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Based on interview and record review the Governing Body failed to oversee the contracted services of transportation and dietary for the Partial Hospitalization Program. The hospital failed to maintain personnel files for contracted dietary and transportation services. The hospital failed to ensure the contracted dietary personnel were following hospital policies (Refer to A620, A628, and A631).

Findings include:

The Administrator acknowledged 9/20/12 at 9:40 a.m. that Dietary and Transportation are contracted services at the Partial Hospitalization Program. The Administrator stated the hospital does not keep personnel files for these employees since it is a contracted service.

Record review of a policy titled "Organization of Administrative Management Services" dated 02/03 stated "Purpose: To ensure that the Hospital is managed effectively and efficiently and to identify services coverage and coordination activities....Overall responsibility for the conduct of the facility rests with the governing body."

Record review of a policy titled "New Employee Orientation Program" dated 03/03 stated "A New Employee Orientation Program shall be held once a month which all new employees are required to attend..."

Based on observation, interview and record review the Hospital failed to document if patients in the Partial Hospitalization Program were given a choice to use "Intracare Community Pharmacy" or a pharmacy of the patients choice.

Findings include:

Observation 9/19/12 at 10:30 a.m. at the Partial Hospitalization Program revealed two medication rooms. Each room contained numerous patient prescription bottles. The majority of the prescriptions came from a pharmacy named "Intracare Community Pharmacy."

Interview 9/19/12 at 1 p.m. with patient ID# 26 revealed that when she was first admitted to the Partial Hospitalization Program the "Nurse" took care of all her prescription needs. The patient does not recall being offered a choice of which pharmacy she would like to use for her prescriptions. The patient stated that the hospital keeps their prescriptions bottles so she was not aware what pharmacy filled her prescriptions.

Record review of 5 patient records at the Partial Hospitalization Program (ID#'s 25, 26, 27, 28 and 29) revealed no documentation regarding what pharmacy the patients chose to get their prescriptions filled.

The Pharmacist (ID# 85) at Intracare Community Pharmacy provided the surveyor 9/20/12 at 9:20 a.m. with a list of patients receiving prescriptions at the Partial Hospitalization Program. The list contained a total of 148 patients the pharmacy is currently serving at the PHP.

Record review of the hospitals "Patient's Bill of Rights" revealed "Basic Rights for All Patients: 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation. 6. You have the right to be told in advance of all estimated charges being made, the cost of services provided by the hospital, sources of the programs's reimbursement..."

Based on interview and record review, the facility failed to ensure that that medical records were accurately written and promptly completed for 8 of 36 sampled patients (Patient ID # 1, # 2, # 22, # 24 (inpatients) and Partial hospitalization program: (outpatients): (Patient ID# ' s 25, 26,27 and 28)

Inpatients:

Patient # 1: Observation records (2) not complete; physician orders not dated (2)

Patient # 2: Observation records not complete; an original order for " Sexual Acting Out " (SAO) precautions was omitted.

Patient # 22: incomplete medical screening exam; observation record incomplete.

Patient # 24: History & Physician exam had conflicting dates on the same document; one date had been altered and was illegible.

Partial hospitalization patients (outpatients):

Record review of 4 of 5 medical records reviewed at the offsite Partial Hospitalization Program revealed physician orders failed to include the time the order was written by the physician. (Patient ID# ' s 25, 26, 27 and 28)

Findings include:

Inpatients:

Patient # 1:

Record review on 09-18-12 of Patient #1 ' s clinical record revealed he was 9 years old and admitted to the facility on 07-09-12 with chief complaint of " I was angry and throwing stuff. " Further review read " 9 year old in protective custody admitted because of severe mood swings, agitation, and aggression that has been going on for weeks. The patient reportedly had been attacking his siblings and also had been trying to stab the foster mom. "

Review of facility form titled " Observation Record q (every) 15 Minutes " , dated 07-12-12 for Patient # 1 failed to indicate the patient was placed on SAO observation. The form has a " check box " for different types of observation precautions, including SAO. The SAO box was not checked. Review of physician orders revealed Patient # 1 had been placed on SAO precautions on 07-12-12.

