e-mail, an allegation of patient abuse on 6/9/2017. She stated she forwarded the e-mail that same evening to the Director of Nursing for Behavioral Health.

-Interview of the Director of Nursing for Behavioral Health conducted during the morning of 6/29/2017 revealed the investigation was not initiated until 6/14/2017, five days later.

-Review of the administrative policy and procedure entitled "Complaints and Grievances" (revision date 04/2016) conducted on 6/29/2017 indicates that "All serious allegations, such as neglect and abuse that may endanger the patient will be reviewed immediately ..."