HospitalInspections.org

Based on review of the hospital's Governing Board ByLaws, clinical records, policies/procedures, documents, and staff interviews, it was determined the Governing Body failed to:

(0049) the Governing Body failed to require that the medical staff be accountable to the Governing Body for the quality of care provided to the patients when the medical staff failed to authenticate medical record entries in a timely manner according to the hospital requirements . This deficient practice poses a potential risk to the health, and safety of the patients when completeness, and accuracy of the medical record is not maintained; quailty patient care is not ensured /maintained, patient satisfaction is not ensured, and the Governing Body does not hold the medical staff accountable.

(0083) ensure the Governing Body had oversight of the contracted services furnished in the hospital. This deficient practice poses a risk to the health and safety of patients, when the Governing Body has not verified that a contractor of services (providing services to the hospital) has complied with all applicable Center's for Medicare and Medicaid Services (conditions of participation, and standards).

(0084) ensure that the Governing Body had oversight of the contracted services performed in the hospital and failed to require that all contracts were evaluated for the services provided under contract, and that those services were provided safely, and effectively for the patients.. This deficient practice poses a risk to the health and safety of patients, if contracts are not evaluated for the services they provided to ensure those services were provided safely, and effectively for the patients.

(0085) ensure that the Governing Body maintained a current list of all contracted vendors, to include the vendor's scope of services provided to the hospital;

(0263) ensure that the Governing Body implemented, and maintained an effective, on-going, data-driven QAPI plan, inclusive of all hospital departments, and services (including those services furnished under contract or arrangement), and focusing on improving health outcomes with the goal of preventing and/or reducing medical errors;

(0652) ensure that the facility has an effective Utilization Review plan, that provides for review of services by the facility, and medical staff.

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 Governing Body fails to evaluate and/or determine the causes of these deficiencies, and to develop an action plan to correct the deficiencies.

Based on review of the facility's policies/procedures, documents, EMR, and staff interviews, it was determined that the facility failed to ensure that the Governing Body implemented, and maintained an effective, on-going, data-driven QAPI plan, inclusive of all hospital departments, and services (including those services furnished under contract or arrangement), and focusing on improving health outcomes with the goal of preventing and/or reducing medical errors. The Governing Body failed to:

(0273) ensure that the Quality Assessment and Performance Improvement (QAPI) program was effective in showing measurable improvements, by measuring, analyzing, and tracking quality indicators;

(0283) ensure that the QAPI program identified opportunities for improvement, set priorities for performance improvement activities, and tracked performance to confirm that improvements are sustained;

(0308) ensure that QAPI activities includes all hospital departments, and services, including those services furnished under contract or arrangement;

(0309) ensure that QAPI activities, specific to the quality of care, and patient safety are prioritized, evaluated, and that the number of distinct improvement projects are conducted annually.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for QAPI, which poses a risk to the health and safety of patients when the facility fails to analyze, trend, evaluate, and prioritize performance improvement projects both on-going, and annually for the quality, and safety of patient care.

Based on review of the facility's policies/procedures, documents, and staff interviews, it was determined that the facility failed to ensure that the facility has an effective Utilization Review plan, that provides for review of services by the facility, and medical staff. The deficient practices poses a risk to the patient(s) receiving benefits under the Medicare and Medicaid programs when rendered services are not reviewed and/or evaluated. The facility failed to:

(0654) ensure that a Utilization Review (UR) committee was established, consisted of at least two (2) physicians, and verified that the committee or group reviews are not conducted by any person who was professionally involved in the care of the patient whose case was reviewed; and

(0657) ensure that under the Prospective Payment System (PPS), the UR Committee reviewed outlier cases with extended length of stays exceeding the threshold for a specific diagnosis.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Utilization Review, which poses a risk to the health and safety of patients when the facility fails to review services for the quality, and safety of patient care.

Based on review of hospital policies/procedures, documents, Electronic Medical Records (EMR), and interviews, it was determined that the Governing Body failed to require that the medical staff be accountable to the Governing Body for the quality of care provided to the patients when the medical staff failed to authenticate medical record entries in a timely manner according to the hospital requirements. This deficient practice poses a potential risk to the health, and safety of the patients when completeness, and accuracy of the medical record was not maintained; quailty patient care was not ensured /maintained, patient satisfaction was not ensured, and the Governing Body did not hold the medical staff accountable.

Findings include:

Policy titled "Dignity Health East Valley Rehabilitation Hospital (DHEVRH) Medical Record Completion" (#HM12.58, last reviewed: 12/2018) revealed: "...patient records shall be considered complete when contents are...authenticated...the medical record shall be completed (dictations and signatures) within thirty (30) days from the patient's discharge according to Medical Staff ByLaws (Rules & Regulations)...."

Policy titled "DHEVRH Quarterly HIM Report" (#HM12.15, last reviewed: 12/2018) revealed: "...the HIM manager or designee will submit a quarterly report to the hospital Quality Committee that addresses quality indicators such as the following...Physician Peer Review of Documentation Summary...Multidisciplinary Review Summary...Record Completion Summary (Delinquent Record %)...measured monthly and quarterly...Recommendations and follow-up...."

Policy titled "DHEVRH Telephone and Written Orders-General" (#PC269, last reviewed: 08/2016) revealed: "...telephone orders...the prescribing practitioner must sign the written record of the telephone order within the time period stated in the Medical Staff ByLaws..."

Document titled "DHEVRH ByLaws of the Medical Staff" (Approval: 04/30/2019) revealed: "...Article X: Medical Staff Committees and Meetings...A...Executive Committee...Duties...duties of the Executive Committee shall be..authority over...activities related to the functions of performance improvement ...responsible for making Medical Staff recommendations directly to...Board of Managers...Health Information Function...responsible for assuring that all medical records meet the highest standards of patient care...the responsible parties shall...conduct a review of records of discharged patients to determine the promptness, pertinence, adequacy, and completeness thereof...Article XIV...Rules and Regulations...a physician member of the Medical Staff shall be responsible for the medical care, and treatment of each patient in the hospital...for the completeness, and accuracy of the medical record...each practitioner must assure timely, adequate professional care for their patients...physicians ensure that medical records are accurate, complete...Medical Records...Verbal and Telephone Orders...all verbal orders must be dated, timed, and authenticated within forty-eight (48) hours by the prescriber...."

Document titled "DHEVRH Board of Managers Minutes" (01/29/2019) revealed:

i. Hospital Wide Quality Committee Report: "...Patient Satisfaction...Provider #1 was asked what might be affecting scores from a physician standpoint...Provider #1 stated that there are two (2) physicians that don't have the best reputations, and could be dragging scores down...s/he hears complaints from patients, but has tried to work on these relationships in order to improve outcomes...." Documentation under "Action" reads: "...Informational...." No documentation under Follow-Up/Responsible Party noted.

ii. Medical Director Report: "...Provider #1 was asked if there was anything that the Board needed to be aware of from a hospital perspective...Provider #1 stated that s/he would keep the Board in the loop about the two (2) physicians that s/he has concerns about...excited about what we have been able to accomplish...is building relationships...with...neurology...to further our development...hoping to implement a program that no one else has...." Documentation under "Action" reads: "...motion to approve all new appointments and re-appointments...." No documentation under Follow-Up/Responsible Party noted.

iii. No documented evidence of Health Information Management EMR physician compliance.

