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Based on document reviews, observations, and interviews, the Condition of Participation (CoP) for Physical Plant and Environment was not met as evidenced by the hospital's failure to ensure maintenance of doors, failure to ensure ice machines had air gaps, the door, in the negative pressure room, did not have gaps, freezer temperatures were maintained within the identified range, and life safety code requirements were met, including having a sufficient amount of water available for the fire suppression system.

Findings:

1. Standard: §485.623(a) Construction also known as C-0221 - Based on observations and interviews, the hospital failed to maintain doors into patient's rooms closets in 1 of 3 patient areas (Medical/Surgical Unit). Please see C-0221 for details.

2. Standard: §485.623(b) also known as C-0222 - Based on observations and interviews, the hospital failed to ensure that ice machines had an air gap to prevent backflow of waste water into the ice machine for 3 of 4 ice machines (ice machine in the Cafeteria, Medical/Surgical Unit, and Emergency Department).

3. Standard: §485.623(b)(5) also known as C-0226 - Based on observations, document review and interviews, the hospital failed to ensure that there were no gaps at the bottom of the door of the negative pressure room to ensure maintenance of proper ventilation for 1 of 1 negative pressure rooms observed in the Emergency Department (ED). In addition, the hospital failed to ensure that the temperature was maintained, within the identified range, in a walk in freezer for 1 of 1 freezers. See C-0226 for details.

4. Standard: §485.623(d) also known as C-0231 - Based observations, document reviews, and interviews conducted by the life safety code surveyors, the hospital failed to ensure that life safety code requirements were met. One of these failures included having an insufficient water supply available for the fire suppression system (sprinkler system).

The cumulative effects of these deficient practices resulted in this CoP being out of compliance.

Based on observations and interviews, the hospital failed to maintain doors into patient's rooms and closet doors in 1 of 3 patient areas (Medical/Surgical Unit).

Finding:

On July 16, 2019, between 10:15 AM and 12:30 PM, all patient room doors and closet doors, on the Medical/Surgical Unit, were observed to be gouged with worn varnish surfaces. These gouged and worn varnish areas created a surface which could not easily be cleaned and sanitized.

These findings were confirmed with the Assistant Vice President of Facilities Planning and the Facilities Manager at the time of the observations.

Based on observations and interviews, the hospital failed to ensure that ice machines had an air gap to prevent backflow of waste water into the ice machine for 3 of 4 ice machines (ice machine in the Cafeteria, Medical/Surgical Unit, and Emergency Department).

Findings:

On July 16, 2019, between 10:15 AM and 12:30 PM, the ice machines, located in the Cafeteria, Medical/Surgical Unit, and Emergency Department, were observed be lacking an air gap thus creating an opportunity for the back flow of waste water into the ice machine.

These findings were confirmed by the Facility Manager and Assistant Vice President of Facilities Planning at the time of the observations.

Based on observations, document review and interviews, the hospital failed to ensure that there were no gaps at the bottom of the door of the negative pressure room to ensure maintenance of proper ventilation for 1 of 1 negative pressure rooms observed in the Emergency Department (ED). In addition, the hospital failed to ensure that the temperature was maintained, within the identified range