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Based on document review and interview, the facility failed to ensure the governing body reviewed facility specific data including but not limited to quality indicators, complaints and grievances, and adverse events resulting in the failure to effectively understand the facility's operations, identify areas for improvement, and take action to improve patient care which could affect all patients served by the facility. Findings include:

Review of the governing body minutes dated 9/25/2018, 11/27/2018, 1/22/2019, and 3/26/2019 revealed that the governing body was over the entire corporate hospital system. The facility currently undergoing survey was mentioned regarding the re-branding of the hospital under the corporate umbrella, approval of the operations committee minutes, that a "triennial survey" was expected, and the results of a compounding survey that had recently taken place. Further review of governing body meeting minutes revealed no evidence of actions, data, complaints and grievances, incidents, or plans specific to this certified facility.

On 6/11/2019 at 1352, Staff A stated that the surveyed facility's data was "not specifically broken out" and that she had requested that to be changed on 6/7/2019. "I can't compare how we are doing to other LTACHs (long term acute care hospital)."

On 6/11/2019 at 1403, Accreditation and Regulatory Compliance Staff U stated, "(This hospital) is considered a unit of (the corporate main hospital) even though it is under a different CCN (CMS [Centers for Medicare and Medicaid Services] certification number)...all of the data is rolled into the main hospital's data."

Based upon document review and interview the facility 1) failed to ensure patient complaints and grievances were recorded, investigated, and responded to for all grievances received, failed to report grievances received to the Quality Assurance Performance Improvement (QAPI) committee and the Governing Body resulting in denying all patients the right to file a grievance and be responded to with resolution and 2) failed to provide the Important Message from Medicare (IMM) in 9 of 13 Medicare patients (#3,#4,#7,#8,#12,#13,#14,#15,#21, and #22) resulting in denying patients the right to file an appeal of discharge with the Quality Improvement Organization (QIO). Findings include:

1. The facility failed to provide the Important Message from Medicare for 9 of 13 Medicare patients. See tag A-117.

2. The facility failed to provide prompt resolution to grievances received and failed to have a process to respond to grievances. See tag A-118.

3. The facility failed to report grievances to the Quality Assurance Performance Improvement (QAPI) committee and failed to report to the Governing Body grievances received. See tag A-119.

Based on interview and record review the facility failed to have a Quality Assessment Performance Improvement Program that utilized data collected to identify areas for performance improvement, failed to have priorities set for performance improvement, and failed to implement initiatives for performance improvement resulting in the failure to identify areas of opportunity to improve patient safety and quality of care for all patients.

See specific Tags:

1. A - 0263 -
Based on interview and record review, the facility failed to implement an ongoing quality improvement and safety program that utilized data collected to identify areas for Performance Improvement resulting in failure to identify opportunities to improve the comprehensive care for all patients served by the facility.

2. A-0309
Based on interview and record review , the governing body failed to ensure an ongoing program for quality improvement, priorities for improved quality of care, and patient safety, was defined, implemented, and maintained resulting in the failure to identify areas of improvement for patient safety and quality of care for all patients.

Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on document review and interview the facility failed to ensure 9 of 13 patients (#3, #4, #7, #8, #12, #13, #15, #21, and #22) Medicare patients received the "Important Message from Medicare" (IMM) as required resulting in the denial of the right to appeal hospital discharge with the Quality Improvement Organization (QIO). Findings include:

On 6/10/2019 at 1030 during the document review of patient #3's medical record it was revealed the patient was a Medicare beneficiary and the IMM was missing from the medical chart. On 6/10/2019 at 1045 Staff Q was asked if the patient (#3) had received the IMM. Staff Q stated, "No. He is a commercial Medicare patient. Commercial Medicare patients do not receive the IMM only regular Medicare patients receive the IMM." Staff Q was then queried how a patient was determined as being regular Medicare. Staff Q responded, "Regular Medicare just states Medicare where commercial Medicare is under a commercial name is listed with the commercial name and then Medicare." Staff Q was then asked where the process starts that identifies the patient as to what type of Medicare the patient is under. Staff Q stated that it is determined by the registration process.

On 6/10/2019 at 1500 an interview was conducted with Staff M, a case manager. Staff M was queried about the provision of the IMM to patients prior to discharge. Staff M stated the IMM was provided to patients "no sooner than 24 hours prior to discharge." Staff M was then queried if the initial IMM was provided by case managers. Staff M stated, "No, that is handled at the time of admission by either the registration clerk or the unit secretary."

On 6/10/2019 at 1600 during document review of patient #21's medical record it was revealed the patient was a Medicare beneficiary and received the initial IMM on 2/5/2019 on the date of admission but failed to receive an IMM prior to discharge on 3/12/2019. On 6/10/2019 at 1610, Staff M, the accreditation specialist, confirmed patient #21 received only one IMM during the patient's stay and did not receive an IMM prior to discharge.

On 6/10/2019 at 1620 during document review of patient #22's medical record it was revealed the patient was a Medicare beneficiary and the patient did not receive an IMM during the patient's stay at the facility from admission on 10/29/2018 and discharge on 12/29/2018. On 6/10/2019 at 1630, Staff M, the accreditation specialist, confirmed patient #22 did not receive an IMM during the patient's hospitalization.

