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.

CONEMAUGH MEMORIAL MEDICAL CENTER 1086 FRANKLIN STREET JOHNSTOWN, PA 15905 Aug. 27, 2015
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on a review of facility documentation and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted policies regarding the investigation of a Complaint/Grievance.

Findings Include:

A review of CONEMAUGH HEALTH SYSTEM, Memorial Medical Center, ORGANIZATIONAL POLICY MANUAL, TITLE: EVENT / INCIDENT REPORTS Dated 3/2015 revealed, "... C. ... The Event/Incident Report is a factual account of the details of an event and provides a method of discovery and a means for an investigation of causes. The specific purposes are: 1. To improve patient care by assuring that appropriate and immediate intervention is done on the patient's behalf and that there is a subsequent prevention of recurrence. 2. To provide a data base to evaluate and develop adequate standards of care. ... D. The Event/Incident Reports should be reported into SRM on the hospital intranet by the employee or staff member who discovers or witnesses the event i.e., the employee or staff member most closely involved. E. Prompt reporting is essential. The event/ incident report should be entered electronically in SRM within 24 hours of the event. ... ." An attachment to the "EVENT / INCIDENT REPORTS" policy and procedure revealed, "Procedure For SRM Event/Incident Reports ... Specific Examples of Patient Events/Incidents Following are examples of patient events/incidents which must be reported. It is not intended to be included. For events/incidents which do not fall under these examples, please refer to the general definition to determine reportability. It is recognized that there may be overlap within these examples and that one event/incident may fall in several categories. ... D. Miscellaneous Events/Incidents ... Patient or family complaint or threat of lawsuit. ... ."

A review of CONEMAUGH HEALTH SYSTEM, Memorial Medical Center, ORGANIZATIONAL MANUAL. TITLE: PATIENT / CUSTOMER COMPLAINT/GRIEVANCE, dated 4/2015 revealed, "Statement of Policy: To ensure patients/families/customers the right to present Complaints and Grievances and in order to identify opportunities to improve in service excellence and promote positive outcomes, it is the policy of Memorial Medical Center to provide a prompt and appropriate response to any complaints or grievances voiced by its customers. Customers include patients. families, physicians, etc. At no time shall a Complaint or Grievance be used to deny a patient current or future access to services provided by Memorial Medical Center. DEFINITIONS: Grievance: is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, and issues related to the hospital's regulatory compliance. For example, complaints about environmental factors (cleanliness, room location etc. would not normally be considered grievances. ... C. Handling of Patient Grievance after Patient is discharged 1. A Grievance is an issue about patient care not resolved at time of the complaint by a staff member. 2. Any calls for assistance, which are unresolved, or the patient cannot be reasonably accommodated will then be treated as a complaint/grievance by the Patient Relations Department. ... ."

1. An interview was conducted with EMP2 on August 19, 2015, at 2:45 PM. "I did not do an SRM because there really wasn't much to say. I spoke with EMP9 at Patient Relations. The aunt was upset because the patient was not able to go to D & A."

2. A telephone interview with EMP10 on August 19, 2015, at 2:40 PM revealed that there was no Complaint or Grievance made to the Patient Relations Department by the patient or patient's family.

3. A telephone interview was conducted with EMP9 on August 25, 2015, at 10:00 AM. "We thought EMP2 had this patient confused with another patient. I would always document on our spreadsheet and I don't have anything. Even a simple complaint like a patient not getting a box of tissues would be on my spreadsheet. Absolutely, I would have done an investigation. This would have been a grievance, it doesn't even sound familiar."
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
Based on a review of facility documentation and interveiw with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted policies to ensure that referral documentation was sent to the receiving facility.