Review of the physician orders for Patient # 1 revealed two (2) physician orders that had times but no dates. There were notations by the nursing staff of ' 24 hour chart check " on 07-12-12 and 07-13-12 " that correspond to the orders; however, the physician failed to date the orders.

Interview on 09-20-12 at 11: 30 a.m. with the Director of Nursing (DON), she stated the physicians are expected to date the orders. She further stated the facility had recently implemented a pre-printed " order set ' to facilitate physician ordering of precautions that included spaces for date and time.

Record review on 09-20-12 of the facility " Medical Staff Bylaws/ Rules & Regulations, " (Rules/Regs, # 11): Orders: :, " ...all orders for treatment and medication must be in writing and signed, dated, and timed by the physician ... "

Patient # 2

Record review on 09-18-12 of Patient # 2 ' s clinical record revealed he was 10 years old and voluntarily admitted to the facility on 07-04-12 with chief complaint of " suicide attempt :took Mom ' s Depakote and Synthroid. " Patient# 2 had a history of Bipolar Disorder, Severe Depression, and Impulse Control Disorder. Initial database/psychosocial history, dated 07-04-12 read: " pt has extensive history of aggression and mood swings for several years ... " " pt assaultive towards mother ... "

Review of Patient # 2 ' s physician orders revealed an order dated 07-09-12 that read " renew SAO related to sexually acting out. " Further review of the physician orders failed to reveal an original order for SAO precautions.

Interview on 09-20-12 at 11: 30 a.m with DON, she was unable to locate the original order for the SAO precautions. The DON stated the nurses will sometimes place the patients on SAO precautions as a nursing judgment depending on the current situation. Nurses notes dated 07-08-12 documented Patient # 2 was placed on SAO precautions. The DON went on to say that a follow-up physician order for SAO was usually obtained by nursing.

Review of facility policy titled " Special Observation Record, " revised 02/11, read: " Policy: Special observation record shall be initialed when a patient is placed on special precautions per a physician order or under the direction of the registered nurse with subsequent authorization from the physician ... "

Review of facility form titled " Observation Record q (every) 15 Minutes " , dated 07-09-12 for Patient # 2 failed to indicate the patient was placed on SAO observation. The form has a " check box " for different types of observation precautions, including SAO. The SAO box was not checked. Review of physician orders revealed Patient # 2 had been placed on SAO precautions on 07-09-12.

Patient # 22:

Record review on 09-19-12 of Patient # 22 ' s clinical record revealed he was 39 years old and was voluntarily admitted to the facility on 08-25-12 for severe depression. He was suicidal and reported feelings of hopelessness. Patient # 22 had a history of Human Immunodeficiency Virus (HIV) and Hypertension.

Review of facility Incident/Occurrence Log for 2012 revealed an incident of alleged " sexual acting out " between Patient # 22 and Patient # 24.

Review of facility form (Patient # 22) titled " Initial Medical Screen, " dated 08-25-12, revealed a section titled " Sexual Acting Out. " The following 4 questions were left blank and unanswered: " Does the patient exhibit seductive behaviors? Does the patient put self at risk for sexual victimization? Is there a recent history of sexual offenses (rape)? and Does the patient have a history of sexual perpetration? Based on this screen, Patient # 22 was documented / assessed as being " Low Risk " for Sexually Acting Out.

Interview on 09-20-12 at 11: 30 a.m with the DON she stated the expectation was that staff complete every question on the initial screening sections located on the Medical Screening Form. She went on to say this form was completed on admission by the Intake RN.

Review of facility form titled " Observation Record q (every) 15 Minutes " , dated 08-29-12 for Patient # 22 failed to indicate the patient was placed on SAO observation. The form has a " check box " for different types of observation precautions, including SAO. The SAO box was not checked. Review physician orders revealed Patient # 22 had been placed on SAO precautions on 08-29-12.