Document titled "DHEVRH Board of Managers Minutes" (04/30/2019) revealed:

i. Health Information Management: "...Josh reported on the HIMS Summary...delinquency rate under 3%...please see packet for additional data...." No documentation under "Action". No documentation under Follow-Up/Responsible Party noted.

ii. Medical Director Report: "...Medical Staff Credentialing...the Board reviewed the Medical Credentialing Report for this quarter...new appointments...automatic suspension...." Documentation under "Action" reads: "...motion to approve all appointments...all in favor...motion passed...." No documentation under Follow-Up/Responsible Party noted.

iii. No documented evidence of follow-up regarding patient satisfaction, and physician concerns noted in the Board of Managers Minutes (01/29/2019).

Documentation of thirty (30) EMR telephone/verbal orders, with date range 10/25/2016 through 08/13/2019 revealed the following: Sixteen (16) out of thirty (30) telephone/verbal orders were not signed within the required forty-eight (48) hours (46% compliance).

Provider #1 confirmed during an interview conducted 08/12/2019 (1530), that s/he attends the Board of Managers meetings, and when patient satisfaction results are reviewed, specifically for low physician scores, attempts are made to determine who the physician is (example: rehabilitation physician vs. internal medicine physician), and that answering the question can be confusing to the patient. Additionally, Provider #1 revealed that s/he is not certain if the medical director for pharmacy goes to the Pharmacy & Therapeutics meetings.

Personnel #2 confirmed during an interview conducted 08/14/2019 (1155) that of the thirty (30) verbal/telephone orders reviewed, eleven (11) verbal/telephone orders were not signed by the physician, and five (5) verbal/telephone orders were signed by the physician but not within the forty-eight (48) hour requirement.

Based on review of the facility's policies/procedures, documents, and interview, it was determined that the facility failed to ensure the Governing Body had oversight of the contracted services furnished in the hospital. This deficient practice poses a risk to the health and safety of patients, when the Governing Body has not verified that a contractor of services (providing services to the hospital) has complied with all applicable Center's for Medicare and Medicaid Services (conditions of participation, and standards).

Findings include:

Policy titled "DHEVRH Contracted Services" (#LD200, last reviewed: 02/2018) requires: "...the hospital provides essential services in a timely manner...directly or under arrangement...contractual arrangements or other agreements...contracted or outside services are utilized to provide care and services not available within the hospital...requires the approval of the Chief Executive Officer (CEO) or his/her designee...any external service provider shall contractually commit to compliance of all federal, state, and local rules and regulations governing the provision of their service, as well as the education, training, licensure, and competence of personnel...all contracts for services delivered by a provider external to this hospital shall be approved by the CEO prior to implementation...all such contracts shall also be reviewed and approved by the Medical Executive Committee...Board of Managers...administration will maintain a copy of all signed contracts...leadership will monitor and evaluate contracted services by establishing expectation for performance for those contracts which provide for the care, treatment, and services to the hosptial's patients...leadership will assure that contract services meet expectation of performance...Board of Managers is responsible for all services furnished by the hospital...Board of Managers shall review and approve all contracts at least annually...all contracts related to patient care shall minimally have an annual quality review...."

Policy titled "DHEVRH Contract Services Monitoring" (#LD205, last reviewed: 02/2018) requires: "...the hospital monitors for the same level of high-quality care regardless of whether the services are provided...through contractual arrangements...the department manager will review information provided by the potential contracted vendor, or supplemental staffing agency, prior to submitting any contractual arrangement for approval...the department manager shall ensure that the proposed provider meets any regulatory requirements...."

Document titled "DHEVRH Board of Managers Minutes" (04/30/2019) revealed: "...Contract Services...The hospital does an annual review of Contracted Services...reported that all of our vendors are in good standing...page 164 of the packet is missing the Modified Barium Swallow vendor (need name of vendor)...Approval...motion made to approve by Provider #1...seconded by Provider #10...all in favor, motion passed...."

Document titled "DHEVRH Medical Executive Committee (MEC) Minutes" dated 08/22/2018, 01/17/2019, and 04/18/2019, revealed no documented evidence of approval of "Contracted Vendor List 2019" as required per "DHEVRH Contract Services Monitoring" (#LD205). Additionally, the MEC Minutes binder provided to the surveyor, revealed no MEC meeting minutes for 09/2018, 10/2018, 11/2018 and 12/2018.

Document titled "Contracted Vendor List 2016" was initially provided to the surveyor, when the contract list was requested on 08/12/2019 (0830). During review of the "Contract Vendor List 2016", it was identified that there was a more current contract list titled "Contracted Vendor List 2019" which was provided to the surveyor on 08/14/2019 (1330), which listed forty-six (46) vendor/supplier names. A random sample of contracts was requested for review. During the review of the sample contracts, it was identified that there were two (2) vendor names not listed on the "Contracted Vendor List 2019": Transfusion Facility Blood Service Agreement (signed 1/20/2017), and Donor Network of Arizona (signed 09/26/2016). Additionally, it was identified that four (4) of six (6) vendors listed on the "Contracted Vendor List 2019" had not been approved by the Board of Managers.

Personnel #4 confirmed during an interview conducted 08/14/2019 (1330) that the Board of Managers Minutes (Governing Body) approved a current list of contracted vendors on 04/30/2019, and that four (4) of six (6) vendors listed on the "Contracted Vendor List 2019" had not been approved by the Board of Managers. Additionally, Personnel #4 confirmed that there was no documented evidence that the identified contracts had been reviewed to ensure vendor compliance with the applicable conditions of participation and standards.

Based on review of facility policies/procedures, documents, and interview, it was determined that the facility failed to ensure that the Governing Body had oversight of the contracted services performed in the hospital and failed to require that all contracts were evaluated for the services provided under contract, and that those services were provided safely, and effectively for the patients.. This deficient practice poses a risk to the health and safety of patients, if contracts are not evaluated for the services they provided to ensure those services were provided safely, and effectively for the patients.

Findings include:

Policy titled "DHEVRH Contracted Services" (#LD200, last reviewed: 02/2018) requires: "...the hospital provides essential services in a timely manner...directly or under arrangement...leadership will monitor and evaluate contracted services by establishing expectations for performance for those contracts which provide for the care, treatment, and services to the hosptial's patients...leadership will assure that contract services meet expectation of performance...Board of Managers is responsible for all services furnished by the hospital...."

