HospitalInspections.org

Based on review of the facility's policies/procedures, Governing Board By-Laws, documents, and interviews, it was determined that a copy of the contracted facility's food license was current and maintained.

Findings include:

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...Article XII...Review of Documents...Section 2...Professional Service Contracts...Governing Board shall review at least annually... (i) the quality of services rendered by...other professional service contractors...(ii) the need for and selection of such...professional service contractors...Governing Board shall also review and make recommendations on any contractual matter...."

Document named "Contract List" (printed 12/15/2020), revealed no documented evidence that Sunridge Village was listed.

Documents titled "Talas Harbor, Governing Board, Meeting Minutes Record", dated 11/12/2020, and 12/09/2020, revealed no documented evidence that the Governing Board approved the contract/agreement with Sunridge Village Assisted Living, to provide food and snacks for the patients.

The contract/agreement for Sunridge Village Assisted Living, providing food services, was requested 12/16/2020 (1630), and an unsigned, incomplete draft contract/agreement was provided via email on 12/17/2020 (0746). Additionally, the date on the contract/agreement showed the date 09/01/2020 of when the contract/agreement was to begin.

The food license for Sunridge Village Assisted Living was requested on 12/16/2020 (1645), and none was provided prior to exit on 12/17/2020 (0830).

Personnel #1 and Personnel #2 both confirmed during a combined interview conducted 12/16/2020 (1700), that Sunridge Village Assisted Living has been providing food services for the patients for several months. Additionally, Personnel #1 and Personnel #2 both revealed that there was no documented evidence that a contract/agreement for Sunridge Village Assisted Living had been reviewed and approved by the Governing Board, and that the facility did not have a copy of the food license.

Based on review of the facility's policies/procedures, documents, medical records, personnel files, and interviews, it was determined that the Governing Body failed to meet the following standards for the Governing Body condition and three (3) additional Conditions were not met.

(A0057) failed to appoint the Executive Director. This deficient practice poses a risk to the health and safety of patients, when the Executive Director is not appointed to oversee the day-to-day functions of the facility which directly impacts patient services; and

(A0083) failed to require that all services provided by a vendor had a written contract/agreement, and that all contracts/agreements had been approved by the Governing Board. This deficient practice poses a risk to the health and safety of the patients, when there is no review of a contract/agreement ensuring the vendor is in full compliance with all State, Federal and Local Laws.

Condition Level Deficiencies:

(A0263) failed to require that a Quality Management (Performance Improvement) process was implemented and reports were submitted to the Governing Board identifying concerns specific to the delivery of hospital services and/or environmental services related to patient care. This deficient practice poses a risk to the health and safety of the patients, when the Governing Board fails to oversee and/or identify areas of concern affecting patient care; and

(A-0652) failed to establish a Utilization Review Committee as required in the Governing Board By-Laws and Medical Staff Rules and Regulations. This deficient practice poses a risk to the health and safety of the patients, when there is no Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge; and

(A-0747) failed to require that the infection control preventionist was recommended by the Medical Staff and approved by the Governing Board, quarterly written reports on Infection Control were reported to the Quality/Performance Improvement Committee and forwarded to the Governing Board .

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Governing Body, which poses a potential risk to the health and safety of patients when the facility fails to ensure that the Executive Director and Infection Control Preventionist were approved by the Governing Board. Additionally, the Governing Board's failure to require: submission of a quality report to the Governing Board, contract approval, Utilization Review Committee performance, and appointment of a healthcare provider. Additionally, Talas Harbor at Bullhead City has corporate representatives that actively participate in the Governing Board meeting, however Talas Harbor at Bullhead City has not held Horizon Health accountable for the multiple deficiencies or failures.

Based on a review of documents and interview, it was determined the Governing Body failed to ensure implementation and maintenance of the Quality Management (Performance Improvement) was effective, ongoing, representing hospital-wide quality assessment and performance improvement.

(A0273) facility failed to require that a Quality Management (Performance Improvement) process was implemented and reports were submitted to the Governing Board identifying concerns specific to the delivery of hospital services and/or environmental services related to patient care. This deficient practice poses a risk to the health and safety of the patients, when the Governing Board fails to oversee and/or identify areas of concern affecting patient care.

The cumulative effect of the systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Quality Assurance and Performance Improvement, which poses a potential risk to the health and safety of patients when the facility fails to ensure quality indicators are being monitored and acted upon.

Based on a review of documentation and interviews, it was determined the Governing Body failed to have in place an effective utilization review plan that provided for review of services provided by the institution and the members of the medical staff to patients.

A-0654 a Utilization Review Committee was not established as required in the Governing Board By-Law and Medical Staff rules and Regulations. This deficient practice poses a risk to the health and safety of the patients, when there is no Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

The cumulative effect of the systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Utilization Review, which poses a potential risk to the health and safety of patients when the facility fails to ensure appropriate utilization evaluation is ongoing for patients and reported to the Governing Body.

Based on review of the facility's policies/procedures, documents, personnel files, and interviews, it was determined that the Governing Body failed to require that:

(A0748) the Infection Control Preventionist was recommended by Medical Staff, and approved by the Governing Board;

(A0749) the Infection Control Committee provide a quarterly written report to the Quality/Performance Improvement Committee, which would then include the report to the Governing Board. This deficient practice poses a risk to the health and safety of patients, when infection control data is not reviewed at least quarterly to identify any trends or concerns that might negatively affect patient care, and that the data is not shared with the Medical Staff or Governing Board; and

(A0776) staff had an annual or on-hire tuberculosis screening completed. This deficient practice poses a risk to the health and safety of the patients, when staff have not been screened for tuberculosis, allowing the potential of tuberculosis exposure.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Infection Control, which poses a risk to the health and safety of patients, when the facility fails to ensure tuberculosis screening is monitored, and that infection control reports providing data are submitted in the required time frame.

Based on review of the facility's policies/procedures, documents, personnel files, and interviews, it was determined that CPR certification required for direct patient-care staff was not maintained or in compliance with COVID-19 guidance published by the American Heart Association. This deficient practice poses a risk to the health and safety of the patients, when staff providing direct patient-care are not current or competent in basic life saving measures.

