Initial Comments:
This report is the result of an unannounced onsite complaint investigation (CHL18C480N) completed November 27-28, 2018 at Fairmount Behavioral Health System. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.13(a)(1) STANDARD
PATIENT RIGHTS: NOTICE OF RIGHTS
Name - Component - 00
A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.
Observations:
Based on a review of policies and procedures and medical records (MR) and staff interview (EMP), it was determined the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare no more than 2 days after discharge for three of six Medicare-insured medical records reviewed (MR13, MR14, and MR19).
Findings include:
Review on November 28, 2018, of facility policy "Important Message from Medicare ...", dated January 2016, revealed "Procedure ... Hospitals must issue the IM [Important Message from Medicare] within 2 calendar days of admission, must obtain the signature of the beneficiary or his or her representative and provide a copy at that time ... Initial Notification Hospitals must deliver the original copy of the IM at or near admission, but no later than 2 calendar days following the date of the beneficiary's admission to the hospital ... The original of the signed and dated form will be given to the patient, a copy placed in the medical record ..."
Review on November 28, 2018 of MR13 revealed the patient was admitted on October 30, 2018. The admission IM document was not provided to the patient until November 5, 2018 [six days after admission].
Review on November 28, 2018 of MR14 revealed the patient was admitted on November 22, 2018. There was no documented evidence in MR14 that the admission IM document was provided to the patient.
Review on November 28, 2018 of MR19 revealed the patient was admitted on October 27, 2018. There was no documented evidence in MR19 that the admission IM document was provided to the patient.
Interview with EMP1 on November 28, 2018, confirmed there was no documented evidence in MR14 and MR19 that the admission IM documents were provided to these patients. EMP1 further confirmed the admission IM document was not provided to the patient in MR13 until November 5, 2018 [six days after admission].
Plan of Correction:Action Plan:
The Director of Admissions reviewed and affirmed Fairmount Behavioral Health System's Policy & Procedure PC 12.03 (Important Message from Medicare, Medicare Notification of Hospital, Discharge Appeal Rights). This policy indicates, "Hospitals must issue the IM within 2 calendar days of admission, must obtain the signature of the beneficiary or his or her representative and provide a copy at that time. Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge."
Date Completed: 01/18/2019
Person Responsible: Director of Admissions
The Director of Admissions retrained all admissions staff on Fairmount's Policy & Procedure PC.12.03. Understanding of Policy and Procedure PC 12.03 and the documentation requirements noted within the P&P were verified by a signed attestation.
Date Completed: 01/18/2019
Person Responsible: Director of Admissions
Monitoring Plan:
The Director of Utilization Review will track 100% of Medicare Important Message forms to ensure appropriate and timely signatures. The Director of Utilization Review will conduct 30 random chart audits per month to verify the appropriate and timely signatures.
Deficiencies will be addressed with responsible staff individually. Non-compliance with facility policy results in disciplinary action up to and including termination.
Monitoring will continue until a period of 3 consecutive months with 100% compliance is achieved and maintained.
Personal Responsible: Director of Utilization Review
482.13(b)(4) STANDARD
PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION
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The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
Observations:
Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to his/her family member or representative of his/her choice and his/her own physician of the hospital admission in 10 of 10 inpatient medical records reviewed (MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21).
Findings include:
On November 27, 2018, surveyor requested EMP2 to provide a policy that included if the patient requested or declined notification to his/her family member or representative of his/her choice and to his/her own physician of the admission to the hospital. None was provided.
Review on November 28, 2018, of MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR21 revealed these patients were admitted to the facility between October 27, 2018 and November 25, 2018.
Further review of MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR21 revealed no documentation in the medical record whether the facility asked each patient if they requested or declined notification to his/her family member or representative of his/her choice and to his/her own physician of the hospital admission including date, time and method of the requested notification.
Interview with EMP2 on November 28, 2018, at 1:45 PM, confirmed the facility did not have a policy for notification of patient's hospital admission to his/her family member or representative of his/her choice and to his/her own physician and there was no documentation in MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21 of whether the patient requested or declined notification to his/her family member or representative of his/her choice and to his/her own physician, including the date, time and method of notification if the patient did request notification.
Plan of Correction:Action Plan:
The Director of Nursing reviewed and revised the Nursing Assessment to prompt nursing to ask if a client would like anyone, family or physician, contacted regarding their admission.
Date Completed: 01/18/2019
Person Responsible: Acting Chief Nursing Officer
The Director of Clinical Services reviewed and revised Fairmount Behavioral Health System's Policy & Procedure RI 1.17 (Patient/Family Involvement in Treatment) to include that the Social Work Department is responsible to contact any identified family members or physician(s) the client wishes to have contacted regarding their admission.
Date Completed: 01/18/2019
Person Responsible: Director of Clinical Services & Director of Social Work
All Nurses and Social Workers received reeducation through routine staff meetings. All Nurses also received reeducation through the Annual Competency Fair held during the first two weeks of January 2018. All reeducation related to the updated Policy and Procedure RI 1.17, forms, and expectations for timely contacts with family and physicians. Understanding of the Policy and Procedure and the requirements noted within the P&P were verified by a signed attestation.
Date Completed: 01/18/2019
Person Responsible: Acting Chief Nursing Officer, Director of Clinical Services & Director of Social Work
Monitoring Plan:
The Action Chief Nursing Officer/designee will conduct 30 random chart audits per month to verify the nursing assessment prompt regarding contact of family and physician upon admission is completed appropriately and timely upon admission.
The Director of Social Work/designee will conduct 30 random chart audits per month to verify contact is made with all parties requested by the client.
Deficiencies will be addressed with responsible staff individually. Non-compliance with facility policy results in disciplinary action up to and including termination.
Monitoring will continue until a period of 3 consecutive months with 100% compliance is achieved and maintained.
Responsible: Acting Chief Nursing Officer, Director of Clinical Services & Director of Social Work
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