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Based on review of facility documents and staff interview(EMP) it was determined that the facility failed to have an Institutional plan and budget that provided for capital expenditures for a three (3) year period.

Findings:

1. The facility current fiscal year, June 30, 2012 to June 30 2013, "Operating Budget" was reviewed on August 16, 2012.

2. An interview with EMP1, on August 16, 2012, at approximately 2:30 PM, revealed "We do not have institutional plan beyond this fiscal year".

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure all completed complaints received a second review by the Quality Management Sub-Committee.

Findings include:

Review on August 14, 2012 the "Amended and Restated Bylaws of Clearfield Hospital A Pennsylvania Nonprofit Corporation," effective October 1, 2011, revealed "... Section 3.13 Duties and Responsibilities of Directors. The Board shall act in good faith while exercising the powers provided in these Bylaws and shall prudently govern the affairs and business of this Corporation. Subject to the powers reserved to the Parent in Article hereof, the Board shall, in the execution of its duties, assume responsibilities including, but not limited to: ... (d) establishing and maintaining a written statement of policy setting forth patient rights and responsibilities in order to promote the interest and well being of patients. ..."

Review of the facility's policy entitled "Patient Bill of Rights," dated July 2010, revealed "... Policy: Clearfield Hospital provides each patient with an explanation of his or her rights and responsibilities ... Purpose: To provide a means to inform patients of their rights and responsibilities during the course of medical care. ..."

Review of the facility's pamphlet entitled "Patient Rights [and] Responsibilities" revealed "...Complaints, Concerns, and Questions You and your family/guardian have the right to: Tell hospital staff about your concerns or complaints regarding your care. This will not affect your future care. Seek review of quality of care concerns, coverage decisions, and concerns about your discharge. Expect a timely response to your complaint or grievance from the hospital. Complaints or grievances may be made in writing, by phone, or in person. The hospital has a duty to respond to these complaints or grievances in a manner that you can understand. To share your concerns with the hospital, please contact the hospital's Patient Relations Department. ..."

Review of facility policy "Patient Conflict Resolution," revised June, 2012, revealed "Policy: Clearfield Hospital considers patient opinions, comments and expressions of dissatisfaction to be important feedback, which will be regularly solicited, investigated in a timely and confidential manner, and resolved when possible. ... Patient Complaints [and] Resolution - all expressions of dissatisfaction by patients, family members, or visitors that cannot be immediately resolved will be documented, investigated, and resolved when possible by the appropriate department manager or medical staff chief/director. The approved complaint form ... will be used for documentation of all complaints received from patients, families, or visitors. All expressions of dissatisfaction/complaints that are received in writing are attached to the form an [sic] entered into the formal investigation and resolution process. Appendix A outlines the process for complaint resolution at Clearfield Hospital. Complaint forms are logged and maintained by the Coordinator in secured files upon resolution. When a complaint resolution indicates a decision to adjust the bill or collection procedures, the Director the Business Office will be consulted. Cases will be reported to the Risk Management or the Infection Control Committee when there is a potential risk identified. A summary of all complaints and follow-ups are reported to the Quality Management Subcommittee for second level review and identification of trends ... Appendix A Patient/Family Complaint Resolution Process ... 2. If unresolved or the complaint is in writing, person receiving the complaint initiates salmon-colored Patient/Family Complaint Form. a. Original form sent to the Coordinator sends a preliminary response letter upon receipt of complaint. ... 5. Complaint Form is completed and forwarded to Coordinator, along with a draft of the final resolution letter. If no draft letter is attached, Coordinator will write the letter. a. Investigation and resolution documented on original form. b. Coordinator will document completion on the log. c. Complainant will be notified of a delay in resolution ... 7. All completed complaints will receive a second review by the Quality Management Sub-Committee. ... 8. Coordinator will trend complaints quarterly and forwards the report to the Quality Management Department to be included in the hospital's dashboard report ..."

1) A request was made for the documentation of the second review of facility complaints by the "Quality Management Sub-Committee." No Quality Management Sub-Committee meeting minutes were provided.

Interview with EMP3 on August 14, 2012, revealed "We do not define membership of the Quality Management Sub-Committee. We do meet and discuss, but there is no documentation of the discussions or meetings." EMP3 further stated there was no formal grievance committee.

Cross Reference with:
482.13(a)(2)(iii) Patient Rights - Notice of Grievance Decision

Based on review of facility policy and procedure, facility documentation and staff interviews (EMP), it was determined the facility failed to ensure complainants received a final resolution letter for five of five complaints reviewed and failed to ensure facility policy required the final written notice provided to the patient contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

Review of facility policy, "Patient Conflict Resolution" revised June, 2012 revealed " Policy: Clearfield Hospital considers patient opinions, comments and expressions of dissatisfaction to be important feedback, which will be regularly solicited, investigated in a timely and confidential manner, and resolved when possible.... Patient Complaints [and] Resolution - all expressions of dissatisfaction by patients, family members, or visitors that cannot be immediately resolved will be documented, investigated, and resolved when possible by the appropriate department manager or medical staff chief/director. ... Appendix A Patient/Family Complaint Resolution Process ... 2. If unresolved or the complaint is in writing, person receiving the complaint initiates salmon-colored Patient/Family Complaint Form. a. Original form sent to the Coordinator sends a preliminary response letter upon receipt of complaint....5. Complaint Form is completed and forwarded to Coordinator, along with a draft of the final resolution letter. If no draft letter is attached, Coordinator will write the letter. a. Investigation and resolution documented on original form. b. Coordinator will document completion on the log. c. Complainant will be notified of a delay in resolution ... Written resolution or interim letter to complainant within 30 days ...".

1) A review of a sample of five complaints dated from April to June 2012 revealed all complainants contacted the facility following discharge. A review of facility documents revealed none of the five complainants received a final resolution letter.

Interview on August 17, 2012 at approximately 12:30 PM with EMP3 confirmed the final resolution letter was not provided to the five complainants reviewed from April to June 2012.

2) Review on August 17, 2012, of the facility's policy entitled "Patient Conflict Resolution," it was noted the policy did not require that the final written notice provided to the patient contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Interview on August 21, 2012, at approximately 10:10AM with EMP3 confirmed the current facility policy did not address the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and date of completion. EMP3 further stated "Our current policy is not that specific."

Cross reference 482.13(a)(2) Patient Rights - Review of Grievances