Findings include:

Policy titled "Orientation of New Employees and Checklist" (#HR001; 05/2020), revealed: "...Purpose...to provide the staff with guidelines for orienting...orientation of all full-time and part-time employees...is coordinated through the Executive Director and Nurse Manager...orientation of on-call, float, and agency staff is arranged...between the Nurse Manager and staff member...supervision and recording the progress that new employees make in performing skills critical to their position will be documented and maintained...Initial orientation of all unit staff includes...CPR certification requirement (all nursing staff must obtain CPR certification)...."

Policy titled "CPR & First Aid Requirements" (#HR004; 05/2019), revealed: "...To define the requirements for staff to be certified in CPR...it is the policy of Talas Harbor...that all clinical staff are required to be trained in CPR...every two (2) years...it is staff's responsibility to renew their CPR every two (2) years and provide an approved CPR card identifying the course provider and date of training for their employee file...if staff go past their expiration date for CPR...staff will not be able to work the unit do to safety reasons...staff member will be placed on a leave of absence until CPR...is current...CPR certification that includes an on-line knowledge component yet still requires an in-person demonstration and skills assessment to obtain certification or recertification is acceptable...."

Document review of "Personnel Files" conducted 12/16/2020, revealed the following specific to CPR:

i. Personnel #15, Personnel #16, and Personnel #21, had on-line issued CPR certifications (not skills demonstrated);
ii. Personnel #3, and Personnel #23, had no documented evidence of current CPR certification.

Document review of "Nursing Schedule" (November - December 16, 2020), revealed the following worked shifts.

i. Personnel #3 - worked thirty-one (31) shifts with no evidence of a current CPR;
ii. Personnel #15 - worked twenty-four (24) shifts with no evidence of a current skills demonstrated CPR;
iii. Personnel #16 -worked twenty (20) shifts with no evidence of a current skills demonstrated CPR;
iv. Personnel #21 - worked twenty (20) shifts with no evidence of a current skills demonstrated CPR;
v. Personnel #23 - worked eighteen (18) shifts with no evidence of a current CPR.

Personnel #2 confirmed during an interview conducted 12/16/2020 (1625), that Personnel #15, Personnel #16, and Personnel #21, had CPR certifications that were obtained on-line and that Personnel #3, and Personnel #23, had no evidence of CPR in their personnel records. Personnel #2 revealed that CPR certification is required to have a skills demonstrated component. Additionally, Personnel #2 confirmed that Personnel #3, Personnel #15, Personnel #16, Personnel #21, and Personnel #23, are all considered clinical staff.

Personnel #4 confirmed during an interview conducted 12/16/2020 (1550), that Personnel #3, Personnel #15, Personnel #16, Personnel #21, and Personnel #23, are all considered clinical staff, providing direct patient-care, and had worked their assigned shifts on the November - December 16, 2020 schedules.

Based on review of the facility's Governing Board By-Laws, Governing Board Meeting Minutes, and interviews, it was determined that the Governing Board failed to appoint the Executive Director. This deficient practice poses a risk to the health and safety of patients, when the Executive Director is not appointed to oversee the day-to-day functions of the facility which directly impacts patient services.

Findings include:

Document titled "Talas Harbor, Governing Board Member's Responsibilities" (no date), revealed: "...Governing Board bears a legal responsibility to govern an organization...Executive Director...Selecting, Supporting, Reviewing...the board is responsible for vetting and selecting Executive Director candidates and selecting a qualified candidate from the pool of applicants...once the Executive Director has been appointed, the board will work collaboratively with him/her to carry out organizational plans...."

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Article VIII...Governing Board Operation...Section 1...General Functions...the Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Directors...Governing Board shall delegate responsibility and authority for the day-to-day management of the Hospital to the Hospital Senior Executive Officer...Article IX...Chief Executive Officer...Section 1...Appointment...Board of Directors or its designee shall appoint a chief executive officer of the hospital (referred to herein as the "Hospital Senior Executive Officer" in accordance with such criteria as may be adopted by the Board of Directors subject to approval by the Governing Board...."

Document (untitled) of Talas Harbor's Organizational Chart (current as of 12/14/2020), revealed the name of Personnel #1, as the Executive Director of Behavioral Health, with no other person identified for this person to report to.

Documents titled "Talas Harbor, Governing Board, Meeting Minutes Record", dated 11/12/2020, and 12/09/2020, showed no documented evidence of Personnel #1 being appointed to the position of Executive Director by the Governing Board.

Personnel #1 confirmed during an interview conducted 12/14/2020, that s/he officially started in the position of Executive Director on 11/02/2020.

Personnel #1 and Personnel #2 both confirmed during an interview conducted 12/16/2020 (1655), that the facility had no other documentation to confirm the Governing Body's appointment of Personnel #1 to the position of Executive Director.

Based on review of the facility's Governing Board By-Laws, Governing Board Meeting Minutes, documents, and interviews, it was determined that all services provided by a vendor had a written contract/agreement, and that all contracts/agreements had been approved by the Governing Board. This deficient practice poses a risk to the health and safety of the patients, when there is no review of a contract/agreement ensuring the vendor is in full compliance with all State, Federal and Local Laws.

Findings include:

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...Article XII...Review of Documents...Section 2...Professional Service Contracts...Governing Board shall review at least annually... (i) the quality of services rendered by...other professional service contractors...(ii) the need for and selection of such...professional service contractors...Governing Board shall also review and make recommendations on any contractual matter...."

Document named "Contract List" (printed 12/15/2020), revealed no documented evidence that Sunridge Village Assisted Living or Sharp's Compliance, Inc. was listed. Additionally, Western AZ Regional Medical Center was still listed as providing daily meals and snacks for the patients.

Documents titled "Talas Harbor, Governing Board, Meeting Minutes Record", dated 11/12/2020, and 12/09/2020, showed no documented evidence that the Governing Board approved the contracts/agreements with Sunridge Village Assisted Living (food services) or with Sharps Compliance, Inc. (biohazard waste removal).