On 6/11/2019 at 0900 an interview was conducted with Staff B, the patient access supervisor. Staff B was queried as to the process of providing an IMM to Medicare patients. Staff B stated registration clerks had been queried in regards to which patients received the IMM and which patients were not receiving the IMM. Staff B stated there seemed to be some confusion as to which patients received that IMM with one of the registration clerks and it may explain why some patients received the IMM upon admission and other patients had not received the notice. Staff B stated that she was unsure of the process of patients receiving the IMM prior to discharge but thought that was addressed by case managers or unit secretaries.

On 6/11/2019 at 1330 a document review was conducted of the policy titled, "Patient Complaint and Grievance Management," policy #5900144, last revised and approved on 1/22/2019. According to the policy (pg. 4, #2, section D) it states, "Medicare beneficiaries, as part of the registration process, are provided upon admission with a document entitled an "Important Message from Medicare" which advises the patient of his/her rights to request a review by Michigan's Healthcare Quality Improvement Organization (MPRO) in connection with discharge and coverage decisions. The Patient Access Team is responsible for distributing the required documents to the Medicare beneficiaries and the Utilization Management Coordinator/Care Management Team will coordinate any appeal process with the patient's health care team and MPRO."


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On 06/10/2019 at 1100 during tour of the facility, review of Patient #4's paper medical record revealed that no Important Message form Medicare (IMM) could be found. Patient #4 was listed as a Medicare patient with an admission date of 04/05/2019 and a current inpatient of the facility.

On 6/10/2019 At 1105 Staff Q the unit secretary, was asked where the IMM should be located in the paper chart, she stated that if he had one it would be in the back of the chart, and if it was not there he would not need one, as only the straight Medicare patients needed the IMM.

On 06/10/2019 at 1330, review of Patient #13's electronic medical record revealed he was a Medicare patient admitted 11/04/2018 and discharged 12/11/2018, however, no IMM was found to be present for the discharge. This was confirmed by Staff M at the time of discovery.

On 06/10/2019 at 1350, review of Patient #15's electronic medical record revealed he was a Medicare patient admitted 12/26/2018 and discharged 02/13/2019, however, no IMM was found to be present for the admission. This was confirmed by Staff M at the time of discovery.



36887

On 6/10/2019 at 1624, review of Patient #12 's electronic medical record revealed he was a Medicare patient. Patient #12, an expired patient, was admitted 5/9/2019; however, no IMM was found to be present for the admission. This was confirmed by Staff M at the time of discovery.

On 6/10/2019 at 1627, review of Patient #7's electronic medical record revealed he was a Medicare patient. Patient #7, an expired patient, was admitted 5/9/2018; however, no IMM was found to be present for the admission. This was confirmed by Staff M at the time of discovery.

On 6/10/2019 at 1633, review of Patient #8's electronic medical record revealed she was a Medicare patient. Patient #8, an expired patient, was admitted 7/15/2018; however, no IMM was found to be present for the admission. This was confirmed by Staff M at the time of discovery.

Based on record review and interview, the facility failed to identify grievances and to follow it's own policy and procedure relating to complaints and grievances for 1 (# 13) of 2 cases reviewed resulting in the failure to accurately track and trend patient concerns and failure to identify potential areas for improvement for all patients served by the facility. Findings include:

On 6/11/2019 at 0833, review of the complaints and grievance log from 6/19/2018 to 6/5/2019 revealed a total of 18 entries as follows: 4 care related/billing, 5 billing, 7 care related, 1 staff perception of patient, and 1 wrong coding. The log had several columns, some of which included patient name, date of birth, complaint description, ticket status, and grievance. It was noted that the ticket status was marked "closed" for all entries with the exception of the last one and that the all entries in the grievance column were marked "No."

Staff U was queried on 6/11/2019 at 0849 as to if she saw any grievances on the complaint and grievance log to which she stated, "Our complaint department told us they didn't have any grievances for the last year. I didn't look at it when I brought it to you...it looks like a few of them should be."

On 6/11/2019 at 0833, review of the complaint made by the mother of Patient #13 on 11/20/2018 revealed concerns regarding food, physician and nursing staff attitude/treatment of the patient, care of the patient, and a concern about potential racism. Electronic review of the complaint information was conducted on 6/11/2019 at 1045 with Staff K. At the end of the complaint description it stated, "The patient's mother has refused to talk to anyone from that site..." Documentation was present regarding a phone call to the complainant following the initial complaint; however, no letters were sent regarding the acknowledgement of the complaint, no details regarding the investigation or outcome of the complaint, and no letter acknowledging the close of the complaint were present in the complaint file. The complaint file was considered closed on 11/29/2018.

At 1045 on 6/11/2019, Patient Representative Staff K was queried as to why no investigation information or letters were present to which she stated, "The unit manager or whoever is doing the investigation does not report back to us...The patient was still on site so most of it was handled verbally face to face."

