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Based on observation and interview, it was determined the CAH failed to ensure an uncluttered physical environment in 1 of 1 eyewash station/decontamination shower observed in the hospital's laboratory. This cluttered environment had the potential to interfere with staff safety by creating a barrier to accessing eyewash/decontamination equipment. Findings include:

The laboratory was toured on 8/25/10 beginning at 1:20 PM. Surveyors observed an eyewash station/decontamination shower stall with boxes stacked on the floor of the stall and the curtain closed, limiting accessibility. The boxes contained urine collection cups for drug screening. Eyewash stations/decontamination showers are used in emergencies to flush away hazardous substances that can cause injury.

During an interview on 8/25/10 at 2:55 PM, the Laboratory Director confirmed boxes were stored in the eyewash station/decontamination shower stall. When asked how staff would access the eyewash station or the shower in the event of an emergency, she replied they would have to move the boxes.

The CAH failed to ensure the laboratory's eye wash station/decontamination shower stall was uncluttered and easily accessible to staff.

Based on staff interview, observation of patient care, and review of hospital policies, it was determined the CAH's governing body failed to ensure an active Infection Control Program had been implemented. This resulted in a lack of direction to staff and compromised the CAH's ability to monitor patients and staff for infections. Findings include:

1. On 8/26/10 beginning at 11:25 AM, Staff D, the former DNS, was interviewed. She stated the CAH had an inactive Infection Control Committee. She stated the committee met last in April of 2009 (16 months prior).

The Administrator was interviewed on 9/01/10, beginning at 3:30 PM. He stated he could not remember why the Infection Control Committee had ceased to function at that time and confirmed the lack of infection control activities. He stated the current DNS was developing a new infection control program.

2. The CAH's infection control program had ceased to function. Refer to C278 as it relates to the lack of infection control activities.

The Governing Body failed to monitor the infection control program and ensure it was functioning.

Based on staff interview, observation of patient care, and review of hospital policies, it was determined the CAH failed to ensure an active Infection Control Program and failed to ensure staff observed isolation precautions in 1 of 1 patient (#1) whose dressing change procedure was observed and had the potential to impact all patients receiving services at the CAH. A failure to have an active Infection Control program had the potential to result in missed opportunities to prevent or control infections in patients and/or personnel. A failure to observe isolation precautions had the potential to cause spread of infection. Findings include:

1. On 8/26/10 beginning at 11:25 AM, the former DNS was interviewed. She explained that until 8/01/10 she had been in charge of the Infection Control Program, filling in for another employee who had been out due to illness for an undetermined period of time (at least a year). She stated that at the time she took over the program, she asked the previous Infection Control Officer what needed to be done, and was told she needed to check the laboratory results monthly to identify possible hospital acquired infections (nosocomial infections). She stated she performed this task monthly and reported the results to Quality Assurance and Medical Staff monthly. In addition, she documented reports from physicians' offices related to patients who developed infections after discharge from the hospital. She stated she included this information on the previously referenced report.

During the interview, she responded to a number of additional questions from surveyors, including the following:

When asked if she maintained a log of infections, in addition to the monthly report (previously referenced), she said she did not.

When asked if she tracked other types of infections (besides hospital-acquired infections), such as staff infections or infections patients had at the time of hospital admission, she said she did not. She stated she thought the Employee Health Nurse might have been monitoring employee infections but she was not sure.

When asked if the CAH had an Infection Control Committee, and how often they met, she replied the hospital did have an inactive committee whose last meeting had been in April of 2009 (16 months prior). A policy, dated 6/18/04, "Infection Control Committee Responsibilities," stated the Infection Control Committee included the Medical Staff Advisor, Infection Control Practitioner, representatives from Nursing Service, Administration, Laboratory, Housekeeping, Pharmacy. It further stated the Infection Control Committee would meet no less often than quarterly.

She concluded by stating it was her last day of work and she intended to suggest during an exit interview that hospital administration assign someone to the role of Infection Control Officer who did not have other responsibilities and could dedicate time to infection control.

2. A policy, dated 6/18/04, "Employee Health Program" stated the Employee Health Nurse and/or Infection Control Nurse would monitor employee infections.

On 8/26/10 at 1:50 PM, Staff F, an LPN, was interviewed. She stated she functioned in the role of the Employee Health Nurse. When asked if she monitored employee infections, she stated she did not do so, that the CAH did not have any active surveillance program. When asked regarding any training for the role of Employee Health Nurse, she indicated she had not received any special training.




