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.

ALLEGHENY VALLEY HOSPITAL 1301 CARLISLE ST NATRONA, PA 15065 March 27, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on a review of medical records (MR) and facility documentation, and employee interviews (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the "Important Message from Medicare (IM)" no sooner than 2 calendar days prior to the patient's discharge for five of five medical records reviewed (MR1, MR2, MR3, MR4, and MR5).

Findings include:

Review of facility policy "Important Message From Medicare (IM) Process" last reviewed June 23, 2011, revealed "...If patient is unable to sign and representative is unavailable, the representative must be contacted by phone, explain I.M. and document phone contact, note understanding, date and time under additional information space on second page of I.M. Notify Case Management...so they can mail a copy to the representative...Deliver follow-up I.M no more than two calendar days before discharge...."

1) Review of MR1 revealed that a copy of the I.M was provided to MR1's representative upon admission. Further review of MR1 revealed that no IM was provided to the patient or patient's representative within two calendar days of MR1's discharge on January 24, 2015.

2) Review of MR1 Progress Notes dated 1/24/15 at 1615 revealed "Social Services: Received call from nursing that pt is for discharge today. Telephone call to (representative) he is objecting to patient's discharge and wants (PCP) to make decision. Further review of MR1's progress notes revealed no documentation that facility staff explained the Important Message From Medicare and that the conversation was documented.

During interview on March 24, 2015 at approximately 1:00 PM, EMP4 confirmed the above findings and revealed "...[representative] was notified by phone about the discharge by the social worker and the physician but the I.M was obviously not discussed...I.M. obviously not there [in the medical record]."

3) Review of MR2 revealed that no I.M. was provided to the patient or the patient's representative within two calendar days of discharge on February 15, 2015.

4) Review of MR3 revealed that no I.M. was provided to the patient or the patient's representative within two calendar days of discharge on February 27, 2015.

5) Review of MR4 revealed that no I.M. was provided to the patient or the patient's representative within two calendar days of discharge on March 5, 2015.

6) Review of MR5 revealed that no I.M. was provided to the patient or the patient's representative within two calendar days of discharge on March 11, 2015.

During interview on March 27, 2015 at approximately 10:00 AM, EMP4 confirmed the above findings and revealed "..No I.M.s were provided on discharge..."
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on a review of facility documentation, and staff interview (EMP), it was revealed the facility failed to ensure the Performance Improvement Activities tracked adverse patient events for two of three events reviewed.

Findings include:

Review of "Quality Improvement Plan 2014" revealed "Performance Improvement Committee.....The Performance Improvement Committee is chaired by the Chief Medical Officer (CMO). In addition to its advisor and planning functions, the committee monitors the development of Hospital quality goals, set priorities concerning quality improvement projects, and assures systematic monitoring and evaluation of quality and appropriateness of patient care."

Review of "Patient Safety Plan - Allegheny Health Network" dated November 2014, revealed "The Patient Safety Program was created to improve the health and safety of patients served by AHN (Allegheny Health Network). ... In order to achieve these goals, the program includes the following: ... 5. Track and trend such events and report the findings to the appropriate hospital and/or medical staff committees."

1. Review of "Root Cause Analysis Action Plan" dated July 4, 2014 and August 12, 2014, failed to include documentation of the tracking process for the action plan developed for the events.

Interview with EMP5 on March 26, 2015, at approximately 1:05 PM confirmed the above findings and revealed "I cannot show you documentation of the I & O (intake and output) tracking."

Interview with EMP1 on March 26, 2015, at approximately 1:15 PM confirmed the above findings and revealed "I did not put audit tracking in this one."
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on review of medical records, facility documentation, and employee interviews (EMP), it was determined that the facility failed to provide necessary medical information for follow-up care for one of five medical records reviewed.

Findings include:

1) Review of facility policy, "Discharge/Transition" reviewed January 13, 2010, revealed the policy does not address test results that are pending at time of discharge.
2) Review of MR6 revealed the patient was discharged to a Skilled Nursing Facility (SNF) on March 10, 2015. Further review of MR6 revealed a final positive lab result dated March 12, 2015 with no documentation that the physician or SNF was notified of this final lab result.
Interview with EMP10 on March 26, 2015, at approximately 10:00 AM, revealed, "There is no documentation in the medical record."