HospitalInspections.org

This Condition is found to be out of complaince due to a Life Safety Survey.

Based on review of facility policies and procedures, personnel files (PF), and interviews with staff, it was determined that the facility failed to obtain written references for personnel for seven of seven licensed personnel employee. (PF10, PF12, PF17, PF21, PF22, PF24 and PF27)

Findings include:

Review of facility policy and procedure "Manager's Guide to Human Resources Policies and Procedures, Reference Requests ... Policy: Kindred verifies applicant information to make the best hiring decision. ... Your role is to: ensure references are verified on all prospective employees. Refer all request for references to the facility's Executive Director, CEO/Administrator, Rehab Manager, Director of Rehab or designee. Manager's Action Items: ... After a conditional offer of employment has been made, ensure criminal background and/or Department of Motor Vehicles record checks are conducted as required by law or Company policy. Any offer is contingent upon successful completion of the reference check."

Review of Kindred Human Resources Hiring guide, dated reviewed August 2008, revealed "Appendix 5 ... Background Checks ... Reference Checks are conducted pre offer. ... At a minimum, obtain references on the applicant's two (2) most recent jobs, or for the past three (3 A) years, whichever is longer. While many former employers are reluctant to provide more information that objective facts about the applicant's former positions and dates of employment, it is important to elicit additional information about the applicant's past performance and reasons for termination. Call all former employers or other references listed on the application."

Review of PF10, PF12, PF17, PF21, PF22, PF24 and PF27 revealed no documentation of written reference checks for these licensed employees.

Interview with EMP2 confirmed there were no written reference checks for these licensed employees. EMP2 further confirmed the facility had a contract with an agency that performed pre employment duties, and they did not obtain the written reference checks.

Based on review of the facility's Medical Staff Rules and Regulations, medical records (MR), and interviews with facility staff (EMP), it was determined the facility failed to ensure transfers to another level of care, health professional or setting were based upon the patient's assessed needs and the facility's capacity to provide care as defined in their Rules and Regulations for five of five medical records where transfers occurred (MR21, MR22, MR23, MR24 and MR25.)

Findings include:

Review of the facility's "Bylaws of the Medical Staff of Kindred Hospital Wyoming Valley," dated Board Approved April 24, 2011, revealed no documented evidence for the transfer of inpatients to a non-medicare affiliated physician.

Review of facility's "Medical Staff Rules and Regulations for Kindred Hospital Wyoming Valley" dated April 24,2012 revealed no documented evidence for the transfer of inpatients to a non-medicare affiliated physician.

Review of MR21 revealed during this inpatient hospital stay the patient was transferred on April 11, 2012 to a physician's office for a neurology follow-up appointment on April 11, 2012.

Review of MR22 revealed during this inpatient hospital stay the patient was transferred to a physician's office for a follow-up ENT appointment on April 24, 2012.

Review of MR23 revealed during this inpatient hospital stay the patient was transferred to a physician's office for follow-up neurology appointment on March 5, 2012.

Review of MR24 revealed during this inpatient hospital stay the patient was transferred to a physician's office for a follow-up neurology appointment on March 23, 2012.

Interview with EMP6 on May 4, 2012, at approximately 9:30 AM confirmed there was no policy or protocol for staff to follow for the transferring of inpatients to physicians' offices for follow-up visits or appointments.

Based on review of facility medical staff rules and regulations, facility policy, medical records(MR), and interview with facility staff (EMP), it was determined the facility failed to ensure discharge summaries were completed within 30 days following discharge for five of 15 closed medical records reviewed. (MR1, MR6, MR8, MR9, and MR20).

Findings include:

Review on May 3, 2012, of the facility's "Medical Staff Rules and Regulations," dated reviewed April 24, 2012, revealed "... B. Medical Records ... 16 a. Delinquent records are those that are incomplete, including signatures/authentication, after thirty (30) days following discharge of patient."

Review on May 3, 2012 of the facility's policy "Record Content," last reviewed February 2012, revealed "... 21 The medical record is complete when its contents: ... B. Are as
assembled, analyzed and authenticated and all final diagnoses, complications, clinical resumes or final progress notes are recorded without the approved use of symbols or abbreviations. the time period for completion of the medical record as specified in the Medical Staff Rules and Regulations and cannot exceed 30 days after discharge."

Review of MR1 revealed a discharge date of December 22, 2011. The discharge summary was completed on March 3, 2012.

Review of MR6 revealed a discharge date of October 12, 2011. The discharge summary was completed December 12, 2011.

Review of MR8 revealed a discharge date of November 14, 2011. The discharge summary was completed February 2, 20/12.

Review of MR9 revealed a discharge date of March 4, 2012. The discharge summary was completed April 29, 2012.

Review of MR20 revealed a discharge date of October 20, 2011. The discharge summary was completed February 1, 2012.

Interview with EMP1 on May 4, 2012 confirmed these discharge summaries were not completed within the required 30 day time frame (MR1, MR6, MR8, MR9, and MR20).