The contract/agreement for Sunridge Village Assisted Living, providing food services for the patients was requested 12/16/2020 (1630), and an unsigned, incomplete draft contract/agreement was provided via email on 12/17/2020 (0746). Additionally, the date on the contract/agreement showed the date 09/01/2020 of when the contract/agreement was to begin.

The contract/agreement for Sharps Compliance, Inc. providing biohazard waste removal, was requested on 12/15/2020 (1350), and a "Manifest Detail Report Invoice" (11/19/2020) was provided.

Personnel #1 and Personnel #2 both confirmed during a combined interview conducted 12/16/2020 (1700), that Western AZ Regional Medical Center has not been providing food services to the facility for several months, and that Sunridge Village Assisted Living is now providing food services for the patients. Additionally, Personnel #1 and Personnel #2 both revealed that there was no documented evidence that contracts/agreements for Sunridge Village Assisted Living or Sharp's Compliance, Inc. had been reviewed and approved by the Governing Board.

Personnel #10 confirmed during an interview conducted 12/16/2020 (1015), that the only documentation s/he had regarding biohazard waste removal was an invoice from Sharps Compliance, Inc., dated 11/19/2020.

Based on review of the facility's Governing Board By-Laws, documents, and interviews, it was determined that Governing Board failed to ensure Quality Management (Performance Improvement) reports were submitted to the Governing Board identifying concerns specific to the delivery of hospital services and/or environmental services related to patient care as evidenced by:

1. Monitor the contract for the management and operations of the hospital Talas Harbor at Bullhead City; and
2. Quality Management (Performance Improvement) reports were not submitted to the Governing Board identifying concerns specific to the delivery of hospital services and/or environmental services related to patient care. This deficient practice poses a risk to the health and safety of the patients, when the Governing Board fails to oversee and/or identify areas of concern affecting patient care.
This deficient practice poses a risk to the health and safety of the patients, when the Governing Board fails to oversee and/or identify areas of concern affecting patient care.

Findings include:

1. The reviewed documents revealed there was a signed Service Agreement with Horizon Mental Health Management, LLC d/b/a Horizon Health Behavioral Health Services effective 04/28/2020, and signed 05/13/2020 by both parties, for Horizon Health to provide certain management services of the "psychiatric" hospital. To provide, in consultation with Horizon, dietary, pharmacy, therapy, nursing, clerical, medical administration direction, housekeeping, plant operations, human resources/physician credentialing, and other required support staff necessary to operate the Program, including but not limited to, nurses, psychiatric technicians, infection control RN, medical director(s), nurse practitioner(s), master level therapists, activity/recreational therapist, unit clerk, medical records and/or information technology staff, billing, financial, and dietary staff. Hospital's nursing, therapy, secretarial, clerical, and other support staff working in the Program, to receive onsite training by Horizon. Provide all hospital and Horizon employees working in the Program all necessary pre-employment and periodic health screening examinations and vaccinations as required. Provide the Program staff: Executive Director (1), Community Education Manager (1), Nurse Manager (1), Chief Nursing Officer (1), Program Secretary (1). On the first working day of the month, a hospital representative shall meet with a Horizon representative to sign and approve an Accounts Receivable Report for the prior month.

There was no documented evidence the Governing Board monitored the activities of Horizon Health. The Governing Body minutes revealed no documentation of indicators for the contracted agency and there was no documentation provided by Horizon Health of the quality program that they had implemented. There were no reports of committee, nursing, and no quality reports.

The following areas of process and systems were identified during the survey where there were failures to policy and/or procedure and there was no documentation of identification by the management team and therefore not reported to the Governing Board.

There was no documentation the Governing Board held the contracted management team accountable to monitor the activity for credentialing the medical staff to ensure appropriate credentialing and privileging was completed and approved by the Governing Board. Refer to Tag 0341

There was no documented evidence the Governing Board held the contracted management team accountable to monitor the staffing needs and the compliance with the policy and procedure for identification of patient needs through the acuity plan required by the hospital. Refer to Tag 0392.

There was no documented evidence the Governing Board held the contracted management team accountable to ensure orientation of new hires providing patient care services, was completed and/or maintained in the personnel files. Refer to Tag 0398

There was no documented evidence the Governing Board held the contracted management team accountable to ensure nursing assessment were being completed as required by hospital policy and procedure as required by hospital policy and procedure. Refer to Tag 449

There was no documented evidence the Governing Board held the contracted management team accountable for the monitoring the process for authenticating telephone orders by the medical staff as required by the Medical Staff Bylaws. Refer to Tag 0454

2. Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...Article VIII...Governing Board Operation...Section 5...Performance Improvement (PI)...Governing Board shall require...Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care...identifying and resolving problems...Governing Board...shall support these activities...shall provide for resources and support systems for the quality assessment and improvement...related to patient care and safety...if necessary, act upon the results reports from PI activities...implementation of corrective action when problems or opportunities for improvement are identified...."

Document titled "Patient Safety Meeting Minutes" (11/12/2020), revealed the following: Patient Incidents - Patient Falls - approve for a Fall Committee daily.

Document titled "Medical Executive Meeting Minutes" (11/12/2020), revealed the following: Reports from Standing Committees/Quality & Performance Improvement - Quality & Performance Improvement- Provider progress notes being completed timely with CPT codes/notes per visit; Medicare Cert's and Re-Cert's to be emailed/faxed to Provider #1 upon admission and to be signed and returned.

Document titled "Governing Board Meeting Minutes" (11/12/2020), revealed the following: Call to Order & Approval of Agenda - Agenda - Committee Reports (no notes); Committee Reports - no performance improvement reports listed.

Document titled "Governing Board Meeting Minutes" (12/09/2020), revealed the following: Call to Order & Approval of Agenda - Agenda - Committee Reports (no notes); Nurse Clinical Report (N/A); Committee/Reports - will be presented at the next quarterly meeting.

Document titled "Talas Harbor Performance Improvement Initiatives" (no date), revealed the following goals: Compliance completing suicide risk assessment; Restraints; Seclusion; Falls; Clinical Quality Indicators (CQI for Horizon Management Company/Mental Health Outcomes); Critical Lab Results; Pharmacy Overall Cost; Linen Turnaround Time; Food Services; Dietician; Radiology Reports. Statement at end of document reads: The above data is reported quarterly in the PI Meeting.

