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Based on observation, interview and review of documentation it was determined that the CAH failed to ensure that all on-campus and off-campus, satellite operations were approved as required by the State of Oregon hospital licensing requirements, and that hospital operations and records were consistent with SA licensing records:
* The CAH commenced operations of an off-campus, satellite for the provision of emergency medical services in 2012, at a location previously reviewed and approved by the SA as an outpatient clinic at 14040 Highway 35, Mt. Hood, 35 miles from the hospital. The SA had not reviewed and approved that satellite location for emergency medical services.
* The CAH provided outpatient laboratory phlebotomy services at an off-campus location at 1021 June Street in Hood River without the required SA review and approval.
* The CAH provided outpatient laboratory phlebotomy services at an approved on-campus provider-based location at 1108 June Street in Hood River without the required SA review and approval for addition of those services.
* Numerous discrepancies and omissions related to provider-based locations and types of services were identified between actual physical locations, multiple hospital lists, and Oregon licensing records.

Findings include:

1. OAR 333-515-0050, OAR 333-535-0000, and OAR 333-675-0000 require that a hospital submit building construction plans to the SA for review and approval prior to building construction/alterations for the addition of new services to the CAH's operations or relocation of existing services. Those areas may not operate until approval to commence services is received from the SA, the Oregon hospital licensing authority.

OAR 333-500-0010(46), OAR 333-500-0025, and OAR 333-500-0027 requires that a separate license be issued for each off-campus, satellite location the hospital intends to operate, and that the hospital comply with the applicable requirements prior to commencement of those operations. The OARs identify three categories of off-campus, satellite locations that include: Outpatient diagnostic, therapeutic, or rehabilitative services; and Emergency medical services.

2. Hospital lists and records reflected that the CAH operated an off-campus satellite for the provision of emergency medical services, at a location previously reviewed and approved by the SA as an outpatient clinic at 14040 Highway 35, Mt. Hood, 35 miles from the hospital. The SA had not reviewed and approved that satellite location for emergency medical services.

"Providence Mountain Emergency Services" policies and procedures were reviewed. Those policies and procedures were extensive and confirmed that the satellite location was holding itself out as and functioning as an emergency department. The policy and procedure titled "PMES Scope of Care," initially dated 08/04/2011 and last revised 10/05/2015, reflected "PMES is a nine bed...emergency department..." The policy and procedure titled "Purpose and objective of PMES," initially dated 08/04/2011 and last revised 10/05/2015, reflected the purpose was "To provide adequate appraisal and initial treatment and/or advice to any patient with an illness of (sic) who is admitted to Providence Mountain Emergency Services...Patients are given the choice of receiving first aid, medical treatment and/or stabilization and transfer if needing more definitive care. EMTALA regulations apply to patient choosing medical treatment."

A hospital full-color marketing brochure was titled "Providence Mountain Emergency Services at Mt. Hood Meadows Ski Resort." That brochure reflected "Providence Mountain Emergency Services is a comprehensive medical and first-aid facility...All of the doctors, nurses and X-ray technicians on staff specialize in high-quality emergency care for skiing and snowboarding injuries and other medical problems."

A hospital document that consisted of a timeline of the development of the emergency department satellite location reflected that the hospital changed the way it billed for services from billing as a "clinic" to billing as an "ER", during the fourth quarter of 2008.

During interview with the CNO on 10/13/2015 at 1700 he/she indicated that the emergency services satellite was seasonally operated and was not planned to open for the coming season until the end of November. He/she stated that the satellite emergency department was only open when there was snow on the mountain. He/she stated that the hospital was in the process of getting the satellite ready for the season including hiring staff for the winter season.

During interview with the CNO on 10/14/2015 at 1245 he/she confirmed that the hospital had been providing seasonal emergency services at the satellite location for several years. He/she stated that several years ago a determination had been made by the hospital that it would be "most advantageous financially to consider it to be an ER" and that the services would be "most clearly defined to the public as an ER."