Review of facility policy titled " Special Observation Record, " revised 02/11, read: " ...Procedure: ...2 Fill in the top portion of the Special Observation Record ... ...2.3 Type of Observation (suicide, assaultive,, etc ...) ... "

Patient # 24

Record review on 09-19-12 of Patient # 24 ' s clinical record revealed he was 40 years old and was involuntarily admitted to the facility on 08-26-12. He was brought to the hospital by the police following an argument with a family member. Patient # 24 had a history of psychosis and cocaine abuse. He was discharged with Schizoaffective Disorder.

Further review of Patient 24 ' s clinical record revealed a six (6) page History & Physical (H & P) Exam documented by the physician. The physician ' s signature and date on the last page of the H & P was timed and dated as follows: " 08-27-12 at 8: 00 a.m. " On the first page of the H & P there was a date at the top of the page that had been altered. It appeared to have originally been dated 8-27-12. This date was written over and was changed to possibly 08-28-12.

Interview on 09-20-12 at 11: 30 a.m. with the DON she stated " I think he added an important notation and changed the date. " She went on to say the physical was new and not accustomed to working in an in-patient setting "




12000


Based on record review of 4 of 5 medical records reviewed at the offsite Partial Hospitalization Program revealed physician orders failed to include the time the order was written by the physician. (Patient ID# ' s 25,26,27 and 28)
Findings include:
Record review revealed the following:
Patient ID# 25: The following dates failed to list the time the physician wrote the order: 6/18/12; 6/21/12; 6/26/12; 7/3/12; 7/10/12; 7/27/12; 7/30/12; 8/1/12; 8/30/12 and 9/17/12.
Patient ID# 26: The following dates failed to list the time the physician wrote the order: 7/26/12; 8/5/12; 8/27/12 and 8/30/12.
Patient ID# 27: The following dates failed to list the time the physician wrote the order: 8/8/12; 8/30/12; 8/28/12; 9/4/12; 9/11/12; 9/13/12 and 9/17/12.
Patient ID# 28: The following dates failed to list the time the physician wrote the order: 6/26/12; 7/16/12; 7/22/12; 7/31/12; 8/8/12; 8/31/12; 9/4/12; 9/11/12 and 9/17/12.
Record review on 09-20-12 of the facility " Medical Staff Bylaws/ Rules & Regulations, " (Rules/Regs, # 11): Orders: :, " ...all orders for treatment and medication must be in writing and signed, dated, and timed by the physician ... "

Based on observation, interview and record review the Hospital failed to ensure that patients leaving the Partial Hospitalization Program each day had prescription bottles with proper labeling of medications.

Findings include:

Tour of the Partial Hospitalization Program (PHP) 9/19/12 at 10:30 a.m. revealed two secured medication rooms where patients prescription bottles were kept and monitored by staff members. Observation at this time revealed that numerous patient bins had a small plastic bag attached to the front of each bin with various pills inside. The plastic bags were not labeled with the name of the medications.

The Nursing Director of the Partial Hospital Program (ID# 81) acknowledged at this time that the the PHP supervises self administration of medication by patients. The Director explained that patients are not allowed to take their prescription bottles home each day so therefore the patients place the medications they need for that evening in unlabed plastic bags to take home. All patients labeled prescription bottles are kept in locked medication storage rooms at the Partial Hospitalization Program.

Interview 9/20/12 at 11:25 a.m. with the Director of Pharmacy (Pharmacist ID# 86) for the hospital revealed she does not oversee or supervise the drug storage areas of the Partial Hospitalization Program. The Pharmacist acknowledged that medications should not be kept in unlabeled plastic bags because "you have to be able to identify the medications."

Record review of a policy titled "Scope of Pharmacy Services" dated 05/06 stated "The Director of Pharmacy Service shall be responsible for: b. The monthly inspection of all pharmaceutical supplies on all services. This may be done by a technician under direct supervision of the pharmacist..."