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3. Isolation procedures were not followed.

Patient #1's medical record documented a 74 year old male who was admitted to Swing bed status on 8/15/10 for acute and chronic cellulitis of his left lower extremity. A culture report of Patient #1's leg wound, dated 8/22/10, documented pseudomonas acidovorans bacteria. An order, dated 8/15/10, placed Patient #1 in isolation for Contact Precautions. The sign for contact precautions on Patient #1's door stated, "ANYONE ENTERING THIS ROOM MUST WEAR: Gloves, Gown."

An observation, beginning at 3:05 PM and ending at 3:35 PM on 8/25/10, showed the leg had large open wounds of greater than 4 inches. The wound was being debrided by the PT so it was difficult to assess the amount of drainage. Using a betadyne solution, the PT was rubbing on the wound with a surgical scrub brush and removing dead tissue with tweezers. The PT was wearing gloves and boots but was not wearing a gown or mask. Patient #1 was sitting in a cloth covered recliner with his legs up. His legs were resting on the chair's foot rest. A cotton bath blanket was between his legs and the foot rest. A waterproof pad was on the floor under the chair but no waterproof barrier protected the foot rest. Periodically, the PT would pour a bottled saline solution on the leg to rinse it. The saline drained directly onto the bath blanket and soaked down to the cloth foot rest. When he was finished, the PT removed his gloves and boots and left the room directly. He opened a hall door and walked downstairs without washing his hands.

The DNS was interviewed about the wound care on 8/25/10 at 4:40 PM. She stated the PT should have worn a gown, placed a waterproof barrier to protect the chair, and washed his hands.

The CAH failed to develop a comprehensive infection control program and to ensure isolation procedures were followed.

Based on staff interview and review of records and policies, it was determined the CAH failed to ensure nursing staff met the needs of patients by completing full nursing admission assessments for 5 of 11 inpatients (#13, #17, #20, #28 and #30) whose records were reviewed. Incomplete initial nursing assessments had the potential to interfere with nursing care planning and to subsequently negatively impact the ability of nursing staff to meet patient needs. Findings include:

A policy, dated 6/26/03, "Admission Assessment and Reassessment," stated that upon admission, nursing staff would complete admission summary sheets that included assessments of biophysical, psychosocial, environmental, educational needs, nutritional assessment, pain assessment, and assessment for discharge planning needs.

In the examples that follow, nursing staff failed to perform, according to policy, complete admission assessments:

1. Patient #20 was an 86 year old male admitted on 8/02/10 for care related to blood disorders, hypertension, depression, diabetes, and anxiety. The Admission Nursing Assessment Form, dated 8/02/10, failed to include vital signs, height, weight, last bowel movement, reason for admission, nursing observations, a list of surgeries and illnesses in the patient's history, family health, and a review of systems (skin, HEENT, respiratory, cardiovascular, gastrointestinal, urinary, musculoskeletal, miscellaneous).

During an interview on 8/24/10 at 3:55 PM, the DNS reviewed the record and confirmed the incomplete nursing assessment.

2. Patient #13 was an 81 year old female, admitted on 5/03/10, for a stroke with weakness. Nursing staff failed to screen for nutritional risk. The Nutritional Risk Screening form in the record was blank.

During an interview on 8/24/10 at 11:00 AM, the DNS reviewed the record and confirmed the incomplete nursing assessment.



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3. Patient #30 was a 51 year old female who was admitted on 7/21/10 after sustaining a fall. She was discharged to swing bed status on 7/24/10.

The Admission Nursing Assessment Form, dated 7/21/10, failed to include vital signs, height, weight, last bowel movement, reason for admission, nursing observations, a list of surgeries and illnesses in the patient's history, family health, and a review of systems (skin, HEENT, respiratory, cardiovascular, gastrointestinal, urinary, musculoskeletal, miscellaneous).

During an interview on 8/24/10 at 3:55 PM, the DNS reviewed the record and confirmed the incomplete nursing assessment.

4. Patient #28 was a 64 year old female, who was admitted on 3/31/10 with diagnoses that included severe nausea, severe vomiting, severe diarrhea, severe anemia, chronic GI bleed, and metastatic masses in lungs. The patient was discharged on 4/03/10.

