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Based on documentation review and interviews with key personnel on January 31, 2013, it was determined that the facility failed to comply with York Hospital policy regarding timelessness of Performance Evaluations.

Findings include:

1. York Hospital Policy No. (HR).174 " Staff Performance Feedback " states:
a. "II. POLICY & PROCEDURES: All staff members have the right to know their Leaders' assessment of their job performance. ...Leaders or their designees are responsible for providing performance feedback ... Thereafter, every staff member will receive performance feedback from their Leader or designee on an annual basis."
b. "Documentation including the attached form and any additional staff feedback will be maintained in the Friendraising Office."

2. A review of the twenty three (23) personnel files was conducted on January 31, 2013. The facility failed to assure that the personnel file for each employee included a periodic evaluation that was updated as required. Three (3) of the files reviewed failed to include an annual updated performance evaluation completed within the previous twelve (12) months.

3. This was confirmed during an interview on January 31, 2013, at 9:20 a.m., with the Director of Human Resources, who stated " I don ' t have any performance evaluations on file for the Licensed Practical Nurses located in the physician practices."

Based on policy review, contract review and interviews with key personnel on January 31, 2013, it was determined that the hospital failed to assure that the services performed under contract were evaluated within the Performance Improvement Program in six (6) of six (6) clinical contracts reviewed.

Findings include:

1. Six (6) clinical contracts were reviewed on January 30, 2013, including 1. Neuro consult utilized in the Emergency Department, 2. Remote Stroke Agreement, 3. First amendment to the participating hospital agreement, 4. Tannex Medical Systems, Inc, 5. Comprehensive Wound Healing, Center Services agreement and 6. Quality Centrix contract.

2. Section VI of the Performance Improvement Plan addresses: Hospital responsibility for quality of contracted services and stated, "All hospital services, off site outpatient services, including the Medical Staff and Allied Health Professional Staff, Family Care Discharge Visit Program, as well as any contractor services which impact in any manner upon the diagnosis, treatment, care or the safety of patients will be subject to this plan.. . The Quality Committee, Medical Executive Committee, and Board of Trustees are responsible for the guidance of organization-wide Quality/Performance Improvement efforts."

3. In an interview with the Risk Manager on January 31, 2013, at 9:10 a.m., she stated, "I didn't see contracted services addressed in 2012 performance improvement quality meeting minutes."

Based on review of credential files, review of policies and procedures, review of information provided and interviews with key staff, it was determined that the facility failed to provide documentation that physicians and other LIP's [Licensed Independent Practitioners] authorized to order restraints or seclusion by hospital policy in accordance with State law, had a working knowledge of hospital policy regarding the use of restraints and seclusion.

Findings include:

1. A review of a letter dated July 5, 2012, sent to all physicians was reviewed January 30, 2013. Attached to the letter was a document titled, ' Restraint Education For The Medical Staff''. The letter was to be signed and dated and return to the physician Quality Leader. This process would be the documentation that physicians and LIP's had a working knowledge of the hospital policy.

2. During an interview with the Risk Manager on January 30, 2013 at 4 p.m., she stated that the former Risk Manager had resigned, and no one knew where the returned letters were located.

3. It was confirmed by the Risk Manager on January 30, 2013 at 4 p.m., that there was no documentation that physicians and LIP's had a working knowledge of the hospital policy related to Restraints and Seclusion.

Based on review of information provided and interviews with key personnel on January 31, 2013, it was determined that the facility failed to ensure that the facility had incorporated quality indicator data into the hospital's quality improvement organization.

Findings include:

In an interview with the Surgical Patient Care Leader and the Leader of Surgical Patient Care, on January 31, 2013, at 9:00 a.m., it was confirmed that although they had identified problems, gathered data and analyzed the data for the problems identified, it was stated that the data had not been presented to the Quality Improvement Committee. Additionally, it was stated that the two (2) leaders really did not know what to do with the data that they had compiled.

Based on review of the York Hospital Quality/P.I. Plan, review of information provided and interviews with key staff January 29 - 31, 2013, it was determined that the program failed to reflect the complexity of the hospital's organization and services and involve all hospital department and services (including those services furnished under contract or arrangement).

Findings include:

1. See Tag A 0084 for additional information regarding quality related to contracts.

2. See Tag A 0273 for additional information regarding quality data.

3. The York Hospital Quality / P.I. Plan, section XVIX. Medical Staff Quality/Performance Improvement Plan, paragraph 8. States, " Each department will review quality indicators, at least annually, and departmental minutes will reflect the following information: indicators chosen, measurements, threshold values that trigger further review, how the reviews will be conducted, and how the results will be reported to the medical staff. "

4. The minutes of the Department of Medicine, Department of Surgery, Emergency Department and Perinatal Committee, from January 2012 through December 2012 were reviewed on January 31, 2013. The minutes of the Departments of Medicine, Emergency Medicine, and Surgery did not contain evidence that a, " review [of] quality indicators " occurred, as required in the hospital ' s Quality / P.I. Plan.

5. This was confirmed by the Risk Manager on January 31, 2013. During an interview on January 31, 2013, at 1:25 p.m., the Risk Manager stated that there was no other place where the documentation of the annual review of the medical staff department indicators would be found, if not in the departmental meeting minutes.





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Based on review of the documentation for quality assessment/performance improvement and interviews with key staff on January 29-31, 2013, it was determined that the Radiology/Nuclear Medicine Department failed to maintain and demonstrate evidence of an ongoing Quality/Performance Improvement Program which demonstrated improvement in outcomes based on changes made as a result of information obtained through a quality assessment study.

Findings include:

1. The Radiology/Imaging Quality Improvement Project related to, "Teleradiology and need for Re-reads", was reported to be a national benchmark study which has been ongoing for several years. The hospital identified a benchmark of 98%. The calendar year 2011 report indicated a sustained compliance level of 100% which was maintained for the entire four quarterly reports. 2012 calendar year data was not provided.

2. The Radiology/Imaging Quality Improvement Project related to "Rate of MRI to Surgical Correlation", was reported to have been initiated January 2012. The hospital identified a benchmark of 98%. The calendar year 2012 report indicated a sustained compliance level of 100% maintained for all four quarterly reports.

3. The Nuclear Medicine Quality Improvement Project related to the rate of "CT/Lung Biopsy/Thoracentesis without complications", was reported to have been initiated January 2012. The hospital identified a benchmark of 92%. The calendar year 2012 report indicated a sustained compliance level of 100% maintained for all four quarterly reports.

4. The hospital ' s Quality Assessment Performance Improvement binder contained a memo to the Leader for Quality Improvement, dated February 23, 2012, in which four (4) potential Radiology/Nuclear Medicine indicators were identified. However; the Leader for Radiology/Nuclear Medicine identified in an interview on January 30, 2013, at 10:30 a.m., that none of these indicators were formally implemented as quality studies for 2012, although they have been discussed as potential studies for 2013.

5. This was confirmed by the Leader for Radiology/Nuclear Medicine during an interview on January 30, 2013, at 10:30 a.m.

Based on observations and interviews with key staff on January 30 and 31, 2013, it was determined that the facility failed to ensure that unauthorized individuals could not gain access to information from or copies of medical records.

Findings include:

1. On January 31, 2013, at 2 p.m., a tour of a nursing unit was conducted. A blue box was observed in the nursing station with no cover on it. The box contained patient medical record information.

2. An interview was conducted with a housekeeper on January 31, 2013 at approximately 1:05 p.m. while on a nursing unit. When asked how the information in the blue box was transported to the recycle bin outside, the housekeeper stated, "The staff on the units put the contents of the blue box into opaque plastic bags and mark the bags 'Confidential'. I'm on the look out for the bag. I place the bag in the corner of the big wheeled bin that I have, with the dirty linen and trash. I never leave the bin in the hallway. I take the bags marked 'Confidential' outside to a locked blue recycle box."

3. During the interview with the housekeeper on January 31, 2013 at 1:10 p.m., the surveyor asked if the housekeepers had been trained in how to handle patient health information and the housekeeper answered, " No, only trained in how to handle biohazardous waste, soiled linen and trash."

Please see Tag A - 0441 for additional information about the security of patient health information.

Please see Tag A - 0457 for additional information regarding authentication of verbal orders in the medical record.

Based on document review and interviews with key personnel on January 30,2013, it was determined that the physicians failed to authenticate their verbal orders within 48 hours in seven (7) of thirty (30) medical records.

Findings include:

1. The Medical Staff Bylaws, Rules, & Regulations states under General Conduct of Care, "2. The order [Verbal orders.] must be authenticated by the ordering practitioner or by a practitioner responsible for the care of the patient within 48 hours..."

2. A review of thirty (30) inpatient medical records was conducted on January 29 and 30, 2013. Seven (7) medical records contained verbal orders that were not authenticated within the 48 hour timeframe (Records E, F, H, K,U, AA and CC).

3. This information was confirmed by the Leader of Integrated Medicine on January 30, 2013, at approximately 3 p.m.

Based on observations and interviews with key personnel on January 29, 30 and 31, 2013, it was determined that the physical plant and overall hospital environment failed to be maintained to assure the safety and well being of the patients.

Findings include:

1. The Family Care Unit revealed two (2) stained ceiling tiles in the corridor. The tiles were immediately replaced. This finding was confirmed with the Pediatric Nurse Manager on January 29, 2013, at approximately 2 p.m.

2. The Pediatric Office had a chipped laminated counter top. This finding was confirmed with the Pediatric Nurse Manager on January 29, 2013, at approximately 2:10 p.m.

3. The Medical -Surgical kitchen contained a cabinet under the sink that was visibly soiled, and not easily cleaned and sanitized. Crackers for patient consumption were stored in that cabinet as well. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:12 p.m.

