Quantum Rehabilitation and Nursing LLC
July 28, 2017 Complaint Survey

Standard Health Citations

FF10 483.10(g)(8)(i)(9)(i)-(iii)(h)(2):RIGHT TO PRIVACY - SEND/RECEIVE UNOPENED MAIL

REGULATION: (g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (g)(9) communications such as email and video communications and for internet research. (i) If the access is available to the facility (ii) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident. (iii) Such use must comply with State and Federal law. (h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: October 13, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview during an abbreviated survey (Complaint ID #: NY 840) the facility did not respect each residents' rights to promptly receive unopened mail. Specifically, two (Resident #1 and Resident #4) of four residents reviewed for residents' rights received mail that was opened by facility staff prior to being delivered to Residents. This was evident through resident and staff interviews. Findings Include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented the resident's cognition as intact. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum data set assessment dated [DATE] documented the resident's cognition as intact. Resident # 4 was unavailable for interview. The resident was discharged from the facility on 03/10/2017. The Facility Policy and Procedure titled Resident Mail dated (MONTH) (YEAR) documented it is the facility's policy to assure that residents are able to send/receive mail in a private and secure manner. Documentation included; all resident mail will remain unopened until the resident receives it. During an interview with Resident #1, he stated that he received opened mail on three occasions; all mail was regarding a hearing related to his discharge decision. He stated the Concierge delivered it opened, one occasion it was opened with a piece of tape taping it back shut. When the resident asked the Concierge about why his mail had been opened she did not have a reason. During an interview on 03/15/2017 at 12:35 PM with 7:00 AM - 3:00 PM Registered Nurse Manager (RNM), he stated he had previously received complaints from other alert and orientated residents that their mail was opened prior to being delivered to them. He stated that Resident #4, who was now discharged , showed him an opened piece of mail and was upset that it was opened prior to being delivered to him. The RNM then informed administration of the issue. RNM stated that Resident #1 also complained about his mail being opened. During an interview on 03/15/2017 at 12:40 PM with 8:00 AM - 4:00 PM with the Director of Concierge services, she stated she has never delivered resident mail to their rooms. During an interview on 03/15/2017 at 1:50 PM with the 8:00 AM - 4:00 PM Receptionist, she stated her job duties included to receive the mail, sort it and send it to the designated departments. Almost everything that has a resident's name goes to the business office (at a different location away from the facility) and it is opened there and some of that mail is returned to her opened prior to going to the resident. Most mail with a residents' name that appears to be from a health insurance company, from doctor's offices or anything that appears to be a bill (based on senders' name) would go to the business office. If the mail is from Medicaid with a resident's name, it goes to the Medicaid coordinator. She stated she had been working at the facility since 07/2016 and that is how it has been done. The Receptionist stated that no one delivers the mail on weekends. During an interview on 03/15/2017 at 3:35 PM with the Administrative Assistant who trained the facility's Receptionist, which included sorting the mail, she stated it is the facility practice that mail addressed to the resident did not necessarily go to the resident, it depends on the article of mail, and the entity it comes from. Center for Medicaid and Medicare Services (CMS) mail addressed to the resident does not go to the resident, it goes to the business office. Social Security mail goes to the resident. She stated she trained the Receptionist to look at the sender, and based on the sender the receptionist determines if the resident gets the mail directly. She stated, It's pretty cut and dry, if it is a bill it goes to the business office, all CMS mail goes to Business office, even if it is addressed to the resident because it is not meant for the resident. The business office then opens the mail. 415.3 (d)(2)(i)

Plan of Correction: ApprovedAugust 24, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A.Resident # 1 was informed that his mail will not be opened without his request.
1.Resident # 4 was discharged on [DATE].
B.All residents have potential to be affected by this deficient practice.

1.All the alert and oriented residents visited by Director Social Services on 03/15/2017 and no other complaints were voiced regarding personal mail received being opened.

2.Director of Social Services was well aware of patient mail delivery process and the mail which is addressed to the patients should not be opened.Director of Social Services continues to forward the mail to the families of cognitively impaired residents. Department of Social Services was re-in serviced on continuing to follow the facility policy on resident mail.
3.Director of Social Services in addition initiated calling the families of the cognitively impaired patients to ensure that they have no issues with resident mail. (Completion date 09/28/2017)
C.Resident Mail policy was reviewed on 03/15/2017 and no changes were required.

1.A re-education of the facility policy on resident mail was initiated on 03/15/2017 by Facility Administrative assistant. ( Completion date 09/28/2017)

2.Recreation Therapy will receive all mail from the front desk receptionist the day it arrives to the facility, as long as the mail delivered the next morning.
In serviced consists of:
- The Director of Social Services continues to forward the mail to the families of cognitively impaired residents.
Director of Social Services is well aware of patient mail delivery process and that the mail which is addressed
to the patients should not be opened.

- All resident mail will remain unopened until the resident receive it.
- Mail for the hospitalized patients will be held pending resident disposition.
- Recreation Staff will deliver all mail in a timely fashion each day and ask resident if they need any help opening
and/ or reading their mail/packages.
- Recreation staff may open resident mail ONLY if the resident asks them to and only in their presence.

2.In addition Administrative Assistant from another paragon facility who trained the front desk Receptionist was educated on the facility policy on 08/15/2017 by the Administrator. Administrative Assistant at our facility is aware of the facility policy on resident mail.
3.All the new hire staff involved in resident mail delivery will be in-serviced on the day of orientation by the Administrative Assistant.
D.Director of Recreation/Designee initiated check the resident mail on a daily basis and if any resident personal mail found open prior to deliver to the patient will be reported to the Administrator immediately for further investigation to ensure in any breach in facility policy.

1.Mail for the hospitalized patient will be held until their return or mail to the patient family if the patient is cognitively impaired.

2.Director of Recreation/ Designee will report any negative finds at the Quarterly QA meetings until 100% compliance achieved.
E.Person responsible for the correction is Director of Recreation/ Designee