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.

HOSPITAL OF UNIV OF PENNSYLVANIA 34TH & SPRUCE STS PHILADELPHIA, PA 19104 Nov. 23, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of facility documents and interview with staff (EMP), it was determined the Governing Body failed to appoint a full time on-site rehabilitation Administrator with delineated duties specific to Penn Institute for Rehabilitation Medicine.

Review on October 13, 2016, of facility document "the Department" dated August 10, 2007, revealed "Rehabilitation Services. After review of the University of Pennsylvania Health System (UPHS) proposal, DOH had decided to permit the licensure of the rehabilitation unit located at Main under the license of the Hospital of the University of Pennsylvania. However, DOH will require compliance with the following terms and conditions to ensure that concerns regarding assurance of patient safety can be addressed through clear accountability, including defined management and professional oversight:..there must be full time on-site rehabilitation unit management, including a physician rehabilitation director and nursing leadership, with clearly defined responsibility, authority, and back-up...These conditions will become a permanent requirement for continuation of these licensure arrangements and will be included in all further DOH surveys of these facilities."
Review on October 13, 2016, of facility document "the Department" dated May 13, 2016, revealed "Please accept this letter as notice of a change in leadership at the Penn Institute for Rehabilitation Medicine (PIRM) which is a unit of the Hospital of the University of Pennsylvania (licensure number 1) and under the management of Good Shepherd Penn Partners pursuant to 28 Pa Code 51.4(c) . Effective April 23rd, 2016, [EMP2] assumed the role of Interim Administrator for the PIRM, replacing [XXX-XXX]. In her role as interim Administrator, [EMP2] will report directly to EMP5, Executive Director of Good Shepherd Penn Partners. I am pleased to announce that [EMP2] was also offered and accepted an appointment to the Chief Nursing Officer for Good Shepherd Penn Partners effective April 23rd, 2016. In this role, she will likewise report directly to [EMP5] and have a dotted-line reporting relationship to [EMP23] Chief Nurse Executive, of the Hospital of the University of Pennsylvania."
Review on October 21, 2016, of facility document "Good Shepherd Penn Partners (GSPP) Position Description & Performance Evaluation" signed by EMP2 on April 23, 2016, revealed "Position Title: Administrator/Chief Nursing Officer-Long Term Acute Care Hospital (LTACH) Program. Location: Penn Medicine at Rittenhouse. Summary of Accountabilities: The Administrator/CNO functions under the direction and supervision of the Executive Director GSPP or designee and assumes responsibility and accountability of the areas of operational and nursing and other clinical services for the GSPP Speciality Hospital at Rittenhouse (LTACH)...Drive patient/client loyalty and physician referral by ensuring staff under your supervision understand the GSPP commitment to service, their own work processes, and have the necessary skills to meet service expectations."
Review on October 21, 2016, of facility document "Organizational Chart" last revised August 16, 2016, revealed EMP2 "Chief Nursing Officer, Good Shepherd Penn Partners (GSPP), and "*Interim Administrator, Penn Institute for Rehabilitation Medicine (PIRM)."

An interview conducted on October 21, 2016, at 10:25AM with EMP2, EMP5 and EMP18 confirmed EMP2 was the Interim Administrator for the Penn Institute for Rehabilitation Medicine and the Chief Nursing Officer for GSPP Speciality Hospital at Rittenhouse LTACH. EMP2 and EMP5 also confirmed EMP2's job description did not delineate the duties of the Interim Administrator for the Penn Institute for Rehabilitation Medicine.

Review on October 21, 2016, of facility document "Organizational Chart" last revised August 16, 2016, revealed EMP6 "*Administrator and Director of Nursing, The Penn Institute for Rehabilitation Medicine. *EMP6 is onboarding. EMP2 is Interim during EMP6 onboarding."

An interview conducted on October 21, 2016, at 11AM with EMP2 and EMP5 confirmed EMP2 was the Interim Administrator for Penn Institute for Rehabilitation Medicine and the Chief Nursing Officer for GSPP Speciality Hospital at Rittenhouse LTACH. EMP2 also confirmed that when EMP6 completed the onboarding training process for the position of Administrator, EMP6 would fulfill the role of Administrator and Director of Nursing in January 2017, for the Penn Institute for Rehabilitation Medicine. Further interview confirmed the facility did not have full-time onsite rehabilitation unit management as specified in the August 10, 2007 document, "the Department".

