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 ST MARGARET 815 FREEPORT ROAD PITTSBURGH, PA 15215 Nov. 28, 2011
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure services provided by the UPMC Homecare Liaison department were provided in accordance with written policy and generally accepted standards of practice.

Findings include:

1. On November 2, 2011, at approximately 9:45 AM a request was made for a policy related to completion of the Face-to-Face Encounter form. No policy was provided.

2. On November 2, 2011, at approximately 10:00 AM, a review of Face-to-Face Encounter forms revealed blank forms with photocopied physician signatures and no other information. Also reviewed were completed forms containing original, handwritten documentation with a photocopied physician signature.

3. During an interview at the above date and time, EMP1 indicated that the Face-to-Face Encounter form was being completed by the Homecare Liaisons only for patients seeking home health services from UPMC/Jefferson Regional Home Health. EMP1 indicated that a form was signed by the physician then photocopied for completion by the Homecare Liaisons. Once completed, the form was faxed to the homecare company as requested.

4. During interviews on November 2, 2011, between 9:45 AM and 10:30 AM, EMP1, EMP4 and EMP5 all confirmed that they had used Face-to-Face forms which contained photocopied physician signatures. The employees all confirmed there was no written policy or procedure to provide guidance for completion of the forms.

At approximately 10:10 AM, EMP4 stated, "I can't say whether they [physicians] were aware were copying their signature. It was just something we did. We just looked at it as a way to expedite the process."

5. During an interview on November 2, 2011, at approximately 2:00 PM, EMP3 confirmed there is no policy or written procedure related to completion of the Face-to-Face form. EMP6 also revealed, "Once we discovered they [liaisons] were copying physician signatures to complete the forms we told them they had to stop. We weren't sure they should be doing that."