Patient #28's medical record contained the hospital's Admission Nursing Assessment Form. The following information was missing off of the assessment form: allergies, current medications, and the patient's name.

During an interview on 8/24/10 at 3:55 PM, the DNS reviewed the record and confirmed the incomplete nursing assessment.

5. Patient #17 was a 71 year old male, who was admitted on 3/29/10 with multiple diagnoses that included type II diabetes mellitus (diet controlled). The patient discharged himself on 3/31/10. Patient #17's Nutrition Risk Screening form was blank.

During an interview on 8/25/10 at 10:35 AM, the DNS reviewed the record and confirmed there was no evidence nursing staff assessed Patient #17's nutritional risk.

The CAH failed to ensure nursing staff met the needs of patients by performing complete initial nursing assessments.

Based on staff interview and review of policies and medical records, the CAH failed to ensure nursing care plans were developed or complete for 3 of 11 inpatients (#17, #34, and #35) whose records were reviewed. This had the potential to result in unaddressed patient needs. Findings include:

A policy, dated 6/26/03, "Admission Assessment and Reassessment," stated admission assessments and plans of care would be completed within 24 hours.

A hospital policy, dated 6/28/05, "Care Plans," stated the plan of nursing care reflected coordination with the overall plan of medical care and was based upon the immediate health needs of the patient.

In the examples that follow, nursing care plans were either missing entirely or incomplete based on initial nursing assessment or the overall medical plan of care:

1. Patient #17 was a 71 year old male, who was admitted on 3/29/10 with diagnoses that included type II diabetes mellitus (diet controlled). The patient discharged himself on 3/31/10. There were no nursing care plans present in the record. There was a blank nursing care plan form in the closed record.

During an interview on 8/25/10 at 10:35 AM, the DNS reviewed the record and confirmed there was no evidence a nursing care plan had been initiated for Patient #17.



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2. Patient #35 was a 77 year old female, admitted to the hospital on 8/03/10 for care related to dehydration and urinary tract infection. She was discharged from the hospital on 8/05/10. A Nutrition Risk Screening form, completed by nursing staff at the admission assessment, dated 8/03/10, indicated Patient #35 was determined to be at high nutritional risk and that Dietary should be notified. There was no evidence Dietary had been contacted for an additional nutritional assessment. There was also no evidence Patient #35's nutritional risk had been addressed on the nursing plan of care.

During an interview on 8/25/10 at 10:45 AM, the DNS reviewed the record and confirmed Patient #35 was assessed by nursing staff to be at high nutritional risk. She also confirmed there was no evidence of a dietary consult or a nursing plan of care to address nutritional needs.

During an interview on 8/25/10 at 12:45 PM, the Dietary Manager stated a request for dietary consult had been initiated on a Friday but she did not see the request until Patient #35 was discharged since she did not work the weekend. She stated nursing staff could have contacted the Dietician directly but did not do so in this case.

3. Patient #34 was a 65 year old patient, admitted to the hospital on 8/15/10 for care related to a fast and irregular heartbeat (tachycardia and dysrhythmia). The nursing plan of care did not address the need to monitor Patient #34's heart rate or rhythm.

During an interview on 8/25/10 at 10:50 AM, the DNS reviewed the record and confirmed the nursing plans of care did not include the need to monitor heart rate and rhythm. She stated she was sure nursing did monitor Patient #34's heart even if it was not on the nursing plan of care.

The CAH failed to ensure nursing care plans were developed for inpatients.

Based on staff interview and review of records and policies, it was determined the CAH failed to ensure documentation was complete for 9 of 11 inpatients (#4, #13, #17, #20, #23, #28, #30, #34, and #35) whose records were reviewed. This resulted in incomplete medical records. It had the potential to interfere with clarity of information, coordination of care, and fully informed consent. Findings include:

A hospital policy, dated 6/28/05, "Charting, General Rules," stated charting should be accurate and complete. Notations on the chart should be preceded by date and time.

Charting was incomplete in the following patient records:

1. Patient #13 was an 81 year old female, admitted on 5/03/10, for a stroke with weakness. A laboratory test, TSH, dated 5/05/10, indicated the results were critically low. There was no documentation in the record that the critically low values were reported by laboratory personnel to nursing staff, or from nursing staff to physician. In addition, the ED Consent to Treatment Form was not completely filled out. Patient #13's name was missing on the top of the form. An area to fill in "condition" was left blank. A second consent, Admission Consent, was blank and unsigned.