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Based on a review of facility policy, documents and interview with staff (EMP), it was determined the Governing Body failed to effectively establish through clear professional accountability and oversight the operation and conduct of the Penn Institute for Rehabilitation Medicine.

Review on October 13, 2016, of facility document "the Department" dated August 10, 2007, revealed "Rehabilitation Services...Among the reasons advanced by UPHS for the issuance of a single license are avoidance of additional administrative costs of creating new governance structure and documents, hiring of additional unnecessary staff...After review of the University of Pennsylvania Health System (UPHS) proposal, DOH had decided to permit the licensure of the rehabilitation unit located at Main under the license of the Hospital of the University of Pennsylvania. However, DOH will require compliance with the following terms and conditions to ensure that concerns regarding assurance of patient safety can be addressed through clear accountability, including defined management and professional oversight."

A review on October 21, 2016, of facility document "Resolution on the Approval of the Hospital of the University of Pennsylvania Plan of Patient Care Defining its Scope of Services" dated December 15, 2015, revealed "INTENTION: The Hospital of the University of Pennsylvania ("Hospital")...have a Plan of Patient Care that defines the Hospital's... scope of services which they provide to their patients consistent with the Hospital's mission and vision...The purpose of this plan is to articulate the organization's structure, philosophy, guiding principles, relationships, activities, scope of care and service, staffing and planning documents, as they relate to the provision of patient care at the Hospital of the University of Pennsylvania...Our mission is to create the future of medicine through: Patient Care and Service Excellence, Educational Pre-eminence, New Knowledge and Innovation, National and International Leadership...The Hospital of the University of Pennsylvania (HUP) is an operating division of the Trustees of the University of Pennsylvania. The Trustees have established Penn Medicine, which is an integrated system for medical education, research and patient care that includes UPHS, HUP...and has delegated governance to the Penn Medicine Board and the Penn Medicine Executive Committee. In turn, the Trustee Board of the Hospital of the University of Pennsylvania, which is a component of the Penn Medicine Board and its Penn Medicine Executive Committee, provides governance oversight to the Hospital. The management responsibility of HUP is under the purview of the Chief Operating Officer of the University of Pennsylvania Health System. The Executive Director of HUP has authority delegated by the Chief Executive Officer of the University of Pennsylvania Health System, and the Executive Vice President of the University of Pennsylvania for the Health System...The Executive Director assumes responsibility for providing and monitoring the quality, affiliation and integration of patient care services throughout the Hospital. The Hospital of the University of Pennsylvania leadership is defined as the leaders of the appropriate governing bodies, the Medical Board and Hospital Senior Management."

Review on October 21, 2016, of facility document "Amended and Restated Inpatient Rehabilitation Facility Operations Agreement dated June 26, 2008 revealed "...Duties and Responsibilities of University of Pennsylvania Health Systems ...2.2(F) Policies and Procedures. At the commencement of this Agreement, UPHS shall provide GSPP with copies of all applicable policies and procedures, and shall provide copies of all amendments thereto as they are made effective from time to time during the term of this agreement."

Review on October 21, 2016, of facility document "the Department" dated May 13, 2016, revealed " Please accept this letter as notice of a change in leadership at the Penn Institute for Rehabilitation Medicine (the PIRM) which is a unit of the Hospital of the University of Pennsylvania (licensure number 1) and under the management of Good Shepherd Penn Partners pursuant to 28 Pa Code 51.4(c). Effective April 23rd, 2016, [EMP2] assumed the role of interim Administrator for the PIRM, replacing [XXX]. In her role as Interim Administrator, [EMP2] will report directly to EMP5, Executive Director of Good Shepherd Penn Partners. I am pleased to announce that [EMP2] was also offered and accepted an appointment to the Chief Nursing Officer for Good Shepherd Penn Partners effective April 23rd, 2016. In this role, she will likewise report directly to [EMP5] and have a dotted-line reporting relationship to [XXX-XXX], PhD, Chief Nurse Executive, and Hospital of the University of Pennsylvania."

