QA Investigation Results

Pennsylvania Department of Health
BELMONT BEHAVIORAL HOSPITAL, LLC
Health Inspection Results
BELMONT BEHAVIORAL HOSPITAL, LLC
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced onsite complaint investigation (CHL19c015n) completed on January 31, 2019, at Belmont Behavioral Hospital. It was determined 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)(2) STANDARD
PATIENT RIGHTS: GRIEVANCES

Name - Component - 00
The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.


Observations:


Based on review of facility policy, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to comply with CMS requirements to consider complaints related to allegations of abuse or neglect a grievance for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5, and MR6).

Review on January 30, 2019, of facility policy, " PRS Complaints and Grievances," dated January 12, 2016, revealed, " ... If the Risk Manager determines that the reported concern involves an allegation of abuse, neglect, ... or PRS [patient] harm the issue is not considered a grievance and is not forwarded to the Care Advocate ... ."

Review on January 30, 2019, of facility's documentation, " Allegations: Staff to PRS August 2018 - January 2019," revealed patient related to MR5 filed an allegation of abuse complaint on August 26, 2018.

Review on January 30, 2019, of facility's documentation, " Allegations: Staff to PRS August 2018 - January 2019," revealed patient related to MR1 filed an allegation of abuse complaint on September 16, 2018.

Review on January 30, 2019, of facility's documentation, " Allegations: Staff to PRS August 2018 - January 2019," revealed patient related to MR3 filed an allegation of abuse complaint on October 12, 2018.

Review on January 30, 2019, of facility's documentation, " Allegations: Staff to PRS August 2018 - January 2019," revealed patient related to MR6 filed an allegation of abuse complaint on November 2, 2018.

Review on January 30, 2019, of facility's documentation, " Allegations: Staff to PRS August 2018 - January 2019," revealed patient related to MR2 filed an allegation of abuse complaint on December 26, 2018.

Review on January 30, 2019, of facility's documentation, " Allegations: Staff to PRS August 2018 - January 2019," revealed patient related to MR4 filed an allegation of abuse complaint on January 6, 2019.

Review on January 30, 2019, of facility's, " 2018 PRS Grievance Report," revealed the above allegations of abuse complaints were not logged as grievances.

Interview on January 30, 2019 at 1:19 PM with EMP11, confirmed the above allegations of abuse complaints were not considered grievances. Further confirmed, since they were not considered grievances, facility's established grievance process was not followed.








Plan of Correction:

Belmont Behavioral Hospital's Policy #150.90 PRS Complaints and Grievances Policy was revised on 3/8/19 to include all verbal and written complaints regarding abuse, neglect, or patient harm regardless of the type of document on which they are reported.

The Director of Risk Management will review the revised process with the Risk Management Coordinator/Care Advocate on Friday, 3/15/19 and obtain a signed attestation.

Effective 3/1/9, the Director of Risk Management or designee will maintain an electronic Grievance Log which documents all verbal and written complaints regarding abuse, neglect, or patient harm received by the facility.

The Director of Risk Management will review the log monthly to ensure the log is accurately maintained and a report will be provided in the Patient Safety Committee.