Initial Comments:
This report is the result of a full Medicare recertification survey initiated on April 7, 2025 and concluded on April 9, 2025, at Eagleville Hospital. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.13(h) STANDARD
PATIENT VISITATION RIGHTS
Name - Component - 00
A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation ....
Observations:
Based on facility policy and interview with staff (EMP), it was determined that the facility failed to ensure patient rights were followed regarding allowance of in-person visitation for hospitalized patients.
Findings include:
A review on April 7, 2025 of the facility "General Handbook ... Resident Rights and Responsibilities", no date, revealed "Visitation- You have the right to: Decide if you want visitors or not while you are here ... Designate those persons who can visit you during your stay. These individuals do not need to be legally related to you."
A review on April 7, 2025 of "General Handbook" revised February 6, 2025, revealed "Due to COVID-19 Pandemic The following modifications apply to the handbook: ... 2. Visitation is suspended at this time."
Interview on April 7, 2025 at 2:40 PM with EMP1, confirmed "We don't allow on-site visitation from family or friends of patients. We do ZOOM or phone calls". Further interview confirmed "in-person visitation has not been allowed since COVID restrictions were put into place a few years ago".
Plan of Correction:
When an individual enters into treatment, a therapist will assess for willingness to engage in a family session during the Biopsychosocial assessment. Family contact will be offered through Zoom video sessions, phone calls, and/or in-person.
6. Individuals will need to provide advanced notice (at least 48 hours) prior to anticipated family visit. The visiting person will need to be placed on the approved visitor list through our security personnel.
Clinicians will include family therapy on the treatment plan as appropriate.
Family sessions will be offered and encouraged once per week.
Clinicians will document family therapy sessions on a Family Session Note utilizing DAP format in the individual's electronic record
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