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.

UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 Nov. 8, 2017
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on a review of facility documents and staff interviews (EMP) it was determined that UPMC Altoona failed to follow their established process for prompt resolution of patient grievances in 5 of 6 correspondences reviewed, by failing to classify complaints/grievances by their adopted policy, and by failing to ensure that the Grievance process is reviewed and analyzed through the hospital's QAPI process.

Findings include:

UPMC Altoona Standards Practice C 14 Subject: Patient/Visitor Complaint/Grievance/Documentation ... Reviewed ... 8/31/17 " I. Policy: It is the policy of UPMC Altoona to treat all patients and families with dignity and respect. We are committed to listening and responding to the needs, preferences, concerns, and complaints of our patients and families. Therefore, it is the policy of this organization to encourage patients and their representatives to express any and all concerns or complaints and to provide as many channels as possible through which a patient may seek resolution. UPMC Altoona will monitor the patterns of complaints and grievances to identify opportunities to enhance patient care, service and patient satisfaction. Patients are also encouraged to freely voice complaints and recommend changes, in so doing, they will not be subject to coercion, discrimination, reprisal or unreasonable interruption of care, treatment or services. It is also the policy of UPMC Altoona to provide guidelines for the prompt resolution of those complaints and grievances. Whenever possible, hospital representatives should try to resolve patient questions or concerns quickly and informally. II. Purpose: The purpose of this policy is to establish a process by which UPMC Altoona patients, or persons on their behalf, can express complaints, initiate grievances, and receive prompt resolution of those complaints and grievances. All complaints/Grievances can be forwarded to the Patient Relations Coordinator or Executive Director of Mission and Patient Experience at (814) 889-3219. III. Roles and Responsibilities: The UPMC Altoona Board of Directors is responsible for the effective operation of the grievance process. Responsibility for the implementation and coordination of the grievance function has been delegated to the Patient Relations Department and the Grievance Committee ... IV. Definitions: A. Patient Complaint: a 'patient complaint" is defined as a verbal concern or issue made to the hospital by a patient or patient representative (grieving party) that can be resolved at the time of the complaint by staff present, including but not limited to Nursing Administration, nursing supervisors or Patient Relations. B. Patient Grievance: A "patient grievance" is a formal or informal written or verbal complaint made to any hospital representative or employee by a "grieving party", regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present. It also includes any formal or informal written complaints of patient abuse or neglect and/or issues related to hospital's compliance with the CMS Hospital conditions of Participation (CoP's) or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. C. Staff Present: "Staff present" includes any hospital staff present when the complaint is made or those staff who can quickly be at the patient's location (i.e., physicians, Nursing, Administration, Administrators on duty, Patient Relations Coordinator, ect.) to resolve the patient complaint. D. Initiating a Grievance: If a patient complaint cannot be resolved at the time of the complaint, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint automatically becomes a grievance ... Quality Assessment and Performance Improvement (QAPI) Program: The Department Director shall prepare for presentation to the Grievance Committee reports regarding investigations and analyses of grievances. Data collected regarding patient grievances, as well as other complaints that are not defined as grievances (as determined by the hospital), must be incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program ... "

1. A review of E-mail correspondences dated Saturday September 30, 2017 at 4:49 PM, from EMP5, to EMP10, EMP3, EMP2, EMP14, EMP15, "Subject: Family complaint I received a call from OTH1 this AM ... OTH2 was a trauma patient with a history of dementia. OTH1 stated OTH2 had been transferred here d/t our 24 hour MRI service, but MRI was not done >24 hours after arrival ... during this time, the patient was in restraints to prevent removing the collar ... called the OTH1 to inform of discharge in morning, before the Nurse was aware or orders had been written. D/T ... OTH2 dementia OTH1 asked for an early discharge, transport was arranged for 4 pm but was not picked up until 6:30 and then arrived at the SNF ... at 8:30 ... OTH1 stated the entire hospital should be more aware and compassionate during care for Dementia patients. EMP5 Administrator on Duty ... "

2. An interview was conducted with EMP2, on October 30, 2017, at 11:25 AM, revealed "There was nothing that indicated I needed to call right away. This should have been investigated. We'll get emails. Every nursing supervisor is different. EMP3 and I both receive the emails ... "

3. A review of E-mail correspondences dated Saturday September 30, 2017 at 4:49 PM, from EMP5, to EMP16, EMP3, EMP2, "Subject: Family complaint I received a family complaint yesterday from OTH3, son of OTH4 on 6F. OTH4 came to the ED for shakiness and syncope and informed the triage nurse OTH4 had fallen 2- 3 weeks ago. while in the ED the patient had to use the BR, the nurse brought a bedside commode and let the railing down then left the room. The patient proceeded to get out of bed indep and fell . OTH4 was diagnosed with a cervical fracture and had additonal x-rays for ankle and foot fractures that were not back when I spoke to patient & son. The son states the fall band was never placed on the patient until after OTH4 fell . The plan is for OTH4 to be discharged to ... Thanks. EMP5 Administrator on Duty ... " This event had no follow up or investigation completed.