A hospital policy, dated 2/27/03, "Reporting Critical Values," stated lab personnel would call and report all critical values directly to the RN in charge of the inpatient and document the date, time, and the last name of the person the critical value was reported to on the report. When a nurse was notified of a critical laboratory value, he/she would inform the physician caring for the patient.

During an interview on 8/24/10 at 11:00 AM, the DNS reviewed the record and confirmed the incomplete and missing consents and lack of documentation critical values had been reported.

2. Patient #17 was a 71 year old male admitted on 3/29/10 with diagnoses that included type II diabetes mellitus (diet controlled). The patient discharged himself against medical advice on 3/31/10. There was no discharge summary present in Patient #17's medical record.

A hospital policy, dated 8/20/10, "Record Content," stated a discharge summary should be completed no later than 14 days after the patient was discharged.

In addition, the Idaho Physician Orders for Scope of Treatment (POST), dated 3/30/10 was signed by Patient #17 but not signed by the physician.

During an interview on 8/25/10 at 10:35 AM, the DNS reviewed the record and confirmed no discharge summary was present in Patient #17's medical record and the POST was unsigned by the physician.

3. Patient #23 was a 63 year old male admitted on 6/25/10 with diagnoses of constipation, bladder disorder, and adverse effects of medication. The following areas in the medical record were incomplete: A Physical Therapy note, dated 6/25/10, was untimed. A "Living Will" was present in the record but not filled out or signed.

During an interview on 8/24/10 at 3:05 PM, the DNS reviewed Patient #23's medical record and confirmed the incomplete charting.

4. Patient #20 was an 86 year old male, admitted on 8/02/10. A laboratory report, dated 8/02/10 at 9:15 AM, indicated critically low lab values (i.e. hemoglobin, hematocrit, platelets, and lymph). There was no documentation in the record the laboratory values were reported by laboratory staff to nursing staff or from nursing staff to the physician. During an interview on 8/25/10 at 10:25 AM, a physician was interviewed. She stated nursing staff had made her aware of the critical laboratory values. She acknowledged the medical record may not have reflected this information.

A Permission for Release of Information form, dated 8/02/10 was incomplete. The boxes were not checked to indicate to whom Patient #20 was authorizing release of information.

The Idaho Physician Orders for Scope of Treatment (POST), dated 7/30/10 was signed by Patient #20 but not signed by the physician.

During an interview on 8/24/10 at 3:55 PM, the DNS reviewed Patient #20's record and confirmed the incomplete charting.

5. Patient #34 was a 65 year old female, admitted to the hospital on 8/15/10 for care related to a fast and irregular heartbeat (tachycardia and dysrhythmia). She was discharged on 8/16/10. The Admission Consent form was incomplete. It did not indicate who she was authorizing to treat her, what type of treatment or operation she was consenting to, or who had explained her options to her. The ED Consent to Treatment Form was also incomplete. It did not indicate what condition for which she was authorizing treatment.

During an interview on 8/25/10 at 10:50 AM, DNS reviewed the record and confirmed the two consent forms were incomplete.

6. Patient #35 was an 87 year old female, admitted 8/03/10 with diagnoses of dehydration and urinary tract infection. The Admission Consent was initialed by Patient #35 but the form was incomplete with blank spaces. It did not indicate who Patient #35 was authorizing to treat her, or what type of treatment or operation she was authorizing, or who had explained her options to her. Patient #35's ED Consent to Treatment Form was also incomplete. There was a space left blank indicating the condition for which the patient was seeking examination and treatment

During an interview on 8/25/10 at 10:45 AM, the DNS reviewed Patient #35's record and confirmed the two consent forms were incomplete.



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7. Patient #28 was a 64 year old female who was admitted on 3/31/10 for severe vomiting, severe diarrhea, severe anemia, chronic GI bleed, and metastatic masses in the lungs.

Contained in Patient #28's closed record was the hospital's Blood Transfusion Verification Record form. The form contained two places for the names of staff verifying information (i.e., transfusion unit number, the patient's identity, confirmation the blood had not expired, confirmation the blood tag number agreed with the number on the bag, and confirmation the blood type and Rh factor on the tag agreed with those on the blood bag). One name was documented on the form as having verified the information. The form stated "Two signatures required." The Blood Transfusion Verification Record form was incomplete.

