HospitalInspections.org

Based on review of facility's Governing Body Bylaws and interview with staff (EMP), it was determined the facility failed to ensure that the Bylaws were reviewed annually.

Findings include:

Review on June 8, 2017, of facility document "Board of Directors Second Amended and Restated Bylaws of Coordinated Health Orthopedic Hospital, adopted January 30, 2012," revealed "Article IX ... These Bylaws shall be reviewed by the Board of Directors as needed, but at least every year, and shall be dated to indicate the time of the last review."

Interview with EMP1 on June 8, 2017, at 12:45 PM confirmed there was no documented evidence of an annual review of the "Board of Directors Second Amended and Restated Bylaws of Coordinated Health Orthopedic Hospital since the year 2012.

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Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure a periodic reexamination of the relationship of the board to the total hospital community was completed for one of five board members (OTH1).

Findings include:

Review of facility documents on June 5, 2017, revealed no documented evidence for OTH1 of a completed periodic reexamination of the relationship of the board to the total hospital community.

On June 5, 6, 7, 8, 2017, surveyor requested documented evidence for OTH1 of a completed periodic reexamination of the relationship of the board to the total hospital community. None was provided.

Interview with EMP1 on June 8, 2017, at 12:15 PM confirmed there was no documented evidence of a completed periodic reexamination of the relationship of the board to the total hospital community for OTH1.

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Based on review of facility policy and procedures, review of facility documents and interview with staff (EMP1), it was determined the facility failed to ensure a conflict of interest statement was completed for one of five board members (OTH1).

Findings include:

Review on June 8, 2017, of facility policy "Conflicts of Interest," reviewed June 2017 revealed " ... Definitions 5. Key Employees/Positions: ... board members ... Procedure 9. All Key Employees/Positions will be required to review and properly complete and timely return the Conflict of Interest Policy on an annual basis."

On June 5, 6, 7, 8, 2017, surveyor requested a completed "Conflict of Interest" for OTH1. None was provided.

Interview on June 8, 2017, at 12:15 PM confirmed there was no documented evidence of a completed "Conflict of Interest" for OTH1.

Based on review of facility policies and procedures and interview with staff (EMP), it was determined the facility failed to ensure that a request was made to the local fire department for an annual inspection for one (1) of one (1) policy reviewed.

Findings include:

Review on June 8, 2017, of facility policy "Fire Plan," reviewed December 2016 revealed "Objectives: ... 8. conduct annual inspections with the local fire inspector/chief and use the recommendations or cited deficiencies as opportunities for improvement."

On June 8, 2017, surveyor requested documentation that the facility requested an annual inspection from the local fire department. None was provided.

Interview with EMP7 on June 8, 2017, at approximately 9:30 AM confirmed there was no documented evidence the facility requested an annual inspection from the local fire department.