A tour of the satellite was conducted on 10/15/2015 at 1330. The sign on the building denoted "Providence Hood River Memorial Hospital Emergency." A sign above the main entrance door further denoted "Emergency Entrance." The signage on the actual doors at the entrance denoted "Emergency Department." EMTALA signage was observed inside the department. The interior of the department was constructed primarily as one large room. Observations revealed gurneys, back-boards, splints, Pyxis (automated medication dispensing machine), emergency code cart, defibrillator, oxygen tanks, portable x-ray machine and other medical and emergency supplies and equipment.

The review of Oregon hospital licensing records maintained by the SA revealed no evidence that the CAH had submitted a license application and building plans to change the existing satellite operations from outpatient to emergency medical services.

3. Hospital lists reflected that the CAH provided outpatient laboratory phlebotomy services at an off-campus location at 1021 June Street in Hood River without the required SA review and approval.

The review of Oregon hospital licensing records maintained by the SA revealed no evidence that the CAH had submitted a license application and building plans to add an off-campus location.

4. Hospital lists and observations during tour on 10/15/2015 at 1030 reflected that the CAH provided outpatient laboratory phlebotomy services at an approved on-campus provider-based location at 1108 June Street in Hood River. However, Oregon licensing records reflect that although the location was reviewed and approved by the SA as an outpatient clinic, the location was not reviewed and approved for outpatient laboratory phlebotomy services.

The review of Oregon hospital licensing records maintained by the SA revealed no evidence that the CAH had submitted a license application and building plans to add outpatient laboratory phlebotomy services to the provider-based location.

5. On 10/15/2015 at 1010 a tour of the provider-based locations identified as at 1151 May Street on hospital lists was conducted. Suite 102 was observed to house the cardiac rehabilitation services and Suite 103 was observed to house the palliative care services.

Observations outside in the parking lot reflected that there was no street address sign on the door of that building. However, the street address sign on the front door of another building to the east of that location was observed to be 1151 May Street.

The building identified by the street address sign as 1151 May Street housed the hospital's women's clinic. However, hospital lists identified that the women's clinic was located at 1125 May Street, Suite 202.

The review of Oregon hospital licensing records maintained by the SA reflected that the most recent submission of a list of on-campus and off-campus locations submitted by the hospital reflected the same addresses for the cardiac rehabilitation, palliative care, and women's clinic services as those on the hospital lists described above. However, those addresses were not consistent with the actual physical locations of those services.

6. Multiple lists of the CAH's provider-based locations, including lists for CLIA certified locations, contained discrepancies and omissions related to services and locations.
Examples include:
* The off-campus location at 1021 June Street was not identified on the hospital's "Satellite Facilities Map" dated 10/01/2015.
* The provider-based location at 1151 May Street, Suite 102, where cardiac rehabilitation was provided, was not identified on the hospital's "Satellite Facilities Map" dated 10/01/2015.
* Radiology services provided at two provider-based locations at 902 12th Street and 14040 Highway 35, Mt. Hood were not identified on multiple hospital lists.
* Outpatient laboratory phlebotomy services provided at two locations at 1021 June Street and 1108 June Street were not consistently identified on multiple hospital lists.
* The location at 1151 May Street contained separate operations that were inconsistently identified on multiple lists as located in Suites 102, 103, and 201.

29708

Based on interview, documentation in 4 of 4 medical records reviewed of patients who were receiving outpatient services (Patients 4, 5, 6 and 7), and review of CAH policies and procedures, it was determined that the CAH failed to implement its patient rights policies and procedures to ensure that all patients, including outpatients, received notification of their rights as CAH patients.

Findings included:

1. The policy and procedure titled "Rights and Responsibilities of Patients" with a revision date of "10/2015" was reviewed. It reflected that "...rights and responsibilities will be provided to patients on admission..."

2. The medical record for Patient 4 was reviewed. The record reflected the patient was receiving outpatient cardiopulmonary services. The record contained a Condition of Admissions consent form that reflected "I acknowledge that I have received and read the 'Patient Rights and Responsibilities' notice provided by PH&S." The form was signed and dated by the patient on 10/13/2015 at 0616.

3. The medical record for Patient 6 was reviewed. The record reflected the patient was receiving outpatient infusion/oncology services. The record contained a Condition of Admissions consent form that reflected "I acknowledge that I have received and read the 'Patient Rights and Responsibilities' notice provided by PH&S." The form was signed and dated by the patient on 10/13/2015 at 0940.

