This report is the result of an unannounced onsite complaint investigation (JOH18C015J)concluding on November 13, 2018, at Crichton Rehabilitative Center. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
103.22 (b)(12) LICENSURE
Name - Component - 00
(12) A patient has the right to
assistance in obtaining consultation
with another physician at the
patient's request and own expense.
Based on a review of medical record (MR1), facility documentation, and interview with staff (EMP) it was determined that Crichton Rehabilitiation Center failed to provide an opportunity for an inpatient to attend a previously scheduled post-operative follow up appointment with their neurosurgeon at the referring hospital, for suture removal, CT scan, and to plan next steps in their treatment course, in one of one medical record (MR1).
Conemaugh Memorial Medical Center ... PolicyStat ID: 1970090 ... Last Reviewed: December 2015 ... Policy Area: Organization-Clinical ... Patient Rights policy. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. CHS acknowledges that the patient has the right to make decisions regarding medical care, this includes discontinuation of therapy to the extent permitted by law. ... 2. A policy on informed decision making which requires patient, parent/guardian or surrogate involvement. This includes involvement in treatment decisions or ethical issues as they arise. ... 4. A policy to render care and treatment appropriate to the patient's condition. 5. A policy that patients are transferred when the hospital is unable to meet the patient's requests or needs for treatment or service. In all cases, the need for transfer is discussed with the patient, parent/guardian or surrogate. Consent is obtained prior to transfer and patients are transferred when a physician at the receiving facility has agreed to accept the patient. ... 7. Addressing the psychosocial needs of the patient which are identified during the hospital stay and initiating the appropriate referrals as necessary. ... 10. Recognition of the patient's right to make decisions involving his/her health care which includes the right to accept or refuse medical treatment. These rights are described more fully in the Informed Consent Policy. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 16. You have the right to discuss your care with another doctor. This will be at your own request and expense. 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... 22. You have the right to make decisions about your care, treatment, and services, including the right to have your family and physician notified of your admission to the hospital. ... ." Attachment to Patient Rights Policy entitled, "Conemaugh Health System A Statement of the Patient's Rights" revealed, "Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, our patient, is addressed in this Statement of Patient's Rights. ... 23. You have the right to request a discharge plan. Upon discharge you will be given information for your follow-up health care. ... ."
Conemaugh Memorial Medical Center ... PolicyStat ID: 5233454 ... Last Reviewed: August 2018 ... Last Revised: October 2017 ... Policy Area: Crichton Rehabilitative Center-Administrative Admission Procedures: Pre-Admission Process policy and procedure. "Procedure ... 3. A pre-admission assessment will be completed on each patient admitted to Crichton Rehabilitation Center. ... 8. Although clinical personnel are required to evaluate and interpret pre-admission assessment information, any member of the admissions team, as mentioned below, may gather or collect said information, regarding the potential patient for the pre-admission assessment. 9. The Admissions Team which includes (but not limited to): the rehabilitation physician, the Admissions Coordinator, Case Manager(s), a Representative from Nursing, the Clinical Evaluator(s), the PPS Coordinator, the Manager of Business Development ... 11. Patients considered for admission to the inpatient rehabilitation program will be assessed in accordance to the criteria outlined in the Medicare Benefits Policy Manual, Section 110 as well as Interquale Criteria for inpatient rehabilitation facilities. ... 17. For those referrals received for facilities outside of Memorial Medical Center, the following information is required to make an appropriate admission decision: A. the patient's medical information B. the patient's level of function used to justify the need for two (2) or more therapy discipline. ... ."
1. Medicare Benefit Policy Manual (MBPM) revised March 10, 2017. "... 110-Inpatient Rehabilitation Facility (IRF) Services ... A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain in the referring hospital, with appropriate rehabilitative treatment provided, until such time as the patient has completed the full course of treatment. ... 110.1.1-Required Preadmission Screening ... The focus of the review of the preadmission screening information will be on its completeness, accuracy, and to the extent to which it supports the appropriateness of the IRF admission decision, not on how the process is organized. ... 110.2-Inpatient Rehabilitation Facility Medical Necessity Criteria ... 110.2.2-Intensive Level of Rehabilitative Services A primary distinction between the IRF environment and other rehabilitation settings is the intensity of rehabilitation therapy services provided in an IRF. ... Although the intensity of rehabilitation services can be reflected in various ways, the generally-accepted standard by which the intensity of these services is typically demonstrated in IRFs is by the provision of intensive therapies at least 3 hours per day at least 5 days per week. ... Brief Exceptions Policy-While patients requiring an IRF stay are expected to need and receive an intensive rehabilitation therapy program, as described above, this may not be true for a limited number of days during a patient's IRF stay because patients' needs vary over time. For example, if an unexpected clinical event occurs during the course of a patient's IRF stay that limits the patient's ability to participate in the intensive therapy program for a brief period not to exceed 3 consecutive days (e.g., extensive diagnostic tests off premises, prolonged intravenous infusion of chemotherapy or blood products, bed rest due to signs of deep vein thrombosis, exhaustion due to recent ambulance transportation, surgical procedure, etc.), the specific reasons for the break in the provision of therapy services must be documented in the patient's IRF medical record. If these reasons are appropriately documented in the patient's medical record, such a break in service (of limited duration) will not affect the determination of the medical necessity of the IRF admission. Thus, A/B MACs (A) may approve brief exceptions to the intensity of therapy requirement in these particular cases if they determine that the initial expectation of the patient's active participation in intensive therapy during the IRF stay was based on a diligent preadmission screening, post-admission evaluation, and overall plan of care that were based on reasonable conclusions. ... ."
2. MR1 Pre-Admission Screening failed to reveal documented evidence that a follow up appointment with the neurosurgeon was scheduled following discharge from Allegheny General Hospital.
MR1 Case Management progress notes revealed, "... 09/07/18 1627 ... Family concerned about follow up appointment with neurosurgeon ... Patient unable to go to outpatient appointment because they are currently in acute inpatient rehab. ... ."
Additional Case Management Progress notes dated September 9, 2018, "... Team conference done this am. Team recommending 24/7 supervision and family training prior to discharge. Family concerned about follow up appointment with neurosurgeon ... in Pittsburgh to discuss next steps in treatment. Administration involved in process. Dr. ... to speak with Neurosurgeon to discuss this matter. ... Corporate policy -we do not take patients for appts, this is an acute rehab for pts that require 24/7 care, appts need to be set up post d.c or physician comes to Crichton to see pt. Issue with bills that are acquired during the apt. Risk of travel, such as patient needing medication, rest room capabilities etc ... called Insurance Rep at insurance who said going for f/u apt was no issue. ... ."
MR1 Physician Progress Note dated September 17, 2018, revealed, "... Patient could be discharged early Wednesday, September 19 and be in Pittsburgh for follow up appointment Wednesday afternoon. Family to arrange appointment and transportation. Reported to me that ... neurosurgeon ... wanted the patient transported immediately today September 17, 2018 and for Crichton to do that. For this reason, the patient was tentatively to be discharged Monday, September 17, 2018 to the care of the family. They can set up arrangements and transportation for follow-up ... including such with ... neurosurgeon... . Crichton Center is an acute inpatient rehabilitation facility. Patient's in acute rehabilitation require 24/7 medical, nursing, and therapy care. ... ."
MR1 Discharge Summary dated September 21, 2018, revealed, "... Discharge Disposition ... In addition, patient's family was inquiring as to why patient cannot be transported from inpatient acute care rehabilitation facility to outpatient appointment, explained liability insurance payment, billing, medicolegal issue. ... F/U Neurosx 1-2 weeks ... ."
3. Interview with EMP1 on October 30, 2018, at 9:00 AM revealed that the facility does not send their patients out for post operative follow-up doctor appointments anymore, but that this used to be past practice many years ago.
Interview with EMP3 on October 30, 2018, at 9:50 AM revealed, "... Our current practice is not to send patients out for any follow-up appointments. ... It's been our practice since ... corporation came on board. We're an acute inpatient rehab, a patient needs to have 24/7 coverage. ... We've not sent patients to appointments since we became part of ... corporation, other doctors have become frustrated because we don't send patients to follow up appointments ... ."
Telephone interview with EMP3 on November 13, 2018, at approximately 3:40 PM revealed, "We have nothing in writing that says a patient can not go to a follow-up doctor appointment while they are an inpatient here. ... ."
Plan of Correction:
1. Crichton Rehabilitation Center will develop Patient Outside Consultation Policy (the "Policy") by 12/06/18.
a. The Policy will be presented by the Administrator of Crichton Rehabilitation Center to the Performance Excellence Steering Committee of Conemaugh Memorial Medical Center on 12/12/18 for approval.
b. Following approval by the Performance Excellence Steering Committee, the Policy will be presented by the Vice President of Ancillary and Post-Acute Services to the Performance Excellence Committee of Conemaugh Memorial Medical Center on 12/19/18 for approval.
c. Once approved by both of the aforementioned Committees, the Policy will reside in the Administrative section of the Crichton Rehabilitation Center policy and procedure manual.
2. The plan of action for education of this Policy is as follows:
a. All Crichton Rehabilitation Center employees will review, receive training, and sign an acknowledgement of understanding of the Policy.
i. Staff meetings
1. Review and training by the Nurse Manager at nursing staff meeting on 12/19/18.
2. Review and training by the Therapy Manager at the therapy staff meeting on 12/20/18.
ii. Face-to-face communication and review
1. Review and training by the Admissions and Case Management Manager to the admissions and case management staff no later than 12/21/18.
2. Review and training by the Administrator to the Medical Director and management team by 12/21/18.
b. A PER14A (Program Education Record) will serve as documentation of the completed training process.
c. New hires will be educated on the Policy as part of the orientation process.
d. The Policy will be reviewed as part of annual required education at Crichton Rehabilitation Center.
3. Compliance will be measured through the Crichton Rehabilitation Center Documentation Committee.
a. The Admissions Coordinator will maintain a log of consultative and follow-up appointment inquiries made by the admissions department to patients and/or patient representatives pre- and post-admission.
b. Self-audits will be conducted monthly reviewing the consultative and follow-up appointment log. Results of self-audits will be reported and monitored through the Crichton Rehabilitation Center Documentation Committee and through the Conemaugh Memorial Medical Center Performance Excellence Steering Committee and Performance Excellence Committee.
c. Compliance with the Policy will be monitored and reported in accordance with the outlined reporting and monitoring process established by Conemaugh Memorial Medical Center.
d. If found to be non-compliant, re-education to be completed by the Management Team at Crichton Rehabilitation Center.
4. Action plan to be completed 1/19/19.
In accordance with 28 Pa. Code 103.22(b)(12), it is the policy of Crichton Rehabilitation Center ("Crichton") to provide assistance to patients in obtaining consultation with another physician at the patient's request and own expense.
1. As part of evaluating a request for admission to Crichton, the Admissions Office will obtain all relevant information related to any scheduled consults or health care appointment(s) scheduled or expected to take place during the inpatient stay, including but not limited to location, date and time of appointment(s), and services or treatment scheduled or anticipated.
2. As part of the communication outlined above, the Admissions Office will inform the patient and/or patient's representative that Crichton policy requires that all scheduled consults or health care appointments, including for example any scheduled follow-up appointments related to a surgical procedure, which are currently scheduled or expected to take place during the inpatient stay must be disclosed to Crichton prior to admission so that Crichton can make arrangements to accommodate such appointments. The patient and/or patient's representative will be informed that failure to disclose a scheduled consult or healthcare appointment could result in the Crichton later refusing the patient's request to attend such consult or appointment and that Crichton will assess any such request after admission on a case by case basis. In addition, the Admissions Office will inform the patient and/or patient's representative that Crichton may not accommodate a patient's scheduled consult or healthcare appointment at a location outside the geographic area served by Crichton, including any location outside the Commonwealth of Pennsylvania. The Admissions Office further will inform the patient and/or patient's representative that, to the extent the patient is a candidate for admission to Crichton and the patient and/or the patient's representative decides to proceed with admission to Crichton, Crichton can assist the patient in receiving care from a provider within the geographic area served by Crichton in lieu of any scheduled consult or health care appointment outside that area.
3. In the event a patient with any scheduled or anticipated consults and/or appointments is admitted to Crichton, Crichton staff will immediately notify Operations Counsel in order to obtain a written agreement between Crichton and the patient's other physician(s) governing the services to be provided by the physician(s) to the patient and compensation related to those services, which must comply with the Stark Law and other applicable federal and state regulations. Crichton staff must also confirm with Operations Counsel that a written agreement with a transport company is in place to allow for the transportation of the patient to the scheduled or anticipated appointment. Lastly, a Crichton staff member must accompany the patient to and from the appointment.
4. If during the course of an inpatient stay a patient or patient's representative requests assistance in obtaining a consultation or health care appointment that was not previously identified as part of the admissions process, Crichton will evaluate the request on a case-by-case basis and make a determination as to the medical appropriateness and reasonableness of the request. As part of this determination, Crichton staff will consider applicable law, consult with Crichton's Medical Director, and refer to the relevant provisions of CMS' Medicare Benefit Policy Manual, Chapter 1, regarding brief exceptions to the intensive level of rehabilitation services provided by Crichton, as well as communicate with the provider with whom the patient has a consult or health care appointment as appropriate to evaluate the medical appropriateness of the request. The case-by-case determination as contemplated by this paragraph will be completed within one (1) business day after receiving the request from the patient and/or patient's representative.
5. In the event it is determined that the patient's request is medically-appropriate, reasonable, and in the patient's best interest, Crichton staff will immediately notify Operations Counsel in order to obtain a written agreement between Crichton and the patient's other physician(s) governing the services to be provided by the physician(s) to the patient and compensation related to those services, which must comply with the Stark Law and other applicable federal and state regulations. Crichton must also confirm with Operations Counsel that a written agreement with a transport company is in place to allow for the transportation of the patient to the scheduled or anticipated appointment. Lastly, a Crichton staff member must accompany the patient to and from the appointment.
6. In the event the follow-up appointment or consult needs to be cancelled or postponed, whether due to a patient's medical condition, inclement weather, or other reason, Crichton staff will communicate promptly with the patient's other physician and re-schedule the appointment to occur as soon as is reasonably feasible.
7. In the event that it is determined that the patient's request is unreasonable or not in the patient's best interest, the patient or the patient's representative will be informed of Crichton's decision, and the patient or patient's representative will be provided with a list of alternative providers who are able to provide the services that the patient is requesting.
8. Any decisions and communications to the patient or patient's representative made under this Policy shall be documented in the patient's medical record.