Review on October 21, 2016, of the facility's policy "PENN INSTITUTE FOR REHABILITATION MEDICINE Performance Improvement Plan 2016" dated December 3, 2015, approved by Good Shepherd Penn Partners Board of Directors revealed "...Good Shepherd Penn Partners Leadership, defined as the GSPP Board of Directors, GSPP Executive Director, GSPP Senior Leadership and elected/appointed Medical Director oversee Penn Rehab's process performance initiatives..Goals and Objectives...Establish an accountability system that is both clinically and professionally sound...Deliver patient services that are consistent with the hospital's mission and scope of services...Administrators. The PIRM Administrator or designee has overall responsibility to the GSPP Executive Director for the quality of patient care services and oversight of the quality program within the hospital...The GSPP Board of Directors is ultimately responsible for quality of care provided by GSPP. The Board authorizes the GSPP Executive Director, Senior Leadership, and the Professional Relations and Quality Oversight Committee to establish a performance improvement program by approving the Performance Improvement Plan. The Board of Directors is responsible for: Ensuring organizational policies, directions, decisions, and operations fulfill the organization's mission and values are uniformly applied across all programs, as appropriate..."

Review on October 21, 2016, of "Organizational Chart" last revised August 16, 2016, revealed EMP2 GSPP Chief Nursing Officer, and Interim Administrator Penn Institute for Rehabilitation Medicine was a direct report to EMP5, GSPP Executive Director. Further review revealed EMP5 was a direct report to [XXX-XXX], MBA, MPT, Board of Chair-Good Shepherd Penn Partners and President and CEO, Good Shepherd Rehabilitation Network. There was no evidence found that EMP2 nor EMP5 was required by job description or organizational structure to report to EMP8, HUP Chief Operating Officer. Further review revealed no documentation that EMP2 nor EMP5 was required by job description or organizational structure to report to EMP23, HUP Chief Nurse Executive.

An interview conducted on October 21, 2016, at 3:45PM with EMP2, EMP5 and EMP10 confirmed that the Penn Institute for Rehabilitation Medicine is a department of the Hospital of the University of Pennsylvania. EMP10 stated "Penn Institute for Rehabilitation Medicine is a department of the Hospital of the University of Pennsylvania, it just happens to be located at 1800 Lombard Street."