4. Similar findings were identified during review of the medical records for Patients 5 and 7 who were also receiving outpatient infusion/oncology services.

5. On 10/13/2015 at 1530 an interview was conducted with the PAR at the patient check in area for outpatient cardiopulmonary and oncology/infusion services. The PAR stated "We don't give patient rights to outpatients. We only give patient rights to bedded patients." He/she confirmed that although patients who were receiving outpatient services signed the "Conditions of Admissions" form indicating they had received patient rights information, they were not actually provided that information.

6. A tour of the provider-based clinic at 1108 June Street was conducted on 10/15/2015 at 1030. Clinic leadership and registration staff were interviewed regarding the method for provision of patient's rights information to clinic patients. During the interview the staff indicated that there was not a formal system for delivery of hospital patient's rights information to each patient. Staff indicated that new patients receive a packet of information in the mail prior to their visit and that a copy of hospital patient's rights is not included in that packet. Staff noted there was a patient's rights brochure located on the counter at the registration desk and that patients "can ask for one" if they wanted a copy.

Based on observation, interview, and documentation in 1 of 2 medical records reviewed for IV medication administration (Patient 6), it was determined the CAH failed to ensure medications were administered in accordance with written orders.

Findings included:

The medical record for Patient 6 was reviewed. The record contained a physician order dated 10/13/2015 for Remicide 300 mg in sodium chloride 0.9% 250 mL IV. The order reflected that the medication was to be administered as follows: "Rate...10 mL/hr for 15 min, then 20 mL/hr for 15 min, then 40 mL/hr for 15 min, then 80 mL/hr for 15 min, then 150 mL/hr for 15 min, then 250 mL/hr."

An observation of Patient 6, in the outpatient oncology/infusion department was conducted with the Clinical Nurse Supervisor on 10/13/2015 at 1220. A bag of IV Remicide medication was observed infusing. The label on the bag reflected that the medication was to be infused at a rate of 125 mL/hour over 2 hours which was inconsistent with the physician order for the medication. This was confirmed during an interview with the Clinical Nurse Supervisor at the time of the observation.

29708

Based on documentation in 9 of 23 medical records reviewed (12, 13, 15, 16, 17, 18, 19, 22, and 23) it was determined that the CAH failed to ensure that all medical records contained complete information in accordance with this regulation and the CAHs own form requirements. Consent forms, and other forms used to reflect patients' receipt of required information and discharge instructions, lacked signatures, dates and times.

Findings include:

1. In the record of Patient 12, the "Consent for Service" form signed and dated by the patient on 10/13/2015 was not timed.

2. In the record of Patient 13, a "Consent for Service" form signed and dated by the patient on 10/13/2015 was not timed.

3. In the record of Patient 15 the "Important Message from Medicare..." was signed and dated by the patient on 08/15/2015. However, the space designated on the form to record the "time" the form was signed was blank.

4. In the record of Patient 16 the "Consent to Operation Administration of Anesthetics and the Provision of other Medical Services" for "Blood Infusion" was dated and timed at 08/16/2015 at 1330. However, it was not signed by the patient, the patient's representative, or any other individual. A handwritten entry denoted "verbal consent [first name] RN present." There was no indication as to why the patient couldn't sign, who obtained "verbal consent", and who wrote the entry.

5. In the record of Patient 17 for an inpatient admission on 05/26/2015 the "Consent for Service" was signed by the patient's representative. However, the date and time the form was signed was not recorded or evident.

6. In the record of Patient 18 the "After Visit Summary" was signed and dated by the patient on 08/26/2015. However, the space designated on the form to record the "time" the form was signed was blank.

7. In the record of Patient 19 the "Important Message from Medicare..." was signed and dated by the patient's representative on 08/25/2015. However, the space designated on the form to record the "time" the form was signed was blank.

8. In the record of Patient 22 for an ED visit on 09/11/2015 the "After Visit Summary" was signed by the patient. However, the space designated on the form to record the "date/time" the form was signed was blank.

9. In the record of Patient 23 for an ED visit on 09/11/2015 the "Consent for Service" was signed by the patient's representative. However, the date and time the form was signed was not recorded or evident.