4. An interview with EMP5, on October 31, 2017, at 9:55 AM, revealed "I talked to the daughter. I would assume there would be some sort of follow up. We get concerns a couple of times a week, more on the weekends. Sometimes we put complaints in RiskMaster or do an email. Families will call a second or third time to say they haven't received a call ... Any complaints we receive should be in RiskMaster. If it's immediately resolved, we don't put it in RiskMaster. Our expectation is that the concerns are taken care of by them (Patient Relations), or further looked into, at least.

5. A review of the Complaint Log "Patient Relations Report by Closure Date" from July 2, 2017 through October 27, 2017 revealed 32 complaints were documented including but not limited to: skill and treatment, patient safety, pain management, staff of courtesy, communication and staff attentiveness. A random Sample of 4 complaints (Comp1, Comp2, Comp3 & Comp4) were selected for review.

Comp1 had an investigation but no written notice.
Comp2 & Comp3 had no investigation and no written response.
Comp4 - was classified wrong and should not have been on the Complaint Log.

6. An interview was conducted with EMP11, on November 7, 2017 at approximately 12:30 PM, EMP11 confirmed that 3 of the 4 complaints could not be resolved by staff present and required a facility to investigation their allegations, classifying the events as a grievance.

7. A review of the Grievance committee Meeting minutes dated September 28, 2017, September 14, 2017, August 31, 2017, August 17, 2017, provided a list of grievances investigated and consisted of the investigation and failed to show documentation that this was incorporated into the hospitals overall QAPI.
8. An interview with EMP11 on November 7, 2017 at approximately 1:10 PM revealed that that trending of complaints and grievances are discussed in the Medical Quality Affairs Committee and agrees that no action plan is discussed.
9. An interview with EMP1, on November 8, 2017, at approximately 1:50 PM revealed "I reviewed the list of quality projects and I agree that there is no quality projects for complaints/grievances ... ."
Cross Reference: 482.12(b)(ii) QAPI Identify Improvement
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on a review of facility documents and staff interviews(EMP) it was determined that UPMC Altoona failed to provide written notice of the resolution of a grievance in one of one Patient/Family complaint.

UPMC Altoona Standards Practice C 14 Subject: Patient/Visitor Complaint/Grievance/Documentation ... Reviewed ... 8/31/17 " I. Policy: It is the policy of UPMC Altoona to treat all patients and families with dignity and respect. We are committed to listening and responding to the needs, preferences, concerns, and complaints of our patients and families. Therefore, it is the policy of this organization to encourage patients and their representatives to express any and all concerns or complaints and to provide as many channels as possible through which a patient may seek resolution. UPMC Altoona will monitor the patterns of complaints and grievances to identify opportunities to enhance patient care, service and patient satisfaction. Patients are also encouraged to freely voice complaints and recommend changes, in so doing, they will not be subject to coercion, discrimination, reprisal or unreasonable interruption of care, treatment or services. It is also the policy of UPMC Altoona to provide guidelines for the prompt resolution of those complaints and grievances. Whenever possible, hospital representatives should try to resolve patient questions or concerns quickly and informally. II. Purpose: The purpose of this policy is to establish a process by which UPMC Altoona patients, or persons on their behalf, can express complaints, initiate grievances, and receive prompt resolution of those complaints and grievances. All complaints/Grievances can be forwarded to the Patient Relations Coordinator or Executive Director of Mission and Patient Experience at (814) 889-3219. III. Roles and Responsibilities: The UPMC Altoona Board of Directors is responsible for the effective operation of the grievance process. Responsibility for the implementation and coordination of the grievance function has been delegated to the Patient Relations Department and the Grievance Committee ... IV. Definitions: A. Patient Complaint: a 'patient complaint" is defined as a verbal concern or issue made to the hospital by a patient or patient representative (grieving party) that can be resolved at the time of the complaint by staff present, including but not limited to Nursing Administration, nursing supervisors or Patient Relations. B. Patient Grievance: A "patient grievance" is a formal or informal written or verbal complaint made to any hospital representative or employee by a "grieving party", regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present. It also includes any formal or informal written complaints of patient abuse or neglect and/or issues related to hospital's compliance with the CMS Hospital conditions of Participation (CoP's) or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. C. Staff Present: "Staff present" includes any hospital staff present when the complaint is made or those staff who can quickly be at the patient's location (i.e., physicians, Nursing, Administration, Administrators on duty, Patient Relations Coordinator, ect.) to resolve the patient complaint. D. Initiating a Grievance: If a patient complaint cannot be resolved at the time of the complaint, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint automatically becomes a grievance ... Quality Assessment and Performance Improvement (QAPI) Program: The Department Director shall prepare for presentation to the Grievance Committee reports regarding investigations and analyses of grievances. Data collected regarding patient grievances, as well as other complaints that are not defined as grievances (as determined by the hospital), must be incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program ... C. Response to a Grievances: Written: All grievances will result in written response ... 2) Final Letter: Within thirty (30) days of receipt of the grievance, the Patient Relations Coordinator should send a final letter ... to the grieving party informing him or her of the outcome of the grievance ... ."