Policy titled "DHEVRH Contract Services Monitoring" (#LD205, last reviewed: 02/2018) requires: "...the hospital monitors for the same level of high-quality care regardless of whether the services are provided...leaders monitor the contract services based on, but not limited to expectations for performance...the hospital CEO, and Medical Executive Committee (MEC) take steps to improve contracted services that do not meet expectations by one or more of the following...increase monitoring of the contract service...provide consultation or training to the contractor...renegotiate the contract terms...terminate the contract...."

Document titled "Operating Agreement of Dignity-Kindred Rehabilitation Hospital East Valley, L.L.C." (effective: 04/29/2015) revealed: "...the Company, and the Business will be operated and managed in a manner that...provide for the delivery of patient care at or above community standard for the industry and/or clinical services...assure the operation, and maintenance of a safe clinical environment for the delivery of patient care...."

Document titled "DHEVRH Board of Managers Minutes" (04/30/2019) revealed: "...Contract Services...The hospital does an annual review of Contracted Services...reported that all of our vendors are in good standing...page 164 of the packet is missing the Modified Barium Swallow vendor (need name of vendor)...Approval...motion made to approve by Provider #1...seconded by Provider #10...all in favor, motion passed...." The minutes revealed no documented evidence of review of contracted services or the evaluation that contracted services are provided in a safe, and effective manner, as required per "DHEVRH Contract Services Monitoring" (#LD205), prior to the Board of Managers approval.

Document titled "DHEVRH Medical Executive Committee Minutes" dated 01/17/2019, and 04/18/2019 revealed no documented evidence of review of contracted services, or the evaluation that contracted services are provided in a safe, and effective manner, as required per "DHEVRH Contract Services Monitoring" (#LD205).

Personnel #4 confirmed during an interview conducted 08/14/2019 (1330) that the Board of Managers Minutes (Governing Body) approved a current list of contracted vendors on 04/30/2019. Additionally, Personnel #4 revealed that there was no documented vendor evaluation to confirm that services performed under contract were provided in a safe, and effective manner.

Based on review of facility policies/procedures, documents, and interview, it was determined that the facility failed to ensure that the Governing Body maintained a current list of all contracted vendors, to include the vendor's scope of services provided to the hospital. This deficient practice poses a high risk to the health and safety of patients, when the Governing Body failed to approve four (4) out of six (6) contracted vendors for 2019.

Findings include:

Policy titled "DHEVRH Contracted Services" (#LD200, last reviewed: 02/2018) requires: "...the hospital provides essential services in a timely manner...directly or under arrangement...contracted or outside services are utilized to provide care and services not available within the hospital...all such contracts shall also be reviewed and approved by the Medical Executive Committee...Board of Managers shall review and approve all contracts at least annually...all contracts related to patient care shall minimally have an annual quality review...."

Document titled "DHEVRH Medical Executive Committee Minutes" dated 01/17/2019, and 04/18/2019 revealed no documented evidence of approval of "Contracted Vendor List 2019" as required per "DHEVRH Contract Services Monitoring" (#LD205).

Document titled "DHEVRH Board of Managers Minutes" (04/30/2019) revealed: "...Contract Services...The hospital does an annual review of Contracted Services...reported that all of our vendors are in good standing...page 164 of the packet is missing the Modified Barium Swallow vendor (need name of vendor)...Approval...motion made to approve by Provider #1...seconded by Provider #10...all in favor, motion passed...." The meeting minutes revealed no documented evidence.

A more current contract list titled "Contracted Vendor List 2019" was provided to the surveyor on 08/14/2019 (1330), which listed forty-six (46) vendor/supplier names. Review of two (2) documents revealed that in a random selection of contracts, only two (2) of six (6) vendor contracts had been approved by the Board of Managers. Additionally, it was revealed that the "Contracted Vendor List 2019" provided only listed the name of the vendor, and did not include the vendor's scope of service.

Personnel #4 confirmed during an interview conducted 08/14/2019 (1330) that the Board of Managers Minutes (Governing Body) approved a list of Contracted Vendors on 04/30/2019, and that from the "Contracted Vendor List 2019", only two (2) out of six (6) contracted vendors had been approved by the Board of Managers, and that the remaining four (4) contracted vendor names had not been approved.

Based on review of the facility's policies/procedures, documents, electronic medical record (EMR), and interviews, it was determined that the facility failed to ensure that the QAPI program was effective in showing measurable improvements, by measuring, analyzing, and tracking quality indicators. This deficient practice poses a risk to the health, and safety of the patients when the facility fails to document, track, trend, and analyze performance indicators to avoid potenitial adverse patient outcomes.

Findings include:

Policy titled "DHEVRH Governance Board of Managers" (#LD100, last reviewed: 02/2018) revealed: "...the hospital Board of Managers is responsible for the governance of the hospital with ultimate authority for the safety, quality of care, treatment, and services...."

Policy titled "DHEVRH Responsibilities of Board of Managers" (#LD105, last reviewed: 02/2018) revealed: "...the Board of Managers responsibilities include...provide oversight among the hospital's leaders, and medical staff for the coordination and integration of these leaders to establish policies and procedures, maintain quality care, and patient safety...."

Policy titled "DHEVRH Plan - Continuous Quality and Performance Improvement (CQPI) Plan" (#LD255, last approved: 10/2016) revealed: "...purpose of the CQPI is to ensure that the hospital provides...high quality, safe...care...the hospital will measure additional indicators for each department within the hospital...Board of Managers...ultimate authority...committed to...quality and safe patient care and services...reporting of organizational performance and improvement is reported at least quarterly with a summary of significant improvements, and significant issues...Board of Managers...oversee the planning, design, implementation, and on-going monitoring...Medical Executive Committee (MEC)...be responsible for the on-going quality of medical care...in conjunction with the Quality Council...shall have responsibility for medical staff improvement...accomplished by...assessing and analyzing data related to the quality and safety of patient care...CQPI Committee....responsible for overseeing...monitoring and assessing data...acting on recommendations from staff, departments, patients, and their families...identifying and prioritizing performance improvement projects...evaluating the overall effectiveness, and adjust as appropriate...CQPI...consists of Administrative/Executive Team, Director of CQPI, and additional members if selected by the Administrative/Executive Team...responsibilities include...prioritization of performance improvement activities...involvement with the medical staff in performance improvement activities...meets a minimum of quarterly to review actives, and recommendations from the CQPI Committee...activities and projects are judged and prioritized based on their impact on...customers...core values...a prioritization grid is used to score and rank activities and projects... CQPI committee members determine the priorities as follows...impact...applicability...requirements...each of the above are scored...Monitoring, Collecting, and Analyzing Data...data alone is insufficient to improve the performance of the organization...process for data use...planning, collecting, assessment/analysis, actions...Assessment and Analysis...must be performed to utilize the data as information that allows the organization to make informed decisions regarding changes in culture, processes, patient care, and performance of business functions...Actions...based on the data and information obtained is planned in order to improve the performance of the organization...actions are planned by the department, team, or organizational structure identified as responsible for the improvement...data measurement and analysis over time determines the ability of the process to succeed...opportunities for performance improvement may be identified by the systemic review of the internal and external data obtained by the organization...measurements that fall below the acceptable expectations and thresholds typically indicate an opportunity for improvement...on an annual basis, the plan will be assessed for it's impact on the organizations improvement with the strategic goals developed...."

