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.

Based on interview and record review, the facility failed to follow the Corporate Compliance Policy when it did not provide a written response to a patient's grievance/complaint.

Findings Include:

During a telephone interview on 1/31/16 at 5:50 p.m. Patient #1 stated he contacted the Corporate Compliance Hotline number provided by the facility on 10/6/15. Patient #1 stated the Corporate Compliance personnel took his complaint concerning erroneous laboratory results. Patient #1 stated the Corporate Compliance and/or the Facility did not contact him with the results of complaint.

Review of Corporate Compliance complaint (dated 10/6/15) reflected Patient #1's complaint.
Issue Summary:
Patient #1 stated Staff #15 obtained false positive results on Patient #1's urinalysis. In addition, Staff #15 mentioned Patient #1's medical information in an unprofessional manner.
The facility self-investigation was completed on 10/19/15.
Case Action Disposition Summary: Staff #10 spoke with Staff #15. Staff #15 had stated that explained to the patient that the drug results were due to previous detox protocol for Benzo regimen. There is a progress note documenting this event. Secondly, Staff #15 stated that she did not discuss any lab results in public. i.e. the "hallway".

Review of the facility provided policy (undated) PROCESS FOR HANDLING THE COMPLIANCE HOTLINE AND WEB REPORTING PROGRAM reflected:
Purpose: To establish protocols for how UHS Compliance Hotline and Web Reporting cases are received, documented, investigated and ultimately resolved.
Procedure: Appropriate action will be taken in response to each call and/or report. In most cases, appropriate action will include an investigation into the allegations of the complaint or concerns, and action plan to resolve the issues, and communication back to the caller, if applicable. Complaints that do not raise a potential compliance issue will be referred to the appropriate department (e.g. risk management, Human Resources, facility management, or other departments as appropriate).

During an interview on 2/1/16 at 2:00 a.m., in the conference room, Staff #2, Risk Manager, stated Corporate Compliance Reporting Program does not provide the facility with information regarding complaints coming into the Compliance Hotline and the interaction between the Corporate Compliance Program and the complainant.

During an interview on 2/2/16 at 3:15 p.m., in the conference room, Staff #3, Director of Clinical Services stated the Corporate Compliance Program and the facility had not contacted the patient regarding the resolution of the complaint.