Facility policy #5900144 titled "Patient Complaint and Grievance Management" last revised 1/22/2019 states, "Grievance: A complaint by the patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related with the hospital's compliance with the Centers for Medicare and Medicaid (CMS) Hospital Conditions of Participation (CoP) or accrediting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations...When a patient grievance is received, it will be entered into the Patient Complaint Management System by the person who receives the details of the complaint. This action will notify those who can address the issue (s). The reviewer will notify the patient and/or the patient's family or representative verbally or in writing that the grievance has been received and that actions to resolve their grievance have begun...Grievances requiring investigation will be referred to the appropriate department director and/or executive who, upon completion of their investigation, will post their findings in the Complaint Management System...The following response timelines apply to all patient grievances: 1. Within seven (7) days of receiving a grievance, written acknowledgement of receipt of this grievance and notice that an investigation has begun will be sent to the patient, and/or the patient's family or representative. When possible, resolution will also be achieved in the first seven (7) days...Upon completing the investigation, a decision is rendered as to how to resolve the grievance and the patient and/or his/her representative is notified in writing..."

Based on document review and interview, the governing body failed to establish an effective process for reviewing and resolving patient grievances resulting in an increased risk of untimely and ineffective grievance resolution for all 4 in-patients and 2 emergency patients currently served by the facility. Findings include:

On 6/11/2019 at 1220, review of the Board of Trustee minutes dated September 2018, November 2018, January 2019, and March 2019 revealed a lack of any reference to patient complaints and grievances.

Staff U was queried on 6/11/2019 at 1200 as to why complaints and grievances were not discussed in the governing body to which she stated, "We have a grievance committee. Well, we used to. Let me check on that."

On 6/11/2019 at 1330, Staff U stated, "We no longer have a grievance committee. We used to have one."

Based on interview and record review, the facility failed to implement an ongoing quality improvement and safety program that utilized data collected to identify areas for Performance Improvement resulting in failure to identify opportunities to improve the comprehensive care for all patients served by the facility. Findings include:

On 06/10/2019 at 1330 a review of the documents titled "(facility name) Quality and Safety Meeting" from March 2018 though April 2019 were reviewed. During document review the Quality Assessment Performance Improvement (QAPI) program failed to have any information of facility improvement measures or priorities to address areas of needed improvement.

On 06/11/2019 at 1330 an interview with staff A occurred. Staff A was asked if any evidence could be provided that would show the collection of data from this facility was used to identify opportunities for performance improvement in the quality of care provided.
Staff A responded, "I am aware that all of our data is rolled into our Corporate data, I have asked that our data be broken out from the general data."

On 06/11/2019 at 1400 staff A provided a document titled "Performance Improvement Plan Pyxis ES Implementation" dated September 2017. Staff A stated "this is the last performance improvement report, it was released January 2018 and it was for all of (corporate name) Facilities."
Staff A stated that "although data was collected there was no information that could be produced to show how indicators were used for improvement measures or their priorities for the QAPI program here at (facility name)."

On 06/11/2019 at 1300 The policy titled "Performance Improvement Plan" #6531792 dated revised 06/2019 was reviewed. On page 2 of 3 under Policy: 2. it states "The safety committee and department committees will direct project teams to effect improvement actions based on identified opportunities for improvement and submit regular reports to the clinical Quality and Patient Safety Council."

Based on interview and record review, the governing body failed to ensure an ongoing program for quality improvement, priorities for improved quality of care, and patient safety was defined, implemented and maintained resulting in the failure to identify areas of improvement for patient safety and quality of care for all patients.

On 06/10/2019 at 1330 a review of the documents titled "(facility name) Quality and Safety Meeting" dated from March 2018 though April 2019 were reviewed. During document review the Quality Assessment Performance Improvement (QAPI) program failed to have any information of facility improvement measures or priorities to address areas of needed improvement.

On 06/11/2019 at 1330 an interview with staff A occurred. Staff A was asked if any evidence could be provided that would show the collection of data from this facility was used to identify opportunities for performance improvement in the quality of care provided. Staff A responded, "I am aware that all of our data is rolled into our Corporate data, I have asked that our data be broken out from the general data." Staff A also stated "although data was collected there was no information that could be produced to show how indicators were used for improvement measures or their priorities for the QAPI program here at (facility name)."

On 06/11/2019 at 1400 staff A provided a document titled "Michigan Market Quality and Patient Safety Program Plan" fiscal year 2019 (corporate name.) On page 6 of 18 it states "Performance Improvement Process, Goals will be formally reassessed and revised annually."

On 06/11/2019 at 1300 The policy titled "Performance Improvement Plan" #6531792 dated revised 06/2019 was reviewed. On page 1 of 3 under Introduction: it states "...Performance and Quality Improvement Plan is based on the concepts of commitment to continuous improvement...The Board of Trustees is responsible for ensuring the organization achieves its commitment...To that end, (facility name) has created a framework for continuously monitoring and improving the safety and quality of care provided to its patients."

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated June 10, 2019.
K-0223
K-0281
K-0300
K-0321
K-0324
K-0325
K-0353
K-0363
K-0781
K-0914
K-0920
K-0921