An interview conducted on October 21, 2016, at 3:50PM with EMP4 and EMP10 confirmed EMP5 was the Executive Director for the Penn Institute for Rehabilitation Medicine. EMP4 and EMP10 stated "All information and identified issues concerning Penn Institute for Rehabilitation Medicine are to be reported to EMP5 (GSPP Executive Director). Information for the Rehab Unit is not to be reported to the Executive Director of the Hospital of the University of Pennsylvania". EMP10 confirmed the job description and the organizational chart did not require EMP2 and EMP5 to report to EMP23. Further interview confirmed that EMP2 and EMP5 were not members of the Senior Management of the Hospital of the University of Pennsylvania. No evidence was found that a clear accountability system had been established between GSPP Executive Director, HUP Executive Director and HUP Chief Nursing Officer.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, facility policy, personnel file (PF) review, and interview with staff (EMP), it was determined the facility failed to ensure the staff received education regarding the relationship between Penn Institute for Rehabilitation Medicine and the Hospital of the University of Pennsylvania Health System during the new employee orientation for five of five personnel files reviewed (PF6, PF7, PF8, PF9 and PF10).
Review on October 13, 2016, of facility document "the Department" dated August 10, 2007, revealed "Rehabilitation Services. After review of the University of Pennsylvania Health System (UPHS) proposal, Department of Health (DOH) has decided to permit the licensure of the rehabilitation unit located at Main under the license of the Hospital of the University of Pennsylvania. However, DOH will require compliance with the following terms and conditions to ensure that concerns regarding assurance of patient safety can be addressed through clear accountability, including defined management and professional oversight:...There must be documentation that all persons working in the rehabilitation unit have been educated regarding the relationship of the rehabilitation unit in the Main Building to the main campus of HUP and the responsibilities of the staff, employees and contractors in the rehabilitation unit to the patient...These conditions will become a permanent requirement for continuation of these licensure arrangements and will be included in all further DOH surveys of these facilities."
Review on October 13, 2016, of facility document "Hospital of the University of Pennsylvania of the University of Pennsylvania Health System Trustee Board Executive Committee. Resolution on the Approval of the Hospital of the University Of Pennsylvania Plan Of Patient Care Defining its Scope of Services" last reviewed on December 16, 2015, revealed ...STAFF EDUCATION PLAN ...Patient care is delivered by competent personnel. Leadership of the Health System assesses the organization's mission and defines the qualifications, competencies and staff needed to carry out the mission. The education plan resulting from the mission is based on continuous learning, assessment, maintenance and improvement of competencies that are needed by staff member.
Review on October 21, 2016, of the facility's policy "Patient Bill of Rights and Responsibilities" last reviewed January 7, 2014, revealed "SCOPE: This policy applies to all patients, employees and staff of the Hospital of the University of Pennsylvania (HUP) and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or conjunction with HUP, operating under HUP license. This policy also applies to (i) those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP's inpatient rehabilitation facility; (ii) private entities that lease space in property owed or lease by HUP only if they provide contracted clinical services to HUP; and (iii) personnel that provide contracted clinical services to HUP patients ... STATEMENT OF PATIENT'S RIGHTS. You have the right to respectful care given by competent personnel which reflects consideration of your cultural and personal values and belief systems and which optimizes your comfort and dignity...You have the right to good quality care and high professional standards that are continually maintained and reviewed."
Review on October 21, 2016, of facility document "Good Shepherd Penn Partners (GSPP) New Orientation Checklist" last reviewed August 1, 2011, revealed "Orientation Activities, Welcome the employee to GSPP, Introduce to GSPP staff members. Explain the mission, vision and philosophy of GSPP. Share the GSPP organizational chart, leadership structure, and strategic direction. Receive information regarding Infection Control practices at GSPP and the Importance of hand hygiene. Review the GSPP HR policies about: smoking, performance management and evaluation, workplace violence, open door policy, racial and sexual harassment. Review the GSPP HR policies on employment ...Review information about the regulatory bodies GSPP must comply with (TJC-The Joint Commission, DOH-Department of Health, CARF-, CMS-Centers of Medicare & Medicaid Services, etc ...)"
Review on October 13, 2016, of facility document "Orientation Schedule for Patient Ambassador revealed "Welcome to Good Shepherd Penn Partners (GSPP)!" We are delighted that you are joining GSPP's Patient Access and Patient Experience team ...Congratulations on your new position and again, welcome to GOOD SHEPHERD PENN PARTNERS, the official therapy provider for PENN MEDICINE. This Immersion Plan is a tool designed to aid you in getting acclimated to GSPP and to your important role in service excellence for our patients."
Review on October 13, 2016, of facility document "Amended and Restated Inpatient Rehabilitation Facility Operations Agreement effective June 30, 2008, revealed " 1.3(H) Good Shepherd Penn Partners (GSPP) warrants that (a) it shall provide training to its Therapists and Nurses regarding workplace safety and other standards, shall establish mechanism to ensure that they comply with all applicable standards...(iv) all other applicable statues, regulations, rules, standards, guidelines and directives of any federal, state, local or other public or private body exercising authority with respect to University Pennsylvania Health System (UPHS)."
Review on October 21, 2016, of PF6 revealed a GSPP New Employee Hire Orientation Checklist form and a New Employee Orientation Schedule completed on March 7, 2016, for the position of Patient Ambassador of the Penn Institute for Rehabilitation Medicine.
Review on October 21, 2016, of PF7 revealed a GSPP New Employee Hire Orientation Checklist form and a New Employee Orientation Schedule completed on May 22, 2016, for the position of Patient Ambassador of the Penn Institute for Rehabilitation Medicine.
Review on October 21, 2016, of PF8 revealed a GSPP New Employee Hire Orientation Checklist form and a New Employee Orientation Schedule completed on March 7, 2016, for the position of Patient Ambassador of the Penn Institute for Rehabilitation Medicine.
Review on October 21, 2016, of PF9 revealed a GSPP New Employee Hire Orientation Checklist form and a New Employee Orientation Schedule completed on April 11, 2016, for the position of Patient Ambassador of the Penn Institute for Rehabilitation Medicine.
Review on October 21, 2016, of PF10 revealed a GSPP New Employee Hire Orientation Checklist form and a New Employee Orientation Schedule completed on April 11, 2016, for the position of Patient Ambassador for the Penn Institute for Rehabilitation Medicine.
An interview conducted on October 21, 2016, with EMP2, EMP5 and EMP13 at 2:30PM confirmed that PF6, PF7, PF8, PF9, and PF10, were contracted employees for Penn Institute for Rehabilitation Medicine as Patient Ambassadors. Further interview confirmed the new employee orientation process was conducted based on the orientation requirements of Good Shepherd Penn Partners. In addition, EMP2 and EMP5 confirmed the Good Shepherd Penn Partner's new employee orientation process does not include orientation components which define the relationship of Penn Institute for Rehabilitation Medicine and the Hospital of University of Pennsylvania. In addition, EMP10 stated "Going forward Penn Institute for Rehabilitation Medicine employees will receive an educational component from the Hospital of the University of Pennsylvania new employee orientation process. This education will be documented in their personnel files."
An observation noted during a tour on October 21, 2016, at 2:45PM with EMP4 and EMP6, revealed a female visitor exiting off of the elevator to the third floor of Penn Institute for Rehabilitation Medicine. EMP12, a patient ambassador greeted the visitor stating "Welcome to Good Shepherd, Can I help you."
An interview on October 21, 2016, with EMP4 and EMP6 at 3:05PM confirmed EMP12 greeted the visitor by welcoming the visitor to Good Shepherd and did not welcome the visitor to Penn Institute for Rehabilitation Medicine.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of facility policy, medical records (MR) and interviews with staff (EMP), it was determined the facility failed to provide a copy of the Patient's Bill of Rights during the admission process for four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy "Patients' Bill of Rights and Responsibilities" lasted reviewed January 7, 2014, revealed "This policy applies to all patients, employees and staff of the Hospital of the University of Pennsylvania (HUP) and those parts...including e.g. HUP's inpatient rehabilitation facility...PROCEDURE...2. Each patient receives a statement of the Patients' Bill of Rights and Responsibilities at the time of admission and/or upon arrival at the patient's room...4. Posters outlining patients' rights and responsibilities are displayed in public areas... They are clearly visible for patients, staff and employees to view."


