Initial Comments:
This report is the result of an unannounced onsite special monitoring survey initated on April 20, 2023 completed offsite on April 25, 2023, at St. Mary Rehabilitation Hospital. At the time of the investigation, 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:
103.24 (4) LICENSURE
INVESTIGATION/ENFORCEMENT PROCEDURES
Name - Component - 00
103.24
(4) investigation and resolution,
when possible, of formal complaints
shall be timely; and
Observations:
Based on review of facility policies, facility documents, and interview with facility staff (EMP), it was determined the facility failed to ensure an internal investigation and resolution of a formal complaint was completed timely for one of one complaint reviewed.
Findings include:
Review on April 20, 2023, of facility policy, "Patient Concerns, Complaints and Grievances," date approved April 2014 revealed, "... B. Standard Procedure for all other concerns, complaints, or grievances... 2. All patient complaints/grievances are addressed as quickly as possible with appropriate follow up, resolution, and communication with the patient or the patient's representative. If the supervisor believes the complaint constitutes grievance, the Director of Continuous Quality Performance Improvement (DCQPI) or CEO will be notified, a phone call to initiate investigation will be made by the DCQPI or CEO to the person expressing the formal complaint/grievance with 48 hours of receipt of written formal complaint/grievance..."
Review on April 20, 2023, of facility complaint documentation dated March 15, 2023, revealed a complaint was filed for PT1 on March 14, 2023. Further review of facility complaint documentation revealed the facility did not conduct an internal investigation to address the complaint allegations.
Interview with EMP1 on April 20, 2023 at 10:55 AM confirmed there was a complaint filed on behalf of PT1 in the fall of 2022 and on March 14, 2023. EMP1 further confirmed an internal complaint investigation was not conducted for the complaint allegations filed March 14, 2023 per the facility's complaint and grievance procedure.
Plan of Correction: Providing quality care is the steadfast goal of the staff at Saint Mary Rehabilitation Hospital. We thank you for the opportunity to reflect and learn from this finding. The following Plan of correction is being implemented.
1. Education regarding policy "Patient Concerns, Complaints and Grievances," is being provided and signed off on by all Leadership staff (Managers and Directors).
a. Signed attestation of the education will be completed by 5/12/23.
2. The facility will monitor and ensure that internal investigations occur in accordance with the policy in the following manner:
a. All new complaints and grievances are identified in the daily (M-F) operations meeting. Complaints or grievances that are reported on a weekend or holiday will be reviewed in the next operations meeting. During this meeting the CEO or DQM (Director of Quality Management) will indicate progress and steps taken to ensure resolution, including timely investigation, of the incident. The incident will not be marked complete until it is confirmed that the appropriate steps have been taken.
b. Documentation of complaints and grievances will be maintained through the daily operations report and the Occurrence report (incident report) system. (Complete as of 5/5/23).
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