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.

NORTHERN LIGHT ACADIA HOSPITAL 268 STILLWATER AVE BANGOR, ME 04401 Dec. 5, 2013
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interviews with key staff on December 5, 2013, it was determined that the facility failed to assure that all patients received a notice of patient rights in advance of furnishing or discontinuing patient care in two (2) of ten (10) patients (Records: G & J).

Findings include:

1. The facility policy, 'Patient Rights', stated, "the registration staff or access center staff have patients sign a summary of patient rights and provide them with a copy upon admission to all Acadia mental health and substance abuse service programs".

2. Review of the medical records (Record G & Record J) indicated a lack documentation of a signed copy of Rights of Recipients of Mental Health Services which was given to all patients, and the signature page of the form is included in the medical record.

3. The above findings were confirmed in an interview with the Process Analysis Staff Developer on December 5, 2013, between the hours of 11:00 a.m. and 2:30 p.m.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on record review and interviews with key staff on December 5, 2013, it was determined that the facility failed to assure that all medical records included an informed consent form in three (3) of ten (10) sampled closed patient records (Records: A, B and J).
Findings include:

1. Patient A's record from the admission of January 4, 2013 contained no signed informed consent document.

2. Patient B's record from the admission of January 8, 2013 contained no signed informed consent document. The record from the January 19, 2013 admission contained a signed informed consent dated February 2, 2013.

3. Patient J's record from the admission of February 4, 2013 contained no signed informed consent document.

4. The above findings were confirmed in an interview with the Process Analysis Staff Developer on December 5, 2013, between the hours of 11:00 a.m. and 2:30 p.m.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on record review and interviews with key staff on December 5, 2013, it was determined that the facility failed to assure advanced directives were discussed with patients or family members in three (3) of ten (10) sampled patient records (Records: A, B and J).

Findings include:

1. Review of Records A, B and J revealed a lack of evidence of an advanced directive, which is signed along with an informed consent for treatment.

2. The above findings were confirmed in an interview with the Process Analysis Staff Developer on December 5, 2013, between the hours of 11:00 a.m. and 2:30 p.m.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of contracts and interviews with key staff on December 5, 2013, it was determined that the governing body failed to ensure that the services performed under a contract contained performance standards and measurements, in one (1) of five (5) contracts. (Contract B) Please see Tag A-0083 for additional information related to the aspects of performance as it related to contracts.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on receord review and interview on December 5, 2013, it was determined that the hospital failed to maintain complete records for each patient. Please see tags A-0117, A-0123, A-0132 and A-0466 regarding completeness of the medical records.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on receord review and interview on December 5, 2013, it was determined that the hospital failed to maintain complete records for each patient. Please see Tags A-0117, A-0123, A-0132 and A-0466 regarding completeness of the medical records.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on review of contracts and interviews with key staff on December 5, 2013, it was determined that the governing body failed to ensure that the services performed under a contract contained performance standards and measurements, in one (1) of five (5) contracts. (Contract B)

Findings include:

1. During a review of five (5) contracts on December 5, 2013, there was no documentation in one (1) of five (5) contracts, Contract B for a Medical Physician, that contract performance standards and measurements were identified.

2. During an interview with the Chief Financial Officer on December 5, 2013, at 2:55 p.m., she stated that she agreed that there were no performance standards and measurements for Contract B included on the Acadia Contract Performance Standards and Measurements Form. She added that it is hard to get physicians to fill things out...they hate paperwork.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on file review and interviews with key staff on December 5, 2013, it was determined that the facility failed to assure that in its resolution of the grievance, the hospital provided the patient with complete information regarding the patient's grievance in five (5) of five (5) sampled grievances.

Findings include:

1. The facility policy, 'Patient Complaint and Grievance Resolution Process' stated, under steps of formal grievances that "the department administrator shall respond with a written resolution within five days (excluding holidays and weekends)". It further stated that 'the department administrator will sign and date the form in the space provided on the form and make a copy of the signed and dated form for the grievant'.

2. The review of five (5) grievance files revealed the lack of a documented response to the grievances filed by these patients.

3. The review of three (3) grievance files revealed that there was a lack of a documented signature of the department administrator or any indication that a copy of the form was provided to the grievant.

4. The review of four (4) grievance files revealed that there was no documented proposed solution to resolve the grievance.

5. These finding were confirmed by the Service Excellence Director on December 5, 2013, at approximately 2:30 p.m., who stated that the patients were given a copy of the grievance form which included the steps taken to investigate, proposed solution to resolve the grievance, and the name of the person responsible for the investigation.