Patient #28's closed record also contained a hospital Consent for Blood Transfusion form, dated 3/31/10 at 10:55 AM. At the top of the form was a place for staff to place the physician's name who ordered the transfusion and a place for the patient's name who authorized the administration of the blood transfusion. Both spaces were blank. The consent form was incomplete.

Patient #28's record contained a nursing care plan, dated 3/31/10, that failed to document the patient's name, diagnoses, physical, psychosocial, and educational needs, and was without a signature or a date. The nursing care plan's identifying information and assessment information were incomplete.

Patient #28's medical record contained a hospital document Admission Summary Sheet. On the backside of this sheet were multiple places where patients or their representatives were to initial thereby acknowledging among other things, they understood who would be their physician, what treatments were going to be used, and what the alternatives to treatment could be. Patient #28's form was blank.

During an interview on 8/25/10 at 11:13 AM, the DNS reviewed the record and confirmed the second signature was missing on the Blood Transfusion Verification Record. She said that she was one of the nurses taking care of Patient #28 and that she did have a second nurse verify the information but failed to document it on the form.

During that same interview, the DNS confirmed the Consent for Blood Transfusion form, the authorization section of Admission Summary Sheet, and Patient #28's nursing care plan were all incomplete.

8. Patient #4 was a 63 year old female, who was admitted on 6/04/10. Patient #4's closed record contained a hospital Admission Summary Sheet form. On the backside of the form was the portion for the patient to authorize the physician to perform treatment after explaining the advantages, possible complications, and possible alternative modes of treatment. Authorization by the patient was depicted by the patient's initials. However, the portions of the form naming the physician and the particular treatments were blank.

During an interview on 8/25/10 at 11:20 AM, the DNS reviewed the record and confirmed the incomplete authorization form.

9. Patient #30 was a 51 year old female who was admitted on 7/21/10 for cellulitis due to bedridden status and suspected caretaker neglect. The patient was discharged to swing bed status on 7/24/10. Patient #30's record contained a nursing care plan that failed to document the patient's name, diagnoses, physical, psychosocial, and educational needs. The nursing care plan was incomplete.

During an interview on 8/24/10 at 3:55 PM, the DNS reviewed the record and confirmed the incomplete nursing care plan.

The CAH failed to ensure records were complete.

Based on staff interview and review of records and hospital policy, it was determined the CAH failed to safeguard medical records against potentially unauthorized use in 4 of 5 patients (#40, #41, #42, and #43) whose release of records forms were reviewed. This had the potential to result in unauthorized release of medical information. Findings include:

The CAH failed to document verification of identity in the patient records that follow:

1. Patient #42's record contained an Authorization for Use and Disclosure of Protected Health Information, dated 8/02/10, that contained a requestor's name that was different than Patient #42's name. The relationship of the requestor to Patient #42 was not stated on the form. The form documented a request for a "birth record." There was no evidence the identity of the requestor was verified to ensure the requestor had required legal authority to request records.

2. Patient #43's record contained an Authorization for Use and Disclosure of Protected Health Information, dated 7/15/10, that contained a requestor's name that was different than Patient #43's name. The relationship to the requestor was not stated on the form. The form documented a request for an "Emergency room report 3/25/10." There was no evidence the identity of the requestor was verified to ensure the requestor had required legal authority to request records.

3. Patient #41's record contained an Authorization for Use and Disclosure of Protected Health Information, dated 4/05/10, that contained a signature with Patient #41's name. The form documented a request for "glucose testing and blood pressure 3/29/10 - 3/30/10." There was no evidence the identity of the requestor was verified to ensure the person who requested information was Patient #41.

4. Patient #40's record contained an Authorization for Use and Disclosure of Protected Health Information, dated 8/14/10, that contained a signature with Patient #40's name. The form documented a request for "all records - for disability." A note indicated the patient (requestor) was "known" to staff accepting the request. There was no evidence the identity was verified to ensure the person who requested information was Patient #40.

An undated hospital policy, "Release of Medical Information," had a section that addressed release of medical information to the patient. It stated the party wishing to inspect the medical record was required to show identification. The policy did not address whether it was acceptable to exempt certain parties from presenting identification based on being known by hospital staff.

A hospital form, Authorization for Use and Disclosure of Protected Health Information, had sections of the form where staff indicated they had verified the identity of the person requesting release of records. There was an area on the form to document how the requestor's identification was verified (through photo identification, matching signatures, or another way).