An observation made during a tour conducted on October 13, 2016, of the facility's 3rd and 4th patient care floors revealed the Patient's Bill of Rights and Notice of Patient Privacy Practices wall hanging signs were located in a secluded hallway in front of the employee's time clock. At the request of the surveyor, the facility agreed to relocate the Patient's Bill of Rights and Notice of Patient Privacy Practices signs to a prominent area on the 3rd and 4th patient care floor for easy access of the information by patients and visitors.
Review on October 21, 2016, of the patient information manual "My Rehabilitation Journey" given to all patients during the admission process revealed no documentation that patients received a statement of the Patient's Bill of Rights and Responsibilities during admission process. Further review of the booklet revealed no evidence that patients were informed as to how to request a copy of the Patient's Bill of Rights or whom to contact to receive the statement of the Patient's Bill of Rights and Responsibilities.

Review on October 21, of MR1 revealed the patient was admitted on [DATE], and discharged on [DATE]. Further review of MR1 revealed no documented evidence that the patient received a statement of the Patient's Bill of Rights and Responsibilities.

Review on October 21, 2016, of MR2 revealed the patient was admitted on [DATE], and discharged on [DATE]. Further review of MR2 revealed no documented evidence that the patient received a statement of the Patient's Bill of Rights and Responsibilities.

Review on October 21, 2016, of MR3 revealed the patient was admitted on [DATE], and discharged on [DATE]. Further review of MR3 revealed no documented evidence that the patient received a statement of the Patient's Bill of Rights and Responsibilities.

Review on October 21, 2016, of MR4 revealed the patient was admitted on [DATE], and discharged on [DATE]. Further review of MR4 revealed no documented evidence that the patient received a statement of the Patient's Bill of Rights and Responsibilities.

An interview conducted on October 21, 2016, at 3:45PM with PT1 on the third floor of the Penn Institute for Rehabilitation Medicine revealed they were not given a copy of the "Patient Bill of Rights and Responsibilities." PT1 stated " I only received the manual "My Rehabilitation Journey" and the patient rights are not in this manual. The manual is is to be used as apart of my therapy rehab."

An interview conducted on October 21, 2016, at 3:55PM with PT2 on the third floor of the Penn Institute for Rehabilitation Medicine revealed they were not given a copy of the "Patient Bill of Rights and Responsibilities." PT2 stated " All the papers I received from Good Shepherd Penn Partners is in this manual [My Rehabilitation Journey] and the patient rights and responsibilities are not in the manual. This is the first time I am having a conversation about my rights and responsibilities."

An interview conducted on October 21, 2016, at 4:05PM with PT3 on the third floor of the Penn Institute for Rehabilitation Medicine revealed they were not given a copy of the "Patient Bill of Rights and Responsibilities." PT3 stated " I received this manual [My Rehabilitation Journey] on admission. I am looking through the manual as we speak and there is no statement called "Patient Bill of Rights and Responsibilities." I do not remember speaking to anyone on admission or receiving a copy of this statement."

