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.

EINSTEIN MEDICAL CENTER MONTGOMERY 559 WEST GERMANTOWN PIKE EAST NORRITON, PA 19403 Dec. 19, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedures, review of medical records (MR) and staff interviews (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare (IMM) no more than 2 days prior to discharge for three of seven medical records reviewed (MR16, MR17, MR23).

Findings include:

Review on December 19, 2018, of facility policy and procedures, "Consent to Care, Grievance, IMM," revised April 2018 revealed it did not contain the time frame for providing the IMM to the patient or the patient's representative at admission and discharge.

Review of MR16 on December 19, 2018, revealed the patient was admitted to the facility on on [DATE], and was discharged to home on August 14, 2018. Further review of MR16 revealed no documented evidence an IMM was provided to the patient or the patient's representative no more than two days prior to the discharge.

Review of MR17 on December 19, 2018, revealed the patient was admitted to the facility on on [DATE], and was discharged to home on September 11, 2018. Further review of MR17 revealed no documented evidence an IMM was provided to the patient or the patient's representative no more than two days prior to the discharge.

Review of MR23 on December 19, 2018, revealed the patient was admitted to the facility on on [DATE], and was discharged to home on August 16, 2018. Further review of MR23 revealed no documented evidence an IMM was provided to the patient or the patient's representative no more than two days prior to the discharge.

On December 19, 2018, surveyor requested Quality Assurance Performance Improvement collection data for providing patients or the patient's representative with an IMM at admission and discharge. None was provided.

Interview on December 19, 2018, with EMP6 at approximately 11:30 AM confirmed there was no documented evidence an IMM was provided to the patient or the patient's representative no more than two days prior to the discharge in MR16, MR17 and MR23.

Interview with EMP1 on December 19, 2018, at approximately 3:15 PM confirmed there was no Quality Assurance Performance Improvement data for providing an IMM to patients or the patient's representative.


Cross Reference:
482.12 - Condition of Participation: Governing Body
482.13 - Condition of Participation: Patient Rights
482.13 (a) (2) (ii) Patient Rights: Grievance Review Time Frames
482.13 (c) (3) Patient Rights: Free From Abuse/Harassment
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility policies and procedures, review of facility documents, review of medical records and interviews with staff (EMP), it was determined the facility failed to ensure the facility was in compliance with all applicable regulations (A-0043), failed to ensure the Condition of Participation for Patient Rights (A-0115), failed to ensure all Medicare patients received the Important Message from Medicare prior to discharge (A-0117), failed to ensure their policy for grievance response time for acknowledgment of a grievance was followed (A-0122) and failed to conduct a thorough investigation by not obtaining signed and dated statements from all staff and witnesses involved in an alleged patient abuse grievance (A-0145).

Findings include:

Review on December 19, 2018, of facility document "Einstein Medical Center Montgomery Corporate Bylaws," reviewed February 20, 2018, revealed, "Article III. Board of Trustees ... Section 3: Responsibilities and Powers of the Board of Trustees. Subject to the Members Reserved Powers, and in compliance with all applicable laws and regulations ... i. Establishing and assuring the operation of a well-defined and organized program designed to enhance patient care through the ongoing objective assessment of important aspects of patient care, including patient safety, availability of resources and the correction of identified problems ... ".


Cross Reference:
482.13 - Patient Rights - Condition of Participation
482.13 (a) (1) Patient Rights: Notice of Rights
482.13 (a) (2) (ii) Patient Rights: Grievance Review Time Frames
482.13 (c) (3) Patient Rights: Free From Abuse/Harassment
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policies and procedures, review of facility documents, review of medical records and interviews with staff (EMP), it was determined the facility failed to ensure all Medicare patients received the Important Message from Medicare prior to discharge (A-0117), failed to ensure their policy for grievance response time for acknowledgment of a grievance was followed (A-0122) and failed to ensure a thorough investigation was conducted by not obtaining signed and dated statements from all staff and witnesses involved in an alleged patient abuse grievance (A-0145).