Findings Include:

A review of facility policy Patient Freedom of Choice, dated November 2013, revealed, "... Discharge planning and the referral processes for all post-acute services will always take into consideration the patient's choice as well as the Insurer's participating providers. Requirements of this policy: 1. The hospital must include in the discharge planning and referral process a list of post-acute facilities and service providers, that are available to the patient , that are participating in the Medicare program, that have appropriate services to meet the patient's needs, and serve the geographic area in which the patient resides. ... 3 Case Management staff or the Primary Care nurse will communicate the physician's referral recommendation or order and Inform the patient of his/her right to choose and ask questions. The hospital must document in the patient's medical record that patient choice was provided. 4. The hospital must, when possible, respect patient and family preferences when they are expressed. ... 6. Once the patient chooses a service provider, the Case Management staff or Primary Care nurse notifies the facility/agency and provides information necessary for a smooth transition of care. ... ." (se)

A review of Policy On Release Of Information And Confidentiality, dated December 2013, revealed, "... Authorizations must be retained as part of the patient's medical record if and when information has been released or if the record has been reviewed by a third party and retained as long as the medical record itself. The authorization should also contain a notation of what information was released, date of release, and who released the information. ... ." (jb)

A review of Facsimile Transmission of Health Information policy and procedure dated July 2014, revealed, "Statement of Policy: It is the policy of Memorial Medical Center to protect patient confidentiality and therefore authorize facsimile transmission of health information to meet the needs of immediate patient care after receiving properly completed authorization for release of information should be limited to what is necessary to meet the requester's [sic]needs. ... 3. Both prior to and following the transmission of fax information relating to Acquired Immunodeficiency Syndrome (AIDS), Psychiatric Care and Drugs/Alcohol Treatment: it is required that the transmitted contact the requestor by telephone to confirm that an individual authorized to receive the information is present at the receiving machine and, upon transmission, has received and secured the information transmitted. ... ."

1. MR1 Case Management Assessment documentation revealed, "... 4/15 15:21 Comments: [EMP4]: Pt has signed releases so that I can fax infor [sic] to D&A Centers ... Hospital and ... 07/15/15 15:21 Comments: [EMP4]: ... Pt also requested that I make a referral to ... in Meadville. I spoke with a staff member there and faxed infog [sic] however pt was being dc today and they did not have any beds. Pt was dc to home and I encouraged pt to follow through with D&A tx. ... 07/15/15 15:21 Discharge comments [EMP4]: no services. ... ."

An interview was conducted with EMP4 on August 18, 2015, at approximately 10:50 AM. "I spoke with the patient and the aunt. The patient signed releases. ... patient's aunt asked me to make a referral to ... Hospital. I made that referral as well. ... patient's aunt was the one that gave me the information. I encouraged the patient to follow up with the other facilities. ... The aunt is the only one who helps the patient. He did state that she could help ... the patient had agreed to everything that I had done. If the patient didn't want to go, then they wouldn't have signed the releases. I encouraged the patient to follow up with ... and ... Hospital. ... ."

An interview was conducted with EMP6 on August 18, 2015, at approximately 11:00 AM. "There was a lot of conversation going on. I don't know if the patient was engaged or not. The patient had foot drop, it wasn't anything that was new. ... Patient wanted to go to a D&A Rehab that also had Physical Therapy. The plan was changed to ... Hospital because they could get all of therapies there. ... I was going on information that the patient gave to me. ... No, the patient never said that they did not want to go to ... Hospital, they just wanted the foot taken care of first."
EMP6 stated that they failed to document the above information in the patient's medical record (MR1).

2. Case Management documentation revealed a Conemaugh Health System Drug and Alcohol Service Guide. "If you or someone you care about is having a problem with drugs or alcohol there are several basic ways to get help: ... ."
Further documentation provided by the facility revealed Drug and Alcohol Treatment Local Resource Guide ... The following list of local resources was developed in an effort to help guide our patients to obtain the drug and alcohol services that best meets his or her needs. ... Inpatient/Residential Detoxification and Rehabilitation Services: ... Hospital (hospital based) ... ."