An interview on October 21, 2016, at 4:15PM, with EMP5 and EMP6 confirmed the Patient's Bill of Rights and Responsibilities signs were not prominently displayed for easy access of information by patients and visitors. In addition, EMP5 and EMP6 confirmed the facility was not in compliance with the facility's policy for providing patients a statement of the Patient's Bill of Rights and Responsibilities at the time of admission and/or upon arrival to the patient's room. Further interview confirmed the facility could not provide documentation that patients received a statement of the Patient's Bill of Rights and Responsibilities during the admission process.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of facility policy, documents, medical record (MR) and interview with staff (EMP), it was determined the Governing Body failed to provide oversight and accountability to the Penn Institute for Rehabilitation Medicine as a distinct entity of the Hospital of the University of Pennsylvania to ensure quality healthcare for one of one MR reviewed (MR1).

Review on October 13, 2016, of facility document "AMENDED AND RESTATED INPATIENT REHABILITATION FACILTY OPERATIONS AGREEMENT. "THIS AMENDED AND RESTATED INPATIENT REHABILITATION FACILITY OPERATIONS AGREEMENT is made this 30th day of June 2008 ... lasted reviewed on June 26, 2008 revealed " ...DUTIES and RESPONSIBILITIES OF UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEMS (UPHS) ...2.2(F) Policies and Procedures. At the commencement of this Agreement, UPHS shall provide Good Shepherd Penn Partners (GSPP) with copies of all applicable policies and procedures, and shall provide copies of all amendments thereto as they are made effective from time to time during the term of this Agreement."
Review on October 13, 2016, of facility policy "Consent to Health Care Services" last reviewed November 4, 2015, revealed "POLICY. Patient consent is generally required by state law before care is provided by the staff of the Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP), as described below...SCOPE. This policy applies to the Hospital of the University of Pennsylvania (HUP), and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with HUP, operating under the HUP license. This policy also applies to: (i) those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g.,HUP's inpatient rehabilitation facility; (ii) private entities that lease space in property owned or leased by HUP only if they provide contracted clinical services to HUP; and (iii) personnel that provide contracted clinical services to HUP patients. PROCEDURE A. Consent Form: 1. On admission to HUP, all patients must sign a "Consent to Hospital Care" form. This consent form must be signed by the patient or legally authorized representative.."
Review on October 13, 2016, of facility policy "Medical Record-Official Medical Record" July 12, 2011, revealed "POLICY: The Official Medical Record serves as the documentation of the healthcare services provided to a patient by a HUP/CPUP inpatient or outpatient practice, physician or other provider and can be certified by the Record Custodian(s) as such...PURPOSE: The purpose of this policy is to define the elements that comprise the Official Medical Record (OMR). This policy identifies the medical record of HUP/;CPUP for business purposes and to ensure that the integrity of the Official Medical Record is maintained so that it can support business needs of UPHS and HUP/CPUP. The OMR is the standard record that is released when a request is made for a medical record...SCOPE: This policy applies to all uses and disclosures of the Official Medical Record for administrative, business (including, treatment, payment and operations), or evidentiary purposes. The policy applies to all patients of the Hospital of the University of Pennsylvania (HUP)...This policy also applies to: (i) those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP's inpatient rehabilitation facility; (ii) private entities that lease space in property owned or leased by HUP only if they provide contracted clinical services to HUP; and (iii) personnel that provide contracted clinical services to HUP patients. IMPLEMENTATION: It is the responsibility of HUP's Health Information Management Director ...to keep records in compliance with this policy. All work force members are responsible for implementing this policy"
Review on October 13, 2016, of MR1 revealed "Good Shepherd Penn Partners|Speciality Hospital at Rittenhouse HOSPITAL CONSENT FORM" dated December 10, 2015, CONSENT TO HOSPITAL CARE: I hereby present myself for outpatient treatment and/or admission to the Hospital listed above and voluntarily consent to care...by authorized agents and employees of the hospital, and or/employees of the Good Shepherd Penn Partners and other affiliated practices of Good Shepherd Penn Partners (the "System Providers").
An interview conducted on October 13, 2016, at 3:30PM with EMP2, EMP5 and EMP11 confirmed the signed consent form in MR1 was a Good Shepherd Penn Partners|Specialty Hospital Rittenhouse HOSPITAL CONSENT FORM. EMP2 confirmed the patient should have received and signed a Penn Institute for Rehabilitation Medicine Consent Form. In addition, EMP5 and EMP12 confirmed that an audit of the Penn Institute for Rehabilitation Medicine consent forms was completed on October 13, 2016, and the Good Shepherd Penn Partners|Speciality Hospital at Rittenhouse Hospital consent forms will no longer be used for patients admitted to Penn Institute for Rehabilitation Medicine.