Cross Reference:
482.12 - Condition of Participation: Governing Body
482.13 (a) (1) Patient Rights: Notice of Rights
482.13 (a) (2) (ii) Patient Rights: Grievance Review Time Frames
482.13 (c) (3) Patient Rights: Free From Abuse/Harassment
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of facility policy and procedures, review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure their approved policy for grievances was followed for two of six grievances reviewed (MR11 and MR13).

Findings include:

Review on December 18, 2018, of facility policy "Patient/Family/Visitor Complaints and Grievances," revised January 17, 2018, revealed, "Grievance Procedure 10. A response to the patient/authorized representative will be generated by the Director of Customer Service and Patient Experience. The Director of Customer Service and Patient Experience or designee will acknowledge receipt of the grievance and will communicate to the complainant the investigation and follow-up process within seven (7) business days of the receipt of the grievance."

Review on December 18, 2018, of facility document revealed a grievance to the facility for MR11 dated August 2, 2018. Review of facility document for MR11 revealed a letter for MR11 to acknowledge receipt of the grievance that was dated September 29, 2018.

Review on December 18, 2018, of facility document revealed a grievance for MR13 dated May 22, 2018. Review of the facility document revealed a letter for MR13 dated June 12, 2018, to acknowledge receipt of the grievance.

Interviews with EMP4 and EMP5 on December 18, 2018, at approximately 10:00 AM confirmed the facility's grievance acknowledgment receipt letters for MR11 and MR13 were not within seven (7) days per the facility policy.


Cross Reference:
482.12 - Condition of Participation: Governing Body
482.13 - Condition of Participation: Patient Rights
482.13 (a) (1) Patient Rights: Notice of Rights
482.13 (c) (3) Patient Rights: Free From Abuse/Harassment
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of facility policies and procedures, review of facility documents and interviews with staff (EMP), it was determined the facility failed to obtain signed and dated statements from all staff and witnesses to conduct a thorough investigation for allegations of patient abuse for one of one medical records reviewed (MR1).

Findings include:

Review on December 18, 2018, of facility policy and procedures, "Patient /Family/Visitor Complaints and Grievances," revised January 17, 2018, revealed, "IV. Complaint/Grievance Procedure 5. The Director of Customer Service and Patient Experience or Patient Advocate initiates an investigation, as appropriate, that includes an interview with involved staff/physician and a review of the medical record. If additional resources are needed for finalization of a grievance, departments are in full cooperation. 7. risk Management, Quality and Clinical Department will be alerted, as appropriate, of any clincal quality of care issue or other potential risk situation." Further review of the policy revealed it did not contain a provision for obtaining signed and dated statements from all staff and witnesses involved in an investigation.

Review on December 19, 2018, of facilty policy and procedures, "Respecting Patient Rights," revised January 17, 2018, revealed, "Patient Rights ... 6. The patient has the right to receive care in a safe setting, and to be free from all forms of abuse and/or harassment. This includes the right to protection from real or perceived abuse, neglect or exploitation."

Review on December 17, 2018, of facility document revealed a grievance for an alleged patient abuse was filed for MR1 on August 29, 2018.

Review on December 19, 2018, of facility documents revealed unsigned, undated handwritten notes regarding investigation of the patient abuse allegation for MR1.

Request on December 19, 2018, was made for documentation of signed and dated statements for all staff and witnesses who involved or who witnessed the alleged patient abuse. None were provided.

Interview with EMP7 on December 19, 2018, at approximately 3:00 PM confirmed there was no documentation of signed and dated witness statements for all staff who were involved or who witnessed the alleged patient abuse.

482.12 - Condition of Participation: Governing Body
482.13 - Condition of Participation: Patient Rights
482.13 (a) (1) Patient Rights: Notice of Rights
482.13 (a) (2) (ii) Patient Rights: Grievance Review Time Frames