1. A review of a Complaint # 1 and internal investigation was completed related to care issues raised by a family member.

2. An interview with EMP2, on November 7, 2017, at 10:30 AM "The complainant was not listed as the POA, or an emergency contact person, I spoke with the complainant directly, but did not know I needed to send a final grievance letter.

3. An interview with EMP11, confirmed the above findings.

Cross Reference: 482.12(b)(ii) QAPI Identify Improvement
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on a review of facility documents and staff interview (EMP) it was determined that UPMC Altoona failed to use data collected to identify opportunities for improvement related restraint monitoring and failed to ensure that the Grievance process is reviewed and analyzed through the hospital's QAPI process.

Findings include:

UPMC Altoona Performance Improvement Plan Fiscal Year 2018 I. Purpose: UPMC Altoona is dedicated to patient-focused care, patient safety, service excellence, superior clinical outcomes, and quality throughout ... V. Objectives: UPMC Altoona leadership has adopted Performance Improvement as key element in its continuous efforts to achieve safety and quality throughout the organization. The objectives are: To provide a Just Culture environment that promotes proactive collaboration among staff and professional disciplines. To continually monitor all aspects of patient care, with special emphasis on those procedures and diagnoses that involve high patient volumes, and/or high risks, problem-prone processes, or unexpected outcomes and events. To promote a systematic approach to performance improvement and process design. VI. Performance Improvement Approach Initiatives are planned and implemented in response to identified gaps between actual and expected performance ... The collection and analysis of data helps in determining performance improvement priorities. Identify opportunities for improvement are prioritized based on: patient safety, grievance/complaints, customer satisfaction, community needs, system-wide initiatives, high risk, high loss issues, problem-prone processes as evidenced in risk management reviews, high volume based on review of aggregated patient data, regulatory requirements, and resources availability. Statistical Tools and Techniques Many Performance improvement activities are initiated at the department level. Each Hospital and Medical Staff department is responsible for identifying important indicators of performance in the areas of patient care and non-patient care service. Departments participate in the process that has been developed to assist in systematically aggregating and analyzing data in order to identify and prioritize opportunities for improvement. This process facilitates the use of statistical tools and techniques to analyze, display, and compare the data internally over time and externally with other sources ... . Identification of Opportunities for Improvement. Identification of opportunities for improvement is the responsibility of all individuals, departments, committees, and teams associated with UPMC Altoona ...A just culture is fostered to support staff willingness to report unanticipated and/or adverse events. There are also formal mechanisms established for identifying opportunities for improvement. Examples include, but are not limited to ... Patient Satisfaction Data and Information ... Event Reports / Risk Management Data, Patient Grievance Process ... Staffing Effectiveness Analysis ... Department of Health and Patient Safety Authority Reports. Internal Patient/Operational Safety Inspection Findings, UPMC Assessment and Reports, annual determination of, and completion of, Clinical Performance Improvement Projects VII. Structure to Support the Implementation of the Performance Improvement Plan The Board of Directors (The Board) establishes the overall direction for quality improvement through the System's Mission, Vision, Values, and plans that are adopted ... Medical And Quality Affairs Committee coordination and integration of CPI Committee and Medical and Quality Affairs Committee functions is achieved through reporting of significant CPI activities to the Medical and Quality Affairs Committee ... CPI Committee Areas for opportunities for improvement ... are reported and discussed in monthly CPI committee meeting that are attended by members of hospital and medical staff departments ... If the opportunity for improvement is solely intra-departmental this information exchange may lead to process changes that are incorporated by the reporting department. Many performance improvement activities are initiated at the department level ... CPI data Aggregation Analysis- Organization, Department, and committee specific measures are identified. Data is systematically complied and analyzed to identify opportunities for improvement and ensure that improvement is sustained oven time. Data and information is used to guide decisions and to understand the performance of processes supporting tbe safety and quality of care, treatment, and services. Data is aggregated across departments and organization when appropriate ... CPI Actions - There are wide range of CPI actions that take place on a daily basis throughout the organization. Examples of these actions include: Department/unit base CPI teams ...