EMP2 stated that the Drug and Alcohol Treatment Local Resource Guide would not have been given to the patient unless they requested it.
A second interview was conducted with EMP2 on August 18, 2015, at approximately 10:00 AM. "... Currently for Freedom of Choice, the patient does not sign a document, it would just be in the Note that choices were given. We are not obligated to have a list of D & A under the Conditions of Participation. It would be a rare occurrence that an inpatient would go to inpatient D & A Treatment Center. ... ."

3. A telephone interview was conducted with EMP7 on August 18, 2015, at approximately 11:00 AM. EMP7 acknowledged that the only authorization to release patient information in the patient's medical record (MR1) was for ... .

4. An interview was conducted with EMP2 on August 18, 2015, at 2:00 PM. "I could not find the authorizations in the medical record for ... Hospital or for ... ."

5. A review of facility electronic documentation dated August 27, 2015, at 9:47 AM revealed, "... At EMP2 request, I am forwarding the attached release form to you. Also, EMP2 found out that: IT was unable to get fax information for the needed dates through interrogation of the fax machines on the Nursing Unit. The facilities in question have not returned our calls requesting confirmation of faxed information. ... ."

An attachment to the electronic documentation revealed the above mentioned authorization to release patient information for ... signed by the patient and EMP4 on July 15, 2015, and stamped by HIM on July 21, 2015, and an authorization to release patient information for ... signed by the patient and EMP4 on July 14, 2015. There was no stamped date from HIM noted on the Release. There was no authorization to release information for ... Hospital included in the documentation.

6. A review of facility electronic documentation dated August 27, 2015, at 11:32 AM revealed, "... We have not found the Release of Information for ... Hospital. The Case Worker clearly documented that they had the patient sign three Releases. One for ... one for ... and one for ... Hospital. The Releases for ... and for ... are in the medical record. The one for ... Hospital is not in the record. ... ."
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on a review of facility documentation and interveiw with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted policies to ensure that referral documentation was sent to the receiving facility.

Findings Include:

A review of facility policy Patient Freedom of Choice, dated November 2013, revealed, "... Discharge planning and the referral processes for all post-acute services will always take into consideration the patient's choice as well as the Insurer's participating providers. Requirements of this policy: 1. The hospital must include in the discharge planning and referral process a list of post-acute facilities and service providers, that are available to the patient , that are participating in the Medicare program, that have appropriate services to meet the patient's needs, and serve the geographic area in which the patient resides. ... 3 Case Management staff or the Primary Care nurse will communicate the physician's referral recommendation or order and Inform the patient of his/her right to choose and ask questions. The hospital must document in the patient's medical record that patient choice was provided. 4. The hospital must, when possible, respect patient and family preferences when they are expressed. ... 6. Once the patient chooses a service provider, the Case Management staff or Primary Care nurse notifies the facility/agency and provides information necessary for a smooth transition of care. ... ." (se)

A review of Policy On Release Of Information And Confidentiality, dated December 2013, revealed, "... Authorizations must be retained as part of the patient's medical record if and when information has been released or if the record has been reviewed by a third party and retained as long as the medical record itself. The authorization should also contain a notation of what information was released, date of release, and who released the information. ... ." (jb)

A review of Facsimile Transmission of Health Information policy and procedure dated July 2014, revealed, "Statement of Policy: It is the policy of Memorial Medical Center to protect patient confidentiality and therefore authorize facsimile transmission of health information to meet the needs of immediate patient care after receiving properly completed authorization for release of information should be limited to what is necessary to meet the requester's [sic]needs. ... 3. Both prior to and following the transmission of fax information relating to Acquired Immunodeficiency Syndrome (AIDS), Psychiatric Care and Drugs/Alcohol Treatment: it is required that the transmitted contact the requestor by telephone to confirm that an individual authorized to receive the information is present at the receiving machine and, upon transmission, has received and secured the information transmitted. ... ."