Document titled "Talas Harbor Performance Improvement (PI) Plan" (Rev. 06/14/2020), revealed: "...purpose of the plan is to ensure the delivery of quality care to all patients...through consistent monitoring of the clinical services...activities of the PI Plan are reported at least quarterly...the Governing Board of Talas Harbor has authorized the Executive Director to implement and monitor the PI Plan...Executive Director or designee is responsible for facilitating the completion of PI activities...Executive Director shall have overall responsibility for the implementation of the PI plan...as part of the overall PI program, the hospital will conduct performance improvement projects...the number and scope of distinct improvement projects is conducted annually must be proportional to the scope and complexity of the hospital services and operations...Talas Harbor...will document what quality/performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects...PI indicators will be reviewed at least quarterly in the Committee-of-the-Whole (COW) meeting...."

Document titled "Falls Log" (2020), revealed the following:

i. Falls Log was hand-written, with falls occurring 08/2020 - 12/2020;
ii. Fall Log had three (3) falls listed for 08/23/2020, 08/27/2020, and 08/31/2020 (Q3);
iii. Two (2) of three (3) falls occurring in 08/2020 were for the same patient.

Personnel #1 confirmed during an interview conducted 12/16/2020, that the document titled "Talas Harbor Performance Improvement Initiatives" (no date), was reviewed at the Medical Executive Meeting (11/12/2020), and that the performance improvement goals, and indicators were reviewed, but that there was no data provided. Additionally, Personnel #1 revealed that there was no quality or performance improvement report reviewed at the 11/12/2020 or 12/09/2020 Governing Board meeting.

Personnel #2 confirmed during an interview conducted 12/16/2020, that the facility had no document evidence of a written quality or performance improvement report that had been provided to the Governing Board for review from 07/2020 - 12/2020 (Q3 and Q4)).

Personnel #3 confirmed during an interview conducted 12/15/2020 (1401), that due to the recent change of leadership at the facility, the Quality/PI Committee has not yet met, and that the facility is required to follow Horizon Health Management's Continuous Quality Improvement (CQI) methodology for tracking and submitting data. Additionally, Personnel #3 revealed that s/he is not certain of all of the indicators being tracked at the facility and/or, if all departments at the facility are participating.

Personnel #4 confirmed during an interview conducted 12/15/2020 (1415), that s/he was not aware of any Quality/PI report that was submitted to the Governing Board which included the three (3) falls occurring in Quarter 3.

Based on review of the facility's Governing Board By-Laws, Medical Staff By-Laws & Rules and Regulations, credential files, documents, and interviews, it was determined that a healthcare provider, providing and over-seeing patient care, was properly appointed by the Medical Staff and Governing Board. This deficient practice poses a risk to the health and safety of the patients, when the healthcare provider is practicing medicine without the required approval or authorization required by the Medical Staff and Governing Board.

Findings include:

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...Article IV...Organization of the Medical Staff...Governing Board shall organize the physicians and other practitioners granted clinical privileges at the Hospital...under Medical Staff By-Laws...Article V...Medical Staff Appointments, Reappointments, Clinical Privileges, Disciplinary Actions and Investigation...Section 1...Governing Board Authority...shall have authority and responsibility for all appointments and reappointments of Medical Staff member...is exercised in accordance with Medical Staff By-Laws & Rules and Regulations...Section 3...General Policy...Governing Board shall consider the Medical Staff recommendations in the exercise of the Governing Board's authority to appoint and reappoint members of the Medical Staff...Article VI...Medical Staff By-Laws...Medical Staff shall be governed by Medical Staff By-Laws, Rules and Regulations...."

Document titled "Talas Harbor, Medical Staff By-Laws" (05/2020), revealed: "...Article 6...Procedures for Appointment and Reappointment...6.1 General Procedure...Medical Staff...consider each complete application for appointment or reappointment...and transmit recommendations thereon to the Board...6.6...Provisional Status...6.6.1...Time Limitations...all initial appointments to the Medical Staff shall be provisional for six (6) months, and may be renewed for two (2) additional six (6) month periods at the discretion of the MEC...6.6.3...Initial Appointment Monitoring by Medical Director...each provisional appointee shall be observed by the Medical Director of the facility to determine his or her eligibility for regular staff membership...6.7...Reappointment Process...6.7.1...Reappointment Form...at least ninety (90) days prior to the expiration date of the present appointment...Executive Director shall provide...a reappointment/re-credentialing application form...failure to return the form shall be deemed a voluntary resignation from appointment...6.7.3...Verification of Information...6.7.5...Reappointment Applicant's Burden...6.7.6...MEC Review...6.7.7...MEC Action...6.7.8...Final Processing and Board Action...."

Personnel File review conducted 12/16/2020 (1400), revealed the following specific to Provider #5:

i. Governing Board appointment expired 07/29/2020;
ii. No current CPR on file.

Document review of Meeting Minutes, (08/2020 - 12/2020), revealed no evidence that Provider #5 was nominated, approved, and appointed at the following meetings:

i. Governing Board Meeting Minutes (08/07/2020 & 08/11/2020);
ii. Medical Executive Committee Meeting Minutes (08/13/2020);
iii. Medical Executive Committee Meeting Minutes (09/09/2020);
iv. Medical Executive Committee Meeting Minutes (10/14/2020);
vi. Medical Executive Committee Meeting Minutes (11/12/2020);
vii. Governing Board Meeting Minutes (11/12/2020);
viii. Governing Board Meeting Minutes (12/09/2020).

Document titled "Psychiatric Advanced Nurse Practitioner Job Description", revealed the following requirements: "...current ARNP License...current AZ RN license...current American Heart Association BLS certification...."

Documents titled "Provider Call Schedules" (08/2020 - 12/2020), revealed that Provider #5 was scheduled, and worked twenty-seven (27) shifts, with an expired appointment.

Personnel #25 confirmed during an interview conducted 12/16/2020 (1600), that the expired 07/29/2020 appointment of Provider #5, was the most current.