Policy: Hs-NA0416 Index title: Nursing Subject: Restraint and Seclusion Date: June 23, 2017 " ... VI. Process Improvement. In an effort to minimize the use of restraint or seclusion and identify opportunities to reduce the risks associated with restraint or seclusion use, data will be collected as part of ongoing performance improvement. The UPMC hospitals will assess and monitor use of restraint/seclusion, implement actions to ensure that only medically necessary restraints and seclusion are used, ensure compliance with regulations, and identify other opportunities for improvement.

UPMC Altoona Standards Practice C 14 Subject: Patient/Visitor Complaint/Grievance/Documentation ... Reviewed ... 8/31/17 " I. Policy ... UPMC Altoona will monitor the patterns of complaints and grievances to identify opportunities to enhance patient care, service and patient satisfaction ... Quality Assessment and Performance Improvement (QAPI) Program: The Department Director shall prepare for presentation to the Grievance Committee reports regarding investigations and analyses of grievances. Data collected regarding patient grievances, as well as other complaints that are not defined as grievances (as determined by the hospital), must be incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program ... "

1. A review of the Continuous Performance Improvement Committee Minutes dated January 11, 2017 ... d. Special Reports: 1. Seclusion & Restraint Report- A new process for acquiring data was implemented housewide September 1, 2016. Nursing staff was reeducated on proper documentation in PC forms, IPOC and orders. The monitoring form was revised to reflect PC documentation requirements. Overall compliance for the medical nursing units in 2016 was 88% with Behavioral Health at 82.6%. Data was shared with the Unit Directors for review with their staff."

2. A review of the "2016 Restraint Usage and Documentation Compliance" revealed overall compliance rate for Medical at 88.2% and Behavioral Health at 82.6%. Reviewing individual units it was revealed that T11 compliance rate was 33.3% & SPCU was at 11.8% for the year.

3. A review of the Continuous Performance Improvement Committee Minutes dated July 12, 2017 ... E. Miscellaneous Reports ... 2. Seclusion & Restraint Report ... This report reflects data gathered from January through June 2017. Overall compliance for medical nursing units was 88% with Behavioral Health at 52%. The Benchmark is 100% compliance with CMS and Joint Commission. Data has been shared with the unit directors for review with their staff.

4. A review of the "2017 Restraint Usage and Documentation Compliance" revealed overall compliance rate for Medical at 88.2% and Behavioral Health at 52.0%. Reviewing individual units it was revealed that T11 rate of compliance was 0.0 %; T14 rate of compliance was 0.0% and SPCU was 29.4% for the the year.

5. A review of the Grievance committee Meeting minutes dated September 28, 2017, September 14, 2017, August 31, 2017, August 17, 2017, provided a list of grievances investigated and consisted of the investigation and failed to show documentation that this was incorporated into the hospitals overall QAPI.
6. A review of the Medical and Quality Affairs Committee Meeting Minutes, for October 11, 2017, August 9, 2017, April 12, 2017, and January 11, 2017 were completed, and revealed: the number of complaints and grievances, the type of complaint, the high areas of origin and the average length of time to resolve the grievance.
7. An interview with EMP11 on November 7, 2017 at approximately 1:10 PM revealed that that trending of complaints and grievances are discussed in the Medical Quality Affairs Committee and agrees that no action plan is discussed.
8. An interview with EMP1, on November 8, 2017, at approximately 1:50 PM revealed "I reviewed the list of quality projects and I agree that there is no Quality projects for complaints/grievances. The Medical Staff Quality Affairs Committee has over sight of the complaints and grievances."
9. A telephone interview with EMP12 was conducted on November 7, 2017, at 12:35 PM. EMP12 stated Regarding Restraint Quality Data (not meeting threshold), EMP12 stated "We have a project going, with EMP18 in the ICU. EMP18 standardized the data collection process. Some areas never use restraints. Data for each unit is put in every month. Trending and fixes are to be put in place at the unit level. I don't know what's going on out on the unit. Data is to be shared with the Directors. It's never changed. I just recently saw the report (Restraint compliance). It was sent to everyone, periodically ... ."

Cross reference: 482.13(a)(2) Patient Rights: Grievances
482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision.