Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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JEFFERSON HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on February 8, 2024, at Jefferson Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.

 Plan of Correction:

Article VII 1(a)(b)(c)(d) REQUIREMENT Grievance and Appeal Procedures:State only Deficiency.
Statement of Principle.

To insure that these rights are safeguarded and that disputes concerning their rights and others are resolved promptly and fairly, patients must have the right to lodge grievances and appeals when informal methods of resolving disputes are unsuccessful. Each facility shall have a grievance and appeal system in effect. Every patient shall be informed of the grievance and appeal system and shall be encouraged to utilize it when informal methods of resolving complaints are unsuccessful.

1. Grievance Procedure.
(a) Any patient, or those helping him, may initiate a complaint orally or in writing, concerning the exercise of these rights or the quality of services and treatment at the facility. The complaint shall be presented as soon as possible to the treatment team leader or other appropriate person.
(b) Every patient shall have the right to the assistance of an independent person and witnesses in presenting his complaint.
(c) The treatment team leader, administrative supervisor, or their designees receiving the complaint shall investigate the complaint and make every effort to resolve it. Based upon this investigation, a decision shall be rendered in writing as soon as possible but within 48 hours after the filing of the complaint. Complaints shall be decided by persons not directly involved in the circumstances leading to the grievance.
(d) The patient shall be given a copy of the complaint and final decision and a copy shall be filed in the patient ' s record.


Based on review of facility documents, a medical record (MR), and staff interviews (EMP), it was determined that facility staff failed to file a copy the final grievance decision in the patient's medical record for one of one grievances reviewed.

Findings include:

Review of facility policy "Grievance and Appeal Procedure - BH #10.03 POL-7205219", last approved 1/31/2024, revealed: " ... 1. Filing a grievance: a. All documentation of the grievance, responses, and appeals will be documented on the Grievance and Appeal form and maintained on the medical record. ... ".

On February 8, 2024, between 9:50 AM and 10:15 AM, review of facility documentation revealed that MR11 filed a grievance with the facility's Patient Relations Department on November 8, 2023. Continued review revealed that facility staff failed to file a copy of the final grievance decision in patient's medical record.

On February 8, 2024, at approximately 10:20 AM, EMP3 reviewed MR11 and confirmed that the final decision letter was not the medical record.

 Plan of Correction - To be completed: 02/19/2024

The Director of Nursing is ultimately responsible for all corrective actions and ongoing compliance associated with this element of performance.

Correcting the non-compliance: Review of Article VII, section (d) of the 5100 survey was reviewed with Jefferson Hospitals Service Excellence Specialist and the Behavioral Health Nurse Manager on 2/13/2024. Attaching a copy of the complaint and final decision to the medical record was not a standard of practice. As a group we discussed possible corrective action measures. The following steps have been implemented immediately to ensure our compliance:

1. When printing the patient acknowledgement and resolution letter the Service Excellence Specialist will print a second copy.

2. The second copy will be given to the Behavioral Health Nurse Manager. The letter will then be placed in the "scan to medical record" bin located on the Behavioral Health unit. This is not a new process for documents to be scanned therefore no additional education is needed.

3. Medical Records Staff will collect the letters from the bin and scan into the patient's electronic medical record.

4. The Behavioral Health Nurse Manager will audit the chart checking that the document was attached to the medical record correctly.

All corrective actions described above were completed by: 2/13/2024

Procedures or activities identified to monitor compliance: The DON developed a log to audit every complaint/grievance received in the Behavioral Health unit. The log will include the patients name and medical record number. We will audit each chart to check that the acknowledgement letter and resolution letters are attached to the medical record.

The frequency of the monitoring activities: Every complaint/grievance for 3 months. Goal is 100% compliance.

The data that will be collected: The date, patient name, medical record number and compliance of the acknowledgement and resolution letters being attached to the medical record.

To who and now often will this data be reported: Compliance will be reported out in the Patient Care Operations Committee.

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