4. The Medical -Surgical kitchen contained a freezer where both staff food and food for patient consumption was stored. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:14 p.m.

5. The Medical -Surgical soiled utility room contained a metal under sink cabinet that was rusty, and not easily cleaned and sanitized. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:17 p.m.

6. The Medical -Surgical soiled utility room contained a countertop by the sink that was delaminated,and not easily cleaned and sanitized. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:20 p.m.

7. The Intensive Care Unit soiled utility room contained a metal under sink cabinet that was rusty, and not easily cleaned and sanitized. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:23 p.m.

8. The Intensive Care Unit clean utility room contained a metal under sink cabinet that was rusty, and not easily cleaned and sanitized. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:25 p.m.

9. The Intensive Care Unit nourishment area contained a metal under sink cabinet that was rusty, and not easily cleaned and sanitized. This finding was confirmed with the Clinical Leader of Integrated Medicine on January 29, 2013, at approximately 2:27 p.m.

10. During tour of the operating rooms, the following observations were made:
a. In Operating Room (OR)#2, the casters were rusty on the trash container, the linen hampers and on one stool.
b. In OR #3, the casters were rusty on the linen hamper.
c. In OR #4, the casters were rusty on the linen hamper.
d. In OR #5, the casters were rusty on the ring stand and the linen hamper.

11. The above findings were confirmed by the Director of Anesthesia and the Clinical Coordinator of the OR on January 30, 2013, at 7:30 a.m.

12. The ceiling tile was observed to be water stained in the stair-well in Biewin near the pharmacy.

13. The above finding was confirmed by the Leader of Diagnostic Laboratory on January 30, 2013, at around 3:00 p.m.

14. During tour of the Catheterization Laboratory, the following findings were observed:
a. In the storage room, there was a box of surgical scrubs on the floor.
b. Three ceiling tiles were water stained
c. In the break room, one ceiling tile was water stained.
d. Outside the X-ray room, a torn X-ray apron was observed.

15. The above findings were confirmed by the Chief Operating Officer on January 31, 2013, at 1:10 p.m.

16. Section 29 CFR (Code of Federal Regulations) section 1910.1450 App B, 7, Signs, directs that "Prominent signs of the following type should be posted: ...(b) Location signs for ...eye wash stations."

17. During tour of the Sterilization area, two (2) Emergency eye wash stations, one (1) in clean area, and one (1) in the dirty area were observed with no signage in the area or outside of the rooms.

18. The above finding was confirmed by the Chief Operating Officer on January 31, 2013, at approximately 8:30 a.m.

Based on document review, review of medical records and interviews with key personnel on January 30, 2013, it was determined that the facility failed to provide the patient with a list of available home health agencies, or inform the patient of their freedom to choose a home health agency.

Findings include:

1. A review of Medical Record T indicated that the patient was to be discharged with home health services. The record failed to contain documentation that the patient had been provided with a list of available agencies. The record indicated that the discharge plan was for the patient to receive services from the home health agency owned by the hospital .

2. During an interview with the patient's Social Work Case Planner, on January 30, 2013, at approximately 11: 07 a.m., it was stated that the patient [Medical Record T] didn't indicate a preference, although the Social Work Case Planner stated that the choices might have been given to the patient.

3. The surveyor and the Social Work Case Planner went to Patient T's room at 11:15 a.m. on January 30, 2013, to interview the patient. During the interview, the patient verified that she/he had not been given a list of available home health agencies. She/he stated ,"I was asked if I had a preference for any particular agency, I was told that the hospital had one, so that's the one I went with..."

4. During an interview with the Leader of Integrated Medicine on January 31,2012, at approximately 9 a.m., she confirmed that the facility failed to have a policy and procedure that addressed this regulation, as it pertained to home health agencies. She stated,"No, we don't have a policy on home health agencies, just facilities."

Based on record review and interview with key personnel on January 31, 2013, it was determined that the facility failed to assure that a history and physical was completed thirty (30) days pre anesthesia or updated within 48 hours pre anesthesia for one (1) of six (6) medical records.

Findings include:

1. The medical record of one (1) patient indicated that he/she had a history & physical on October 26, 2012, and then had a bronchoscope on December 3, 2013. The history & physical was not updated within 48 hours of having a procedure preformed.

2. This finding was confirmed by the Leader of Surgical Patient Care on January 31, 2013, at 10:50 a.m.

Based on record review and interviews with key personnel on January 30, 2013, it was determined that the facility failed to assure that operating room reports were signed within thirty (30) days of the procedure in one (1) of five (5) medical records.

Findings include:

1. Review of five (5) surgical records on January 30, 2013, indicated that Record CCC, who had surgery on December 26, 2012, lacked evidence that the physician signed the operating report within 30 days of the operation. The report was still unsigned at the time of the review of the surgical records.

2. This finding was confirmed by the Clinical Coordinator of the Operating Room on January 30, 2013, at 10:45 a.m.