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.

FAIRMOUNT BEHAVIORAL HEALTH SYSTEM 561 FAIRTHORNE AVENUE PHILADELPHIA, PA 19128 Nov. 28, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of policies and procedures and medical records (MR) and staff interview (EMP), it was determined the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare no more than 2 days after discharge for three of six Medicare-insured medical records reviewed (MR13, MR14, and MR19).

Findings include:

Review on November 28, 2018, of facility policy "Important Message from Medicare ...", dated January 2016, revealed "Procedure ... Hospitals must issue the IM [Important Message from Medicare] within 2 calendar days of admission, must obtain the signature of the beneficiary or his or her representative and provide a copy at that time ... Initial Notification Hospitals must deliver the original copy of the IM at or near admission, but no later than 2 calendar days following the date of the beneficiary's admission to the hospital ... The original of the signed and dated form will be given to the patient, a copy placed in the medical record ..."

Review on November 28, 2018 of MR13 revealed the patient was admitted on [DATE]. The admission IM document was not provided to the patient until November 5, 2018 [six days after admission].

Review on November 28, 2018 of MR14 revealed the patient was admitted on [DATE]. There was no documented evidence in MR14 that the admission IM document was provided to the patient.

Review on November 28, 2018 of MR19 revealed the patient was admitted on [DATE]. There was no documented evidence in MR19 that the admission IM document was provided to the patient.

Interview with EMP1 on November 28, 2018, confirmed there was no documented evidence in MR14 and MR19 that the admission IM documents were provided to these patients. EMP1 further confirmed the admission IM document was not provided to the patient in MR13 until November 5, 2018 [six days after admission].
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to his/her family member or representative of his/her choice and his/her own physician of the hospital admission in 10 of 10 inpatient medical records reviewed (MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21).

Findings include:

On November 27, 2018, surveyor requested EMP2 to provide a policy that included if the patient requested or declined notification to his/her family member or representative of his/her choice and to his/her own physician of the admission to the hospital. None was provided.

Review on November 28, 2018, of MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR21 revealed these patients were admitted to the facility between October 27, 2018 and November 25, 2018.

Further review of MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR21 revealed no documentation in the medical record whether the facility asked each patient if they requested or declined notification to his/her family member or representative of his/her choice and to his/her own physician of the hospital admission including date, time and method of the requested notification.

Interview with EMP2 on November 28, 2018, at 1:45 PM, confirmed the facility did not have a policy for notification of patient's hospital admission to his/her family member or representative of his/her choice and to his/her own physician and there was no documentation in MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21 of whether the patient requested or declined notification to his/her family member or representative of his/her choice and to his/her own physician, including the date, time and method of notification if the patient did request notification.