Personnel #4 confirmed during an interview conducted 12/16/2020 (1605), that to his/her knowledge, Provider #5 had worked the assigned shifts according to the "Provider Call Schedule" (08/2020 - 12/2020).

Personnel #1 confirmed during an interview conducted 12/16/2020 (1625), that the facility had no other appointment/reappointment documentation for Provider #5, and that the current appointment expired on 07/29/2020.

Based on review of the facility's policy/procedure, documents, and interviews, it was determined that Registered Nurses (RN's) were not knowledgeable about the acuity plan, which is the process utilized to determine the type and skill mix to meet the patient needs for nursing services. This deficient practice poses a risk to the health and safety of the patients, when the RN does not understand how the acuity plan should be utilized when determining patient assignments.

Findings include:

Policy titled "Staffing Summary and Plan for Acuity" (05/2020), revealed: "...primary focus of a patient...acuity system is to respond to the constant changing patient care needs on a clinical care unit, on a shift-by-shift basis...although formal acuity-based staffing systems are not required...THBHC decided to develop a formal approach to determining patient care needs to guide their daily staffing...this tool allows for identification of four (4) levels of patient acuity...Level 1...average hours of care = 2.0...Level 2...average hours of care = 3.0...Level 3...average hours of care = 3.5...Level 4...average hours of care = 24 hours or 8 hours/shift...nursing will measure workload demand of the patient population of each unit using a standardized too based on acuity and from those results implement staffing patterns designed to meet those needs with a qualifying workforce...RN Supervisor, in collaboration with the clinical staff will complete the acuity tool prior to 0600, 1400, and 2200 daily...the nursing-based acuity is collected and submitted to the CNO...or designee prior to 0600, 1400, and 2200 daily to ensure adequate staffing within the facility...all registered nurses will be trained on the use of the acuity tool during new hire orientation...RN's must be able to articulate how to use the tool, including how to document and score acuity for the patients...."

Document titled "Talas Harbor, Registered Nurse (RN), Job Description", revealed the following:

i. Primary Job Responsibilities -Specific to Charge Nurse position: completes the daily assignment sheets, insures that the unit is running smoothly throughout the shift, assisting staff on shift with all necessary requests;
ii. Acuity (knowledge, training, use of) not listed.

Documents titled "Talas Harbor at Bullhead City Patient Acuity System" (11/2020), were reviewed, and the following observations were made:

i. Forms incomplete (multiple areas);
ii. Unable to determine how staffing assignments were made based on acuity;
iii. Unable to determine the acuity score for each individual patient;
iv. Number of required staff (RN, LPN, MHT, Unit Secretary).

Personnel #7 confirmed during an interview conducted 12/14/2020 (1409), that s/he has had orientation, but has not been trained on acuity.

Personnel #6 confirmed during an interview conducted 12/14/2020 (1425), that s/he has had orientation, but cannot recall if s/he was trained on acuity. Additionally, Personnel #6 revealed that s/he is uncertain how to complete the acuity tool.

Personnel #3 confirmed during an interview conducted 12/14/2020 (1401), that s/he does not review the acuity tool before the start of each shift.

Personnel #4 confirmed during an interview conducted 12/15/2020 (1415), that a new acuity tool has been sent to Horizon Health (management company) for approval, and that s/he is currently waiting to hear back.

Personnel #14 confirmed during an interview conducted 12/16/2020 (0710), that the Charge RN is responsible for making the patient assignment, and that s/he has never been trained on how to use the acuity tool.

Based on review of the facility's policy/procedure, personnel files, and interview, it was determined that orientation of new hires providing patient care services, was not completed and/or maintained in the personnel files. This deficient practice poses a risk to the health and safety of the patients, when there is no documented evidence that a new employee has been trained, and his/her competency validated prior to participating in, or providing patient care.

Findings include:

Policy titled "Orientation of New Employees and Checklist" (#HR001; 05/2020), revealed: "...provide the staff with guidelines for orienting new employees...orientation of full and part-time employees is coordinated through the Executive Director and Nurse Manager...completion of the orientation program is required of all nurses and mental health technicians/aides and therapists for employment in the mental health area regardless of employment status...supervision and recording the progress that new employees make...will be documented and maintained...."

Personnel File review conducted 12/16/2020 (1400), revealed the following missing orientation documentation for the following: Personnel #3, Personnel #5, Personnel #7, Personnel #12, and Personnel #19.

Personnel #25 confirmed during an interview conducted 12/16/2020 (1600), that the orientation documentation for Personnel #3, Personnel #5, Personnel #7, Personnel #12, and Personnel #19, was unable to be located.

Personnel #2 confirmed during an interview conducted 12/16/2020 (1700), that the Personnel File documents (to include orientation competency), requested 12/16/2020 (1200), were unable to be located.

Tag0449
Based on review of the facility's policies/procedures, medical records, and interview, it was determined that nursing personnel failed to complete the nursing assessment, and reassessment for each patient, on each shift in 2 of 2 medical records reviewed. This deficient practice poses a risk to the health and safety of the patients, when nursing personnel fails to complete the required nursing documentation, thereby not being able to determine the patient's current physical or psychiatric status for a particular day and/or shift.

Findings include:

Policy titled "Nursing Admission Process" (#PC008; 05/2020), revealed: "...B...Every patient is to receive a Nursing Assessment upon admission...Assessment...A...completed within eight (8) hours of admission...completed by a RN...."

Policy titled "Reassessments" (#PC022; 05/2020), revealed: "...Purpose...To assure that patient assessment will be a continuous process from admission to discharge...C...Reassessments prompted by significant changes in the patient are documented in the progress notes...D...An RN reassessment is completed each shift not to exceed every twelve (12) hours and more frequently if the patient's condition changes...."

Policy titled "Multidisciplinary Progress Notes" (#RC004; 05/2020), revealed: "...Purpose...Documentation is systematically provided which describes in a behavioral format the patient's response to treatment, medical necessity and progress...Policy...Documentation will reflect adherence to specific principles...C ...The frequency of the nursing progress note or documented re-assessment of the patient occurs every shift not to exceed twelve (12) hours by an RN...."