1. MR1 Case Management Assessment documentation revealed, "... 4/15 15:21 Comments: [EMP4]: Pt has signed releases so that I can fax infor [sic] to D&A Centers ... Hospital and ... 07/15/15 15:21 Comments: [EMP4]: ... Pt also requested that I make a referral to ... in Meadville. I spoke with a staff member there and faxed infog [sic] however pt was being dc today and they did not have any beds. Pt was dc to home and I encouraged pt to follow through with D&A tx. ... 07/15/15 15:21 Discharge comments [EMP4]: no services. ... ."

An interview was conducted with EMP4 on August 18, 2015, at approximately 10:50 AM. "I spoke with the patient and the aunt. The patient signed releases. ... patient's aunt asked me to make a referral to ... Hospital. I made that referral as well. ... patient's aunt was the one that gave me the information. I encouraged the patient to follow up with the other facilities. ... The aunt is the only one who helps the patient. He did state that she could help ... the patient had agreed to everything that I had done. If the patient didn't want to go, then they wouldn't have signed the releases. I encouraged the patient to follow up with ... and ... Hospital. ... ."

An interview was conducted with EMP6 on August 18, 2015, at approximately 11:00 AM. "There was a lot of conversation going on. I don't know if the patient was engaged or not. The patient had foot drop, it wasn't anything that was new. ... Patient wanted to go to a D&A Rehab that also had Physical Therapy. The plan was changed to ... Hospital because they could get all of therapies there. ... I was going on information that the patient gave to me. ... No, the patient never said that they did not want to go to ... Hospital, they just wanted the foot taken care of first."
EMP6 stated that they failed to document the above information in the patient's medical record (MR1).

2. Case Management documentation revealed a Conemaugh Health System Drug and Alcohol Service Guide. "If you or someone you care about is having a problem with drugs or alcohol there are several basic ways to get help: ... ."
Further documentation provided by the facility revealed Drug and Alcohol Treatment Local Resource Guide ... The following list of local resources was developed in an effort to help guide our patients to obtain the drug and alcohol services that best meets his or her needs. ... Inpatient/Residential Detoxification and Rehabilitation Services: ... Hospital (hospital based) ... ."

EMP2 stated that the Drug and Alcohol Treatment Local Resource Guide would not have been given to the patient unless they requested it.
A second interview was conducted with EMP2 on August 18, 2015, at approximately 10:00 AM. "... Currently for Freedom of Choice, the patient does not sign a document, it would just be in the Note that choices were given. We are not obligated to have a list of D & A under the Conditions of Participation. It would be a rare occurrence that an inpatient would go to inpatient D & A Treatment Center. ... ."

3. A telephone interview was conducted with EMP7 on August 18, 2015, at approximately 11:00 AM. EMP7 acknowledged that the only authorization to release patient information in the patient's medical record (MR1) was for ... .

4. An interview was conducted with EMP2 on August 18, 2015, at 2:00 PM. "I could not find the authorizations in the medical record for ... Hospital or for ... ."

5. A review of facility electronic documentation dated August 27, 2015, at 9:47 AM revealed, "... At EMP2 request, I am forwarding the attached release form to you. Also, EMP2 found out that: IT was unable to get fax information for the needed dates through interrogation of the fax machines on the Nursing Unit. The facilities in question have not returned our calls requesting confirmation of faxed information. ... ."

An attachment to the electronic documentation revealed the above mentioned authorization to release patient information for ... signed by the patient and EMP4 on July 15, 2015, and stamped by HIM on July 21, 2015, and an authorization to release patient information for ... signed by the patient and EMP4 on July 14, 2015. There was no stamped date from HIM noted on the Release. There was no authorization to release information for ... Hospital included in the documentation.

6. A review of facility electronic documentation dated August 27, 2015, at 11:32 AM revealed, "... We have not found the Release of Information for ... Hospital. The Case Worker clearly documented that they had the patient sign three Releases. One for ... one for ... and one for ... Hospital. The Releases for ... and for ... are in the medical record. The one for ... Hospital is not in the record. ... ."