Based on observation, interview and record review the Hospital failed to ensure the Food Service Supervisor (ID# 69) managed the offsite Partial Hospitalization Program. Food and refrigerator temperatures were not being documented per policy. Food once opened was not dated. Chlorine levels in the manual dishwasher sink were not documented.

Findings include:

Tour 9/19/12 at 10:30 a.m. of the offsite Partial Hospitalization Program (PHP) revealed the following:
-Ice scoop on top of the ice-machine was not in a draining position
-A refrigerator was used for storing food products but no temperature log was kept by contract staff
-A sliced ham, cheese slices and lunch meat were observed in the refrigerator. Each item had been previously opened and they were not dated as to when they were first opened
-A metal tray of Salisbury Steak was covered with tin-foil wrapped around it and it was not dated as to when it was first placed in the refrigerator
-Pots and knives were observed in a three compartmental sink. No dishwasher was observed.

Interview at this time with a contract staff member working in the kitchen (ID# 80) confirmed that the dietary department does not monitor the temperature of the refrigerator. The dietary member acknowledged that all food items should have been dated once opened. The staff member stated that the staff check the chlorine levels in the three compartmental sink using test strips but the staff do not document if the chlorine level is appropriate for sanitizing.

Interview 9/20/12 at 1:45 p.m. with the primary Food Service Supervisor (ID# 69) of the hospital revealed she does not oversee or manage the dietary department at the offsite Partial Hospitalization Program. The Food Service Supervisor was told that dietary services at the offsite location were contracted and she did not need to worry about it.

Record review of a policy titled "Director of Support Services" (no date) stated "Directs and coordinates food production and service; and central supply procurement and handling activities for the hospital by performing the following duties personally or through subordinates to include staffing, training and development, communications and documentation to insure that patient needs are met as a reasonable cost while meeting and / or exceeding regulatory guidelines."

Record review of a policy titled "Food Storage" dated 06/03 stated "All leftover items are covered, labeled and dated. Perishable storage: Thermometer in all refrigerators and freezers for monitoring purposes; temperatures are documented daily and deviations from standards are immediately reported to the Supervisor, Director and / or Plant Operations."

Record review of a policy titled "Sanitation - Utensils" dated 06/03 stated "Manual Dishwashing - Chemical Method: chlorine or iodine can be added to the final rinse compartment as a sanitizing agent. chlorine levels should be maintained at a level of 50-100 ppm; iodine levels should be maintained at 12.5-25 ppm. Chemical levels should be tested intermittently with the proper chemical test strips to ensure proper chemical levels."

Based on observation, interview and record review the Hospital failed to ensure the offsite Partial Hospitalization Program (PHP) dietary department had menus.

Findings include:

Tour 9/19/12 at 10:30 a.m. of the offsite Partial Hospitalization Program (PHP) revealed a kitchen area where food was being prepared for patients. No menus were posted.

Interview at this time with a contract dietary staff member (ID# 80) at the PHP revealed that the dietary department did not have menus. The dietary staff member did not have any menus to follow in preparing the meals for the patients.

Record review of a policy titled "Patient Menus" dated 06/03 stated "Policy: Patients will receive adequate nutritious meals utilizing at least a three week rotating menu cycle. The rotating menu cycle is written in conformance with accepted dietary standards and current nutritional guidelines."

Based on observation, interview and record review the Hospital failed to ensure the offsite Partial Hospitalization Program (PHP) dietary department had a diet manual available to contracted food service personnel.

Findings include:

Tour 9/19/12 at 10:30 a.m. of the offsite Partial Hospitalization Program (PHP) revealed a kitchen area where food was being prepared for patients.

Interview at this time with the Food Service Supervisor (ID# 80) at the PHP revealed that the kitchen staff were contracted employees. The Food Service Supervisor stated that the dietary department did not have a therapeutic diet manual.

Record review of a policy titled "Diet Manual" dated 06/03 stated "Diet Manual Policy: An approved diet manual will be available in the dietary services department and at each nursing unit..."