Medical Record review conducted 12/15/2020 and 12/16/2020, revealed the following specific to documentation in the Nursing Notes:

i. Patient #1 - 10/23/2020 - 10/26/2020) - multiple entries and pages incomplete;
ii. Patient #2 - 12/05/2020 & 12/07/2020 (0700-1900 & 1900-0700) - multiple entries and pages incomplete.

Personnel #4 confirmed during an interview conducted 12/16/2020 (1215), that the medical records for both Patient #1 and Patient #2, had multiple missing entries. Additionally, Personnel #4 revealed that the missing entries are required to be documented and completed by the nurse on each shift.

Based on review of the facility's policies/procedures, medical records, and interview, it was determined that nursing personnel failed to complete the nursing assessment, and reassessment for each patient, on each shift. This deficient practice poses a risk to the health and safety of the patients, when nursing personnel fails to complete the required nursing documentation, thereby not being able to determine the patient's current physical or psychiatric status for a particular day and/or shift.

Findings include:

Policy titled "Nursing Admission Process" (#PC008; 05/2020), revealed: "...B...Every patient is to receive a Nursing Assessment upon admission...Assessment...A...completed within eight (8) hours of admission...completed by a RN...."

Policy titled "Reassessments" (#PC022; 05/2020), revealed: "...Purpose...To assure that patient assessment will be a continuous process from admission to discharge...C...Reassessments prompted by significant changes in the patient are documented in the progress notes...D...An RN reassessment is completed each shift not to exceed every twelve (12) hours and more frequently if the patient's condition changes...."

Policy titled "Multidisciplinary Progress Notes" (#RC004; 05/2020), revealed: "...Purpose...Documentation is systematically provided which describes in a behavioral format the patient's response to treatment, medical necessity and progress...Policy...Documentation will reflect adherence to specific principles...C ...The frequency of the nursing progress note or documented re-assessment of the patient occurs every shift not to exceed twelve (12) hours by an RN...."

Medical Record review conducted 12/15/2020 and 12/16/2020, revealed the following specific to documentation in the Nursing Notes:

i. Patient #1 - 10/23/2020 - 10/26/2020) - multiple entries and pages incomplete;
ii. Patient #2 - 12/05/2020 & 12/07/2020 (0700-1900 & 1900-0700) - multiple entries and pages incomplete.

Personnel #4 confirmed during an interview conducted 12/16/2020 (1215), that the medical records for both Patient #1 and Patient #2, had multiple missing entries. Additionally, Personnel #4 revealed that the missing entries are required to be documented and completed by the nurse on each shift.

Based on review of the facility's policies/procedures, Medical Staff Rules & Regulations, medical records, and interviews, it was determined that verbal and/or telephone orders given by a healthcare provider were not authenticated within the required forty-eight (48) hours. This deficient practice poses a risk to the health and safety of the patients, when a healthcare provider fails to authentic a verbal/telephone order verifying that the verbal/telephone order given was accurate, and intended for the correct patient.

Findings include:

Policy titled "Verbal & Telephone Orders" (#RC006; 05/2020), revealed: "...Purpose...To provide staff with direction to ensure safe patient care when telephone or verbal orders are given by a privileged Medical Staff member...E... Authentication of orders...1...All verbal and telephone orders must be authenticated and countersigned by the prescriber or other responsible practitioner within forty-eight (48) hours...2 ...Authentication must include signature, date, and time of authentication...."

Policy titled "Medication Ordering, Preparation, Dispensing & Administration" (#MM018; 05/2020), revealed: "...It is the policy of Talas Harbor...that all medications dispensed will follow all regulations and standards for the program...Ordering of Medication...1...Verbal order should be used sparingly and only in the case of an emergency...2...Telephone and verbal orders are to be signed off by the physician or LIP within forty-eight (48) hours...."

Document titled "Talas Harbor, Medical Staff Rules & Regulations" (05/2020), revealed: "...5.4...Member Orders...5.4.1...All orders for medicine and/or treatment for patients admitted to the facility shall be in writing...a verbal order or telephone order shall be considered written if accepted by a licensed nurse or licensed pharmacist and sign and dated...physicians making verbal or telephone orders shall countersign...within forty-eight (48) hours...."

Medical Record review conducted 12/15/2020 and 12/16/2020, revealed the following specific to verbal/telephone orders:

i. Patient #1 - 10/22/2020 - 10/26/2020 - A total of thirteen (13) verbal/telephone orders, none authenticated within the required forty-eight (48) hours;
i. Patient #2 - 11/30/2020 - 12/16/2020 - A total of twenty (20) verbal/telephone orders, none authenticated within the required forty-eight (48) hours.

Provider #1 confirmed during an interview conducted 12/16/2020 (1100), that verbal/telephone orders may not be authenticated due to COVID, and the provider providing Tele-health visits, vs. in-person visits. Additionally, Provider #1 revealed that s/he comes to the facility two (2) times/week, and that orders are not always flagged to be signed.

Personnel #3 confirmed during an interview conducted 12/16/2020 (1145), that verbal/telephone orders for Patient #1 and Patient #2, were not authenticated.

Based on review of the facility's job description, personnel file, Governing Board Meeting Minutes, documents, and interview, it was determined that the person in charge of dietary services was not qualified or appointed by the Governing Board. The deficient practice poses a risk to the health and safety of the patients, when the person in charge of dietary services is not trained by education and/or experience, to understand the requirements of storing, handling or serving food provided to patients.

Findings include:

Document titled "Director of Business Development/Marketing Job Description" (04/2019), revealed no documented reference to managing dietary services in the position summary, essential functions, daily and monthly responsibilities, skills and qualifications, preferred qualifications or other duties.

Document titled "Governing Board hereby appoints Personnel #12 to oversee the Dietary Services and Registered Dietician for Talas Harbor at Bullhead City", dated 09/23/2020, signed by Executive Director (no longer employed). Additionally, a yellow Post-It note was attached that read "Ron, 09/23/2020", and "Nat".

Documents titled "Governing Board Meeting Minutes" dated 11/12/2020, and 12/09/2020, revealed that the Governing Board did not appoint a Food Service Director who was qualified by experience, training and/or education.