Document titled "CQPI Committee Minutes" (01/15/2019) revealed the following:

i. Patient Safety Committee Report: "Discussion" reads: "...Dec Falls: 10 (0 with injury); Q4 Falls: 24 (0 with injury)...improvement from previous quarter...fall huddles, bed alarm rounding, and education continues...." Documentation under "Action" reads: "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #45.

ii. Pharmacy & Therapeutics Committee Report: "Discussion" reads: "...Bar Code Scanning Dec = 91%; Q4 2018 Bar Code Scanning = 92%... no longer incentivizing this for the RNs...." Documentation under "Action" reads: "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #10.

iii. No documented evidence of a Safety Committee Report, Medical Staff Quality Report, or Compliance Committee presented to the CQPI Committee. Documentation under "Discussion" for these three (3) committees/reports reads: "...Tabled...." No documented evidence under "Action". Documentation under "Follow-Up/Responsible Party reads: Safety Committee Report - Personnel #46; Medical Staff Quality Report - Provider #1; and Compliance Committee - Personnel #47.

iv. Medical Director "E" (excused) from the meeting, no other physician in attendance.

Document titled "CQPI Committee Minutes" (04/15/2019) revealed the following:

i. Patient Safety Committee Report: "Discussion" reads: "...Mar Falls: 10 (1 with injury); Q1 Falls: 32 (2 with injury)...increase from previous quarter...fall huddles, bed alarm rounding and education continues...." Documentation under "Action" reads "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #2.

ii. Pharmacy & Therapeutics Committee Report: "Discussion" reads: "...Bar Code Scanning Mar = 91%; Q1 2019 Bar Code Scanning = 91%; Benchmark set for 95%...verbal warning will be given to RN at or below 60% and will slowly increase this to 95% each quarter...." Documentation under "Action" reads "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #10.

iii. Complaints/Grievances and Incident Reports: "Discussion" reads: "...Incident Report Summary (up from Q4)...Jan = 41 (2.9% rate)...Feb = 31 (2.3% rate); Mar = 32 (2.2% rate); Q1 Total = 104 (up)...Med Variances continue to be the largest category followed by Falls and Hypoglycemic events...Majority of incidents are in the Level 0-1 severity category; Falls...Jan = 14 (no injury); Feb = 8 (1 injury); Mar = 10 (1 injury)...." Documentation under "Action" reads: "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #48.

iv. No documented evidence of a Safety Committee Report, Medical Staff Quality Report, or Compliance Committee presented to the CQPI Committee. Documentation under "Discussion" for these three (3) committees/reports reads: "...Tabled...." No documented evidence under "Action". Documentation under "Follow-Up/Responsible Party reads: Safety Committee Report - Personnel #2; Medical Staff Quality Report - Provider #1; and Compliance Committee - Personnel #47.

v. Medical Director "E" (excused) from the meeting, no other physician in attendance.

Document titled "CQPI Committee Minutes" (08/02/2019) revealed the following:

i. Patient Safety Committee Report: "Discussion" reads: "...Q2 Falls: 30 (2 with injury)...fall huddles, bed alarm rounding and education continues...." Documentation under "Action" reads "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #3.

ii. Pharmacy & Therapeutics Committee Report: "Discussion" reads: "...Bar Code Scanning: Apr: 91%; May: 91%; June: 93%...Q2: 91.67%......." Documentation under "Action" reads "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #3.

iii. Health Information Management Report: "Discussion" reads: "...Delinquency Rate...June 0%...." Documentation under "Action" reads "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #3.

iv. Performance Improvement Teams/Initiatives: "Discussion" reads: "...Insulin Administration...still seeing unlabeled..." Documentation under "Action" reads "...Informational...." Documentation under "Follow-Up/Responsible Party reads: Personnel #2 and Personnel #10.

v. No documented evidence of a Safety Committee Report, Medical Staff Quality Report, or Compliance Committee presented to the CQPI Committee. Documentation under "Discussion" for these three (3) committees/reports reads: "...Tabled...." No documented evidence under "Action". Documentation under "Follow-Up/Responsible Party reads: Safety Committee Report - Personnel #3; Medical Staff Quality Report - Provider #1; and Compliance Committee - CEO.

vi. Medical Director "E" (excused) from the meeting, no other physician in attendance.

Personnel #3 confirmed during an interview conducted 08/13/2019 (1230), that the 2019 CQPI Committee minutes did not have documented evidence of tracking or analyzing the data that was below threshold and/or follow-up for missing reports. Personnel #3 revealed that the only QAPI plans was the KRS Quality Strategic Plan (no approval date by the Board of Managers), and the "DHEVRH Plan - Continuous Quality and Performance Improvement (CQPI) Plan" (last approved by the Board of Managers: 10/05/2016). Additionally, Personnel #3 confirmed that there is a separate Patient Safety Committee that meets quarterly, prior to the CQPI Committee meetings, but that not all of the data from the Patient Safety Committee is captured in the CQPI Committee meetings.

Personnel #4 confirmed during an interview conducted 08/14/2019 (1050), that s/he had reviewed the 2019 CQPI Committee minutes, and that there was no documented evidence of analyzing the data that was below threshold and/or follow-up for missing reports. Additionally, Personnel #4 stated that the Board of Managers is provided a packet of quality indicators/data for their quarterly meetings, but that the Board of Managers meeting minutes showed no documented evidence of discussion of the information.

Based on review of the facility's policies/procedures, documents, and interviews, it was determined that the Governing Body failed to ensure that the QAPI program identified opportunities for improvement, set priorities for performance improvement activities, and tracked performance to confirm that improvements are sustained. This deficient practice poses a risk to the health, and safety of the patients when the Governing Body fails to have oversight of the QAPI program that affects health outcomes, patient safety, and quality of care.

Findings include:

Policy titled "DHEVRH Governance Board of Managers" (#LD100, last reviewed: 02/2018) revealed: "...the hospital Board of Managers is responsible for the governance of the hospital with ultimate authority for the safety, quality of care, treatment, and services...."

Policy titled "DHEVRH Responsibilities of Board of Managers" (#LD105, last reviewed: 02/2018) revealed: "...the Board of Managers responsibilities include...provide oversight among the hospital's leaders, and medical staff for the coordination and integration of these leaders to establish policies and procedures, maintain quality care, and patient safety...."