During an interview on 8/26/10 at 8:50 AM, the Director of Medical Records was interviewed. She stated the hospital was in a small town and they knew a lot of the patients who requested records. She explained they generally asked for photo identification if they did not know the person making the request.

The hospital failed to ensure policies were followed to prevent potentially unauthorized access to medical record information.

Based on staff interview, observation, and review of medical records, it was determined the CAH failed to ensure comprehensive POCs were developed by an interdisciplinary team, for 4 of 4 swing bed patients (#1, #30, #36, and #38), who received physical therapy services. This resulted in a lack of direction to staff caring for these patients. Findings include:

1. Patient #1's medical record documented a 74 year old male who was admitted to Swing bed status on 8/15/10 for acute and chronic cellulitis of his left lower extremity. He was currently a patient as of 8/26/10. A culture report of the leg wound, dated 8/22/10, documented the culture had grown pseudomonas acidovorans bacteria. An order, dated 8/15/10, placed Patient #1 in isolation for Contact Precautions. The sign for contact precautions on Patient #1's door stated, "ANYONE ENTERING THIS ROOM MUST WEAR: Gloves, Gown."

On observation, beginning at 3:05 PM and ending at 3:35 pm on 8/25/10, Patient #1's leg had large open wounds of greater than 4 inches long. The wounds were being debrided by the PT so it was difficult to assess the amount of drainage. The PT stated he debrided the wound 3 times a week and nurses cleaned the wound 2-3 times per day. Using a betadyne solution, the PT rubbed on the wound with a surgical scrub brush and removed dead tissue with tweezers. The PT was wearing gloves and boots but was not wearing a gown. Patient #1 was sitting in a cloth covered recliner with his legs up. His legs were resting on the chair's foot rest. A cotton bath blanket was between his legs and the foot rest. A waterproof pad was on the floor under the chair but no waterproof barrier protected the foot rest. Periodically, the PT would pour a bottled saline solution on the leg to rinse it. The saline drained directly onto the bath blanket and soaked down to the cloth foot rest.

Patient #1's PATIENT CARE PLAN, dated 8/15/10-8/23/10, did not include plans related to isolation or wound care. The POC did not include direction for the PT. A plan specific to physical therapy's role in Patient #1's care was not documented.

The PT was interviewed on 8/25/10 at 10:20 AM. He stated a plan specific for therapy had not been developed for Patient #1. He stated a specific form, with a section for a therapy plan, was utilized for outpatients. He stated the form used for inpatients did not have a section for a therapy plan and a plan had not been developed.

2. Patient #36's medical record documented a 70 year old female who was admitted to Swing bed status on 7/23/10 and discharged on 8/03/10. She was admitted following a total knee replacement. The primary PT documented an evaluation visit to Patient #36 on 7/26/10. A subsequent visit by a secondary PT was documented on 7/28/10. Visits by a PTA were documented on 7/30/10 and 8/02/10. A specific plan for therapy services was not documented.

The PT was interviewed on 8/25/10 at 10:20 AM. He stated a plan specific for therapy had not been developed for Patient #36.

3. Patient #38's medical record documented an 84 year old male who was admitted to Swing bed status on 2/12/10 and discharged on 5/4/10. The patient was admitted following the repair of a fractured hip. The primary PT documented 24 therapy visits to Patient #38 between 2/12/10 and 4/30/10. Another PT had documented visits to Patient #38 on 3/24/10 and 3/31/10. A PTA had documented visits to Patient #38 on 3/26/10, 3/29/10, and 4/02/10. A specific plan for physical therapy was not documented.

The primary PT was interviewed on 8/25/10 at 11:45 AM. He stated a plan specific for therapy had not been developed for Patient #38.

4. Patient #30's medical record documented a 51 year old female who was admitted to Swing bed status on 7/21/10 and discharged on 7/24/10. Her diagnosis was cellulitis with hemiplegia. The primary PT documented an evaluation visit to Patient #30 on 7/23/10. A specific plan for therapy services was not documented.

The primary PT was interviewed on 8/25/10 at 10:20 AM. He stated a plan specific for therapy had not been developed for Patient #30.

The secondary PT was interviewed on 9/01/10 at 11:25 AM. She stated she provided therapy services when Staff A was not available. She stated she referred to Staff A's evaluation and progress notes when providing services, since a POC for therapy services was not available.

The PT did not participate in POCs for patients who received therapy services.