Personnel File review conducted 12/16/2020, revealed the following specific to Personnel #12:

i. Hired 05/15/2019 as Marketing Director;
ii. No documented orientation specific to Food Services;
iii. No documented evidence of experience working in Food Services;
iv. Food Handler Card, expires 12/2022.

Personnel #12 confirmed during an interview conducted 12/16/2020 (1550), that s/he was initially told by the previous Executive Director to sign up for the Food Handler's card, and get qualified. Personnel #12 revealed that s/he was also instructed to sign up for the Food Manager's exam, but that s/he has not completed that exam. Additionally, Personnel #12 confirmed that s/he has not had previous training in Food Services, and that s/he was not familiar with the ADHS State rules specific to Dietary Services for a hospital.

Based on review of the facility's Governing Board By-Laws, Medical Staff Rules & Regulations, and interviews, it was determined that a Utilization Review Committee was established. This deficient practice poses a risk to the health and safety of the patients, when there is no Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

Findings include:

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...Article IV...Organization of the Medical Staff...Governing Board shall organize the physicians and other practitioners granted clinical privileges at the Hospital...under Medical Staff By-Laws...Article VII...Quality of Professional Services and Patient Care Evaluation...Section 2...Medical Care Evaluation Reports...Governing Board shall require, consider, and if necessary act upon, Medical Staff reports of...utilization review...executive committee of the Medical Staff shall, through its chairman...designee...cause the preparation and presentation of such required reports to the Governing Board at each Governing Board meeting or otherwise...Hospital Senior Executive Officer shall provide the Medical Staff with the necessary administrative assistance to facilitate such reporting, regular analysis of the clinical practice, and utilization review activities...reports shall be sufficient to document Medical Staff compliance...."

Document titled "Talas Harbor, Medical Staff Rules & Regulations" (05/2020), revealed: "...11...Utilization Review...attending member is required to document the need for admission and for continued stay...utilization reviews are scheduled on a systematic basis according to the Utilization Review Plan of the facility...failure to furnish such required documentation may result in corrective action...."

Personnel #5 confirmed during an interview conducted 12/16/2020 (0930), that s/he has worked at the facility approximately four (4) months, and that s/he has not participated in a Utilization Review Committee.

Provider #1 confirmed during a telephone interview conducted 12/16/2020 (1100), that due to the multiple changes of leadership, a Utilization Review Committee has not yet been set up.

Based on review of the facility's Governing Board By-Laws, Infection Control Plan, Medical Executive Committee Meeting Minutes, Governing Board Meeting Minutes, and interview, it was determined that the Infection Control Preventionist had not been recommended by Medical Staff, and approved by the Governing Board. This deficient practice poses a risk to the health and safety of the patients, when the credentials and knowledge of the person in charge of over-seeing infection control practices for the facility are not reviewed, verified, and approved.

Findings include:

Policy titled "Infection Control Program" (#IC041; 06/2020), revealed: "...Infection Preventionist shall be responsible for coordinating the hospital's Infection Control Program, and report findings through the Infection Control Committee...Infection Preventionist will...serve as a consultant...serve as liaison...collect and report all data...be involved in training programs...in-service training...present surveillance reports...coordinate a disaster plan...pandemic influenza...with local, state, and/or federal authorities...serve as resource to the medical staff...."

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...."

Document titled "Talas Harbor, Infection Control Plan" (06/2020), revealed: "...Governing Body is ultimately responsible for the Infection Control and Quality Improvement activities throughout the hospital..Infection Preventionist will monitor and report activities to the Infection Control Committee...."

Document review of Meeting Minutes, (08/2020 - 12/2020), revealed no evidence that Personnel #4 was recommended and approved, at the following meetings:

i. Governing Board Meeting Minutes (08/07/2020 & 08/11/2020);
ii. Medical Executive Committee Meeting Minutes (08/13/2020);
iii. Medical Executive Committee Meeting Minutes (09/09/2020);
iv. Medical Executive Committee Meeting Minutes (10/14/2020);
vi. Medical Executive Committee Meeting Minutes (11/12/2020);
vii. Governing Board Meeting Minutes (11/12/2020);
viii. Governing Board Meeting Minutes (12/09/2020).

Personnel #4 confirmed during an interview conducted 12/16/2020 (1610), that s/he will be the on-site manager for infection control, and just spent several weeks in training specific to infection control. Additionally, Personnel #4 revealed that to his/her knowledge, s/he had not been recommended by the Medical Staff or approved by the Governing Board.

Based on review of the facility's policies/procedures, Infection Control Plan, Performance Improvement Plan, documents, and interviews, it was determined that the Infection Control Committee failed to provide a quarterly written report to the Quality/Performance Improvement Committee, which would then include a report to the Governing Board. This deficient practice poses a risk to the health and safety of patients, when infection control data is not reviewed at least quarterly to identify any trends or concerns that might negatively affect patient care, and that the data is not shared with the Medical Staff or Governing Board.

Findings include:

Policy titled "Infection Control Program" (#IC041; 06/2020), revealed: "...Talas Harbor...will maintain an active, effective hospital-wide Infection Control Program...to monitor all infectious processes in order to prevent, identify, and control infectious diseases...shall be implemented through the Infection Control Committee within the Committee-of-the-Whole (COW)...Infection Preventionist shall be responsible for coordinating the hospital's Infection Control Program and report findings through the Infection Control Committee...Infection Control Committee shall meet quarterly, and consist of the following representatives...Executive Director, Infection Preventionist, Chief Nursing Officer, Nurse Manager, Physician Advisor, Human Resources...monitor the hospital's infection control program and review data regarding patient and employee infections...infection control improvement projects will be approved, implemented, and evaluated by PI...."

Policy titled "Guidelines for Infection Control" (#IC038; 06/2020), revealed: "...Talas Behavioral Health influences the infection risk to patients and personnel...all personnel need to understand...their own role in infection control...Infection Preventionist...shall monitor the departments at least quarterly to ensure infection control standards are being followed...."

Document titled "Talas Harbor, Governing Board By-Laws" (08/11/2020), revealed: "...Purpose...the purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care...Governing Board has ultimate responsibility...for safety and quality of care, treatment and services rendered in the Hospital...Article VIII...Governing Board Operation...Section 5...Performance Improvement (PI)...Governing Board shall require...Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care...identifying and resolving problems...Governing Board...shall support these activities...shall provide for resources and support systems for the quality assessment and improvement...related to patient care and safety...if necessary, act upon the results reports from PI activities...implementation of corrective action when problems or opportunities for improvement are identified...."

Document titled "Talas Harbor, Infection Control Plan" (06/2020), revealed: "...Governing Body is ultimately responsible for the Infection Control and Quality Improvement activities throughout the hospital...Committee-of-the-Whole (COW) is responsible for the development and implementation of the quality assessment and improvement activities for the Infection Control Program...staff will be assigned specific responsibilities for review and evaluation of data collected...Infection Preventionist will monitor and report activities to Infection Control Committee...purpose...identify and reduce risks of acquiring and transmitting infections...based on the results of data collection...the quality...will be evaluated to identify trends and patterns...when results indicate...an opportunity to improve a process, a determination is made to purse action to bring about improvement...follow-up monitoring will occur as decided in the action plan in order to evaluate effectiveness of actions...Infection Preventionist will compile a monthly report of all infection control activities...communicated to the COW and to the Board annually...."

Document titled "Talas Harbor Performance Improvement (PI) Plan" (Rev. 06/14/2020), revealed: "...purpose of the plan is to ensure the delivery of quality care to all patients...through consistent monitoring of the clinical services...activities of the PI Plan are reported at least quarterly...the Governing Board of Talas Harbor has authorized the Executive Director to implement and monitor the PI Plan...Executive Director or designee is responsible for facilitating the completion of PI activities...Executive Director shall have overall responsibility for the implementation of the PI plan...as part of the overall PI program, the hospital will conduct performance improvement projects...the number and scope of distinct improvement projects is conducted annually must be proportional to the scope and complexity of the hospital services and operations...Talas Harbor...will document what quality/performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects...PI indicators will be reviewed at least quarterly in the Committee-of-the-Whole (COW) meeting...."

Document review of Meeting Minutes, (08/2020 - 12/2020), revealed no evidence of performance improvement data or reports specific to infection control being presented, discussed and/or reviewed at the following:

i. Governing Board Meeting Minutes (08/07/2020 & 08/11/2020);
ii. Medical Executive Committee Meeting Minutes (08/13/2020);
iii. Medical Executive Committee Meeting Minutes (09/09/2020);
iv. Medical Executive Committee Meeting Minutes (10/14/2020);
v. Patient Safety Meeting Minutes (11/12/2020);
vi. Medical Executive Committee Meeting Minutes (11/12/2020);
vii. Governing Board Meeting Minutes (11/12/2020);
viii. Governing Board Meeting Minutes (12/09/2020).

Personnel #1 confirmed during an interview conducted 12/16/2020, that the document titled "Talas Harbor Performance Improvement Initiatives" (no date), was reviewed at the Medical Executive Meeting (11/12/2020), and that the performance improvement goals, and indicators were reviewed, but that there was no data provided. Additionally, Personnel #1 revealed that there was no quality/ performance improvement report or infection control report that was reviewed at the 11/12/2020 or 12/09/2020 Governing Board meeting.

Personnel #2 confirmed during an interview conducted 12/16/2020, that the facility had no document evidence of a written quality/performance improvement report or infection control report that had been provided to the Governing Board for review from 07/2020 - 12/2020.

Personnel #3 confirmed during an interview conducted 12/15/2020 (1401), that due to the recent change of leadership at the facility, the Quality/PI Committee has not yet met, and that the facility is required to follow Horizon Health Management's Continuous Quality Improvement (CQI) methodology for tracking and submitting data. Additionally, Personnel #3 revealed that s/he is not certain of all of the indicators being tracked at the facility and/or, if all departments at the facility are participating.

Personnel #4 confirmed during an interview conducted 12/15/2020 (1415), that s/he was not aware of any infection control quarterly report that has been prepared by the Infection Control Committee.

Based on review of the facility's policies/procedures, personnel files, and interviews, it was determined that an annual or on-hire tuberculosis screening was completed for all staff. This deficient practice poses a risk to the health and safety of the patients, when staff have not been screened for tuberculosis, allowing the potential of tuberculosis exposure.

Findings include:

Policy titled "Guidelines for Infection Control" (#IC038; 06/2020), revealed: "...Talas Behavioral Health influences the infection risk to patients and personnel...all personnel need to understand...their own role in infection control...following infection control principles will be followed by the employees...personnel shall comply with employee health policies and procedures...shall annually submit tuberculin screen and fill out an Employee Annual Health Screening form...Infection Preventionist...shall consult with employees whose annual physical produces abnormal results and make recommendations for follow-up...shall monitor the departments at least quarterly to ensure infection control standards are being followed...."

Policy titled "Tuberculosis (TB) Infection Control Program" (#IC062; 06/2020), revealed: "...our facility has instituted a Tuberculosis Infection Control Program...includes early identification...assignment of responsibility for the oversight of TB infection control...the Infection Preventionist is designated to oversee the TB program...screening and surveillance of...employees for latent tuberculosis infection and active TB as appropriate...Employee Health Coordinator will document positive employee tuberculin skin tests (TST's)...and chest x-rays...."

Personnel File review conducted 12/16/2020 (1400), revealed the following missing or expired tuberculosis screening documentation:

i. Missing tuberculosis documentation: Personnel #3, Personnel #4, Personnel #5, Personnel #15, and Personnel #20;
ii. Expired tuberculosis documentation: Personnel #12, Personnel #14, Personnel #16, Personnel #21, Personnel #23, Provider #1, and Provider #3.

Personnel #4 confirmed during an interview conducted 12/16/2020 (1500), that annual TB screening is required per the hospital's policies/procedures.

Personnel #25 confirmed during an interview conducted 12/16/2020 (1600), that no other documentation for the missing or expired TB screenings were able to be located.