Policy titled "DHEVRH Plan - Continuous Quality and Performance Improvement (CQPI) Plan" (#LD255, last approved: 10/2016) revealed: "...purpose of the CQPI is to ensure that the hospital provides...high quality, safe...care...the hospital will measure additional indicators for each department within the hospital...Board of Managers...oversee the planning, design, implementation, and on-going monitoring...a prioritization grid is used to score and rank activities and projects...."

Documents titled "DHEVRH Board of Managers Minutes" (01/29/2019; 04/30/2019), confirmed no documented evidence of setting priorities for performance improvement activities, or tracking performance to ensure improvements are sustained.

Documents titled "DHEVRH Medical Executive Committee Minutes" (01/17/2019; 04/18/2019), confirmed no documented evidence of setting priorities for performance improvement activities, or tracking performance to ensure improvements are sustained.

Documents titled "DHEVRH CQPI Committee Minutes" (01/15/2019; 04/15/2019, 08/02/2019), confirmed no documented evidence of setting priorities for performance improvement activities, or tracking performance to ensure improvements are sustained.

Documents titled "DHEVRH Patient Safety Committee Meeting Minutes" (01/11/2019, 04/03/2019), confirmed that patient safety data, and information was reported, with opportunities for improvement identified. Both Patient Safety Committee meetings were held prior to the CQPI Committee meetings, and Board of Managers meetings (dates noted above), however, the identified patient safety data, and information, with opportunities for improvement, showed no evidence of being referred to the governing body (Board of Managers).

The surveyor reviewed the above committee meeting minutes. It was revealed, that there was no documented evidence that data below threshold, or on-going identified patient care problems/concerns, were analyzed, tracked, and/or evaluated. Additionally, there was no documented evidence, or required action to address that for the three (3) CQPI Meetings held during 2019, there were no reports presented from the following: Safety Committee, Medical Staff Quality, or Compliance Committee.

Personnel #3 confirmed during an interview conducted 08/13/2019 (1230), that the 2019 CQPI Committee minutes did not have documented evidence of tracking or analyzing the data that was below threshold and/or follow-up for missing reports. Additionally, Personnel #3 revealed that the data in the CQPI Meeting Minutes was provided for the packet that is given to the Board of Managers.

Personnel #4 confirmed during an interview conducted 08/14/2019 (1050), that s/he had reviewed the 2019 CQPI Committee minutes, and that there was no documented evidence of analyzing the data that was below threshold and/or follow-up for missing reports. Additionally, Personnel #4 stated that the Board of Managers is provided a packet of quality indicators/data for their quarterly meetings, but that the Board of Managers meeting minutes showed no documented evidence of discussion of the information.

Based on review of the facility's policies/procedures, documents, and interviews, it was determined that the Governing Body failed to ensure that the QAPI program included all hospital departments, and services, including those services furnished under contract or arrangement. This deficient practice poses a risk to the health, and safety of the patients when the Governing Body has not required that the Dietary Services Manager, Infection Control Coordinator, or evaluation of contract services be included in the CQPI Committee.

Findings include:

Policy titled "DHEVRH Governance Board of Managers" (#LD100, last reviewed: 02/2018), revealed: "...the hospital Board of Managers is responsible for the governance of the hospital with ultimate authority for the safety, quality of care, treatment, and services...."

Policy titled "DHEVRH Plan - Continuous Quality and Performance Improvement (CQPI) Plan" (#LD255, last approved: 10/05/2016), revealed: "...purpose of the CQPI is to ensure that the hospital will measure additional indicators for each department within the hospital...Board of Managers...ultimate authority...committed to...quality and safe patient care and services...reporting of organizational performance and improvement is reported at least quarterly with a summary of significant improvements, and significant issues...Board of Managers...oversee the planning, design, implementation, and on-going monitoring...."

Documents titled "CQPI Committee Minutes" (01/15/2019; 04/15/2019; 08/02/2019), revealed the following: No documented evidence that the Dietary Services Manager or Infection Control Coordinator attended any of the three (3) 2019 CQPI Committee meetings. Additionally, there was no documented evidence that services furnished under contract or arrangement, was included in any of the three (3) 2019 CQPI Committee meetings.

Personnel #21 confirmed during an interview conducted 08/13/2019 (1510), that s/he attends the CQPI Committee meetings, but that s/he does not present any data on behalf of Dietary Services. Additionally, Personnel #21 revealed that s/he is not involved in monitoring performance improvement activities for Dietary Services.

Personnel #23 confirmed during an interview conducted 08/13/2019 (0907), that s/he has been the Infection Control Coordinator for the past three (3) months, but that s/he has not attended any CQPI Committee meetings.

Personnel #3 confirmed during an interview conducted 08/13/2019 (1230), that the Dietary Services Manager or Infection Control Coordinator had not been previously invited to attend the CPQI Committee meetings, and that 08/02/2019, was the first CQPI Committee that s/he has chaired.

Based on review of the facility's policies/procedures, documents, and interview, it was determined that the Governing Body failed to ensure that QAPI activities, specific to the quality of care, and patient safety are prioritized, evaluated, and that the number of distinct improvement projects are conducted annually . This deficient practice poses a risk to the health, and safety of the patients when the Governing Body fails to demonstrate compliance with this requirement.

Findings include:

Policy titled "DHEVRH Governance Board of Managers" (#LD100, last reviewed: 02/2018), revealed: "...the hospital Board of Managers is responsible for the governance of the hospital with ultimate authority for the safety, quality of care, treatment, and services...."

Policy titled "DHEVRH Responsibilities of Board of Managers" (#LD105, last reviewed: 02/2018), revealed: "...the Board of Managers responsibilities include...provide oversight among the hospital's leaders, and medical staff for the coordination and integration of these leaders to establish policies and procedures, maintain quality care, and patient safety...."

Policy titled "DHEVRH Plan - Continuous Quality and Performance Improvement (CQPI) Plan" (#LD255, last approved: 10/2016) revealed: "...Board of Managers...ultimate authority...committed to...quality and safe patient care and services...Board of Managers...oversee the planning, design, implementation, and on-going monitoring...."

Documents titled "DHEVRH Board of Managers Minutes" (01/30/2018; 04/30/2018; 07/31/2018; 01/29/2019; 04/30/2019), confirmed no documented evidence of the Governing Body, setting priorities for performance improvement of quality of care, and safe patient care. Additionally, the documents revealed no documented evidence that performance improvement actions were evaluated, or that distinct improvement projects was conducted annually.

The surveyor reviewed the above "DHEVRH Board of Managers Minutes". It was revealed, that there was no documented evidence or required action requested by the Board of Managers to address that for two (2) CQPI Meetings held during 2019 (01/15/2019; 04/15/2019), there were no reports presented from the following: Safety Committee, Medical Staff Quality, or Compliance Committee, and therefore data from these reports were not reported to the Board of Managers at any time during 2019.

Personnel #3 confirmed during an interview conducted 08/13/2019 (1230), that the 2019 CQPI Committee minutes had no documented evidence of reports from the following: Safety Committee, Medical Staff Quality, or Compliance Committee. Additionally, Personnel #3 revealed that the data in the CQPI Meeting Minutes is provided for the packet that is given to the Board of Managers.

Based on review of facility's policies/procedures, documents, Electronic Medical Records (EMR), and interview, it was determined that the facility failed to ensure that the medical staff adhere to the facility's requirements that telephone/verbal orders be signed by the physician no later than forty-eight (48) hours after the order is given. This deficient practice poses a potential risk to the health, and safety of the patients when the medical staff fails to authenticate a telephone/verbal order to ensure the accuracy, and integrity of the order.

Findings include:

Policy titled "DHEVRH Telephone and Written Orders-General" (#PC269, last reviewed: 08/2016), revealed: "...telephone orders...the prescribing practitioner must sign the written record of the telephone order within the time period stated in the Medical Staff ByLaws..."

Document titled "DHEVRH ByLaws of the Medical Staff" (Approval: 04/30/2019), revealed: "...Article XIV...Rules and Regulations...a physician member of the Medical Staff shall be responsible for the medical care, and treatment of each patient in the hospital...for the completeness, and accuracy of the medical record...each practitioner must assure timely, adequate professional care for their patients...physicians ensure that medical records are accurate, complete...Medical Records...Verbal and Telephone Orders...all verbal orders must be dated, timed, and authenticated within forty-eight (48) hours by the prescriber...."

Document titled "DHEVRH Board of Managers Minutes" (01/29/2019), revealed:

i. No documented evidence that a Health Information Management report was presented. No documented evidence of physician EMR compliance.

Document titled "DHEVRH Board of Managers Minutes" (04/30/2019), revealed:

i. Health Information Management: "...Josh reported on the HIMS Summary...delinquency rate under 3%...please see packet for additional data...." No documentation under "Action". No documentation under Follow-Up/Responsible Party noted. No documented evidence of medical staff EMR compliance, specific for telephone/verbal orders.

Documents titled "DHEVRH Continuous Quality & Performance Improvement Committee Minutes" (01/15/2019, 04/15/2019, 08/02/2019), revealed:

i. Health Information Management: No documented evidence of medical staff EMR compliance, specific for telephone/verbal orders.

Documentation of thirty (30) EMR telephone/verbal orders, with date range 10/25/2016 through 08/13/2019, revealed the following: Sixteen (16) out of thirty (30) telephone/verbal orders were not signed within the required forty-eight (48) hours (46% compliance).

Personnel #2 confirmed during an interview conducted 08/14/2019 (1155), that of the thirty (30) verbal/telephone orders reviewed, eleven (11) verbal/telephone orders were not signed by the physician, and five (5) verbal/telephone orders were signed by the physician but not within the forty-eight (48) hour requirement.

Based on review of facility's policies/procedures, documents EMR, and interview, it was determined that the facility failed to ensure that the medical staff adhere to the facility's requirements that the completion of the EMR be signed by the physician no later than thirty (30) days after the patient's discharge. This deficient practice poses a potential risk to the health, and safety of the patients, when the medical staff failed to complete, and authenticate the patient's medical record that was used for accurate billing, and/or for continuity of care.

Findings include:

Policy titled "Dignity Health East Valley Rehabilitation Hospital (DHEVRH) Medical Record Completion" (#HM12.58, last reviewed: 12/2018), revealed: "...patient records shall be considered compete when contents are...authenticated...the medical record shall be completed (dictations and signatures) within thirty (30) days from the patient's discharge according to Medical Staff ByLaws (Rules & Regulations)...."

Policy titled "DHEVRH Quarterly HIM Report" (#HM12.15, last reviewed: 12/2018), revealed: "...the HIM manager or designee will submit a quarterly report to the hospital Quality Committee that addresses quality indicators such as the following...Physician Peer Review of Documentation Summary...Multidisciplinary Review Summary...Record Completion Summary (Delinquent Record %)...measured monthly and quarterly...Recommendations and follow-up...."

Document titled "DHEVRH ByLaws of the Medical Staff" (Approval: 04/30/2019), revealed: "...Article X: Medical Staff Committees and Meetings...A...Executive Committee...Duties...duties of the Executive Committee shall be..authority over...Health Information Function...responsible for assuring that all medical records meet the highest standards of patient care...Article XIV...Rules and Regulations...a physician member of the Medical Staff shall be responsible for the medical care, and treatment of each patient in the hospital...for the completeness, and accuracy of the medical record...each practitioner must assure timely, adequate professional care for their patients...physicians ensure that medical records are accurate, complete...Medical Records...all clinical entries in the patient's medical record including dictation, and transcription shall be accurately dated, and authenticated...a medical record shall be deemed delinquent when not complete within thirty (30) days after patient discharge...."

Document titled "DHEVRH Board of Managers Minutes" (01/29/2019), revealed:

i. No documented evidence of Health Information Management report presented. No documented evidence of physician EMR compliance that the patient's medical record is completed within thirty (30) days after patient discharge.

Document titled "DHEVRH Board of Managers Minutes" (04/30/2019), revealed:

i. Health Information Management: "...Josh reported on the HIMS Summary...delinquency rate under 3%...please see packet for additional data...." No documentation under "Action". No documentation under Follow-Up/Responsible Party noted.

Document titled "DHEVRH Continuous Quality & Performance Improvement Committee Minutes" (01/15/2019), revealed:

i. Health Information Management: "...Delinquency Rate...Dec = 2%...Delinquency Rate...Q4 = 1%...." Documentation under "Action" reads: "...Informational...." Documentation under Follow-Up/Responsible Party reads: Personnel #49.

Document titled "DHEVRH Continuous Quality & Performance Improvement Committee Minutes" (04/15/2019), revealed:

i. Health Information Management: "...Delinquency Rate...Mar = 4%...Delinquency Rate...Q1 = 2% (up)..." Documentation under "Action" reads: "...Informational...." Documentation under Follow-Up/Responsible Party reads: Personnel #48.

Document titled "DHEVRH Continuous Quality & Performance Improvement Committee Minutes" (08/02/2019), revealed:

i. Health Information Management: "...Delinquency Rate...April 6%...May 3%...June 0%...." No documentation under "Action". Documentation under "Action" reads: "...Informational...." Documentation under Follow-Up/Responsible Party reads: Personnel #3.

Document named "Delinquencies with Charts" was provided and revealed the following data:

i. 05/2019 - a total of twenty (20) EMRs were found not to be 100% complete within the required thirty (30) days after patient discharge. The number of days of non-compliance (greater than thirty (30) days) was from one (1) day, with a maximum of nineteen (19) days.

ii. 06/2019 - a total of ten (10) EMRs were found not be to 100% complete within the required thirty (30) days after patient discharge. The number of days of non-compliance (greater than thirty (30) days) was from one (1) day, with a maximum of twelve (12) days. Additionally, there were six (6) EMRs that had not been reviewed for the thirty (30) day compliance.

The above documents were reviewed, and found that the "DHEVRH Continuous Quality & Performance Improvement Committee Minutes" (08/02/2019), read: "...Delinquency Rate...June 0%....", but during interview the surveyor was informed that based on the "Delinquencies with Charts" report, Delinquency Rate for June was 7.3%

Personnel #3 confirmed during an interview conducted 08/14/2019 (1038), that the "Delinquencies with Charts" report tracks data indicating that the EMR was not completed within the required thirty (30) days after patient discharge, and that the June 2019 data showed EMR delinquency rate for this requirement to be 7.3%.

Based on review of the facility's policies/procedures, documents, and interviews, the facility failed to ensure that a Utilization Review (UR) committee was established, consisted of at least two (2) physicians, and verified that the committee or group reviews were not conducted by any person who is professionally involved in the care of the patient whose case was reviewed. This deficient practice poses a risk to the health, and safety of the Medicaid and Medicare patients, when the facility could not demonstrate that a UR Committee wasi established, and on-going to address the review of services provided by the facility, and medical staff.

Findings include:

Policy titled "DHEVRH Plan -Utilization Review Plan" (#LD290, last reviewed: 09/2016) revealed: "...The Hospital, it's Board of Managers, and Medical Staff, in conformance to regulatory, and accreditation requirements...describes its UR Plan, that provides for review of services furnished by the hosptial and by members of the medical staff to all patients...purpose...address the medical necessity of admissions, length of stay, and professional services...assure effective and efficient utilization of the hospital services...promote and maintain high quality care through analysis, review, and evaluation of clinical practices within the hosptial...assure than any influence other than need is identified, analyzed, and minimized toward the encouragement of appropriate utilization...UR Plan is the responsibility of the Medical Staff...the hospital through its Medical Staff, elects to carry out the function of UR through the Medical Executive Committee (MEC)...MEC appoints a minimum of two (2) UR physicians...it is the responsibility of physicians to review cases and case data with the MEC to make appropriate decisions...the attending physician of any patient being discussed during the UR portion of the committee meeting may be invited to attend the meeting, but does not have voting power...no physician involved in the UR review process shall review any cases in which he/she is professionally involved...the Case Management representative or designee appointed by the Chief Executive Officer (CEO) serves as secretary of the UR subcommittee and is responsible for all minutes and records...the hospital administration provides assistance to the UR Committee by considering, and acting upon decisions, and recommendations made by the UR Committee with respect to the UR Plan...The UR Plan is reviewed, and evaluated annually by the Medical Staff, and Board of Managers...."

Document titled "DHEVRH ByLaws of the Medical Staff" (approval: 04/2019) revealed: "...Functions of the MEC...Utilization Management Function...functions may include, but not limited to...admission review of the patient records for the purpose of determining appropraite level of care, certifying admission, and initial assignment of appropriate lengths of stay...continued stay reviews...review and assessment of aspects of the quality of care being provided...identifying utilization-related problems through the analysis of admission review, continued stay, and support service appropriateness...analysis of delays in the provisions of support services...conducting on-going retrospective monitoring of the hosptial's utilization of resources for the purpose of identifying problems , and documenting the results of actions taken...reporting findings to appropriate committees , and programs of the Medical Staff, the CEO, and the Board of Managers...."

Document titled "DHEVRH Utilization Review Committee" (07/25/2019) revealed that three (3) physician names were listed as "participants", but that two (2) of three (3) physicians were "E" (excused) from the meeting.

Document titled "DHEVRH Board of Manager Minutes" revealed that the UR Plan was last approved on 10/05/2016.

Personnel #12 confirmed during an interview conducted 08/14/2019 (0800), that the "DHEVRH Utilization Review Committee" meeting minutes (07/25/2019), was the only UR Committee meeting minutes available, and that prior to that time, s/he was not aware that a formalized UR Committee was required, and that Personnel #47 never informed him/her of this requirement. Personnel #12 revealed that a formalized UR Committee has only met one (1) time in the past year, with the meeting date of (07/25/2019), and that only one (1) physician was present. It was revealed that s/he provides UR/Discharge Planning data for the CQPI Committee meetings. Additionally, Personnel #12 confirmed that s/he has reviewed the "DHEVRH Plan -Utilization Review Plan", put was not aware that the plan requires annual review by the MEC or Board of Managers.

Based on review of the facility's policies/procedures, documents, and interviews, it was determined that the facility failed to ensure that under the Prospective Payment System (PPS), the UR Committee reviewed outlier cases with extended length of stays exceeding the threshold for a specific diagnosis. This deficient practice poses a potential risk to the health, and safety of the patients, when a UR Committee did not discuss patient care needs in a timely manner to include medical necessity or length of stay.

Findings include:

Policy titled "DHEVRH Plan - Utilization Review Plan" (#LD290, last reviewed: 09/2016) revealed: "...UR Committee...the Medical Executive Committee (MEC) appoints a minimum of two (2) Utilization Review physicians...it is the responsibility of the physicians to review cases, and case data with the MEC...data and information originate from the hospital utilization review screening sub-committee...MEC minutes shall include UR discussion, that at a minimum reflect a summary of the number/type of cases reviewed, problems identified, recommendations, and corrective action plans as they relate to UR...the Case Management representative or designee appointed by the CEO serves as the secretary of the UR sub-committee, and is responsible for all minutes, and records...the findings, disposition of cases, and issues reviewed by the UR sub-committee are reflected in the committee minutes will be submitted to the MEC for review...."

Document titled "DHEVRH Medical Executive Committee Minutes" (01/17/2019) revealed:

i. Utilization Review: "...LOS Efficiency: 2.90...Discharge to Community 85.5%...Discharge to SNF 4.0%...Discharge to Acute 10.5%...Facility PEM Score 83...." Documentation under "Action" reads: "...Informational...." No documentation under Follow-Up/Responsible Party noted.

ii. Medical Staff Participants attending the meeting: Provider #1, Provider #11; Medical Staff Participants not attending the meeting: Provider #10, Provider #12.

Document titled "DHEVRH Medical Executive Committee Minutes" (04/18/2019), revealed the following:

i. Utilization Review: "...LOS Efficiency: 3.10...Discharge to Community 76.9%...Discharge to SNF 10.6%...Discharge to Acute 12.5%...Facility PEM Score 78.5 with a goal of 82.5...." Documentation under "Action" reads: "...Informational...." No documentation under Follow-Up/Responsible Party noted.

ii. Medical Staff Participants attending the meeting: Provider #1, Provider #11, Provider #12; Medical Staff Participant not attending the meeting: Provider #10.

Documents were reviewed, but no documented evidence of thresholds were found, with the exception of the Facility PEM Score noted in the 04/18/2019 MEC Minutes. The documents revealed no UR discussion, that at a minimum reflected a summary of the number/type of cases reviewed, problems identified, medical necessity, recommendations, and/or corrective action plans. It was noted, that the MEC meets quarterly, but the UR data documented does not refer to the time period that the data was collected. Additionally, there has only been one (1) UR Committee meeting held in the past year (07/25/2019).

Personnel #3 confirmed during an interview conducted 08/14/2019 (1030), that the facility is paid under the PPS. Additionally, Personnel #3 revealed that UR Committee meeting minutes dated: 07/25/2019, was the only UR Committee meeting minutes available.

Personnel #12 confirmed during an interview conducted 08/14/2019 (0800), that s/he has never been asked to attend the MEC meeting, and that the UR/case management data is collected, and sent to the Quality Department. Additionally, Personnel #12 revealed that there have been patients who have had an extended length of stay, and that these cases are discussed in the weekly patient care meetings with the providers/staff, and that the case managers would document the information in the patient's EMR.

Based on review of the facility's policies and procedures, observation on tour, and staff interviews, it was determined that the facility failed to require that medical supplies, and dietary nourishments used for patient care were not expired. This deficient practice poses a potential risk for the health and safety of patients, when the hospital cannot ensure that the potential risk for infection, negative outcomes and/or false laboratory testing may result when using expired supplies and/or nourishments.

Findings include:

Policy titled "DHEVRH, Hospital Wide Infection Control Plan" (#IC-105, last reviewed: 02/2018), requires: "...an effective Infection Prevention and Control Program (IPCP) requires the involvement of leadership, physicians, and staff, to develop, implement and evaluate the program...strategies to minimize risks...environmental rounds will be monthly to evaluate infection control practices...."

Policy titled "DHEVRH Food Storage" (#FDS 6.23, last reviewed: 02/2018), requires: "...to provide a rotation/inventory system that will ensure that foods are used on a first-in-first-out basis...to prevent the contamination of perishable items caused by continuous holding and storage of foods...all foods (dry, refrigerated)...shall be rotated on a first-in-first-out basis...shall be rotated so that the most recent deliveries are placed in the latter part of the storage area...previously delivered items are place in front..."

Expired supplies is not addressed in the Infection Control Plan.

Observations on hospital tour conducted 08/12/2019 (1000-1050), the surveyor identified a total of fifty-one (51) expired supplies and/or nourishments from the following departments:

Nursing Unit (1st Floor for patient rooms #101-113): A total of twenty (20) expired supplies and/or nourishments was found in the Medication Room and Nourishment Room. These expired items included: BD Vacuatiner blue top vials, Hormel Thick & Easy Apple Juice, and Cranberry Juice. Confirmation of the above expired items were confirmed with Personnel #19 and Personnel #30.

Nursing Unit (1st Floor for patient rooms #114-126): A total of twenty-four (24) expired supplies and/or nourishments was found in the Medication Room and Nourishment Room. These expired items included: Nutricia Pro-Stat, Chlora-Prep, Xpert Nasal Sample Collection Kit, Hormel Thick & Easy Apple Juice, Cranberry Juice, and Orange Juice, and Juven Therapeutic Nutrition Powder.

The above expired items were confirmed with Personnel #29 and Personnel #39.

Nursing Unit (2nd Floor): A total of seven (7) expired supplies and/or nourishments was found in the Medication Room and Nourishment Room. These expired items included: BBL Culture Swab, Alaris Luer Lock Caps, BD Vacutainer gray top, Hormel Thick & Easy Apple Juice.

The above expired items were confirmed with Personnel #40.

Personnel #25 confirmed during an interview conducted 08/12/2019 (1430), that refrigerated nourishments supplied to the Nourishment Rooms on each Nursing Unit should be stocked according to the expiration dates, with the furthest expiration date being placed in the back or the refrigerator, and the nearest expiration date being placed in the front of the refrigerator.

Personnel #25 revealed that dietary personnel are responsible for stocking the refrigerators in the Nourishment Rooms on each Nursing Unit.

Personnel #2 confirmed during an interview conducted 08/13/2019 (0815), that the above identified supplies and/or nourishments were expired, and should have been removed from inventory no later than the expiration date. All fifty-one (51) expired supplies and/or nourishments were individually logged by the surveyor, and given to Personnel #1, #2, and #3 for inspection prior to being discarded.

Based on review of the facility Emergency Preparedness plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for tracking of staff and sheltered patients during an emergency. Failure to adequately track patients and staff during an emergency could lead to harm to both patients and staff if staff and patient location/whereabouts are not known.

Findings include:

The facility Emergency Plan specifically relating to the facility process for the tracking of sheltered/evacuated patients and staff during an emergency was requested on August 13, 2019. The emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency.

The Resource Chief Executive Officer (CEO) and the Director of Plant Ops confirmed during an exit conference on August 13, 2019, the emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency.

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to have policies and procedures for safe evacuation from the facility including consideration of care needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance. Failure to include a process for cooperation and collaboration could lead to harm to both patients and staff.

Findings include:

The facility Emergency Plan specifically relating to the facility process for safe evacuation on August 13, 2019. The plan did not include policies and procedures for safe evacuation from the facility including consideration of care needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance.

The Resource CEO and the Director of Plant Ops acknowledged on August 13, 2019, during the exit conference, that the Emergency Plan did not include policies and procedures for safe evacuation from the facility including consideration of care needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance.

Based on review of the facility emergency plan, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for sheltering in place during an emergency. Failure to adequately shelter in place during an emergency could potentially lead to harm for both patients and staff, if the facility does not have processes and supplies readily available to institute when patients and staff cannot leave the facility.

Findings include:

The facility Emergency Plan related to a process for sheltering patients and staff during an emergency was requested on August 13, 2019. The Emergency Plan (EP) did not identify a process for sheltering patients and staff during an emergency.

The Resource CEO and the Director of Plant Ops confirmed on August 13, 2019, the facility EP plan did not identify a process for sheltering patients and staff during an emergency.

Based on review of the facility Emergency Preparedness (EP) Testing Requirements, facility documents and staff interview, it was determined the facility failed to conduct exercises to test the emergency plan at least annually. Failure to conduct exercises to test the emergency plan could lead to harm to both patients and staff.

Findings include:

The facility's documentation related to their Emergency Preparedness Testing Requirements was requested on August 13, 2019. The Emergency Preparedness Testing Requirements did not have documented the following: Participate in a full-scale exercise that is community-based.

The Resource CEO and the Director of Plant Ops confirmed during an interview on August 13, 2019, that the facility EP did not have documentation to demonstrate their participation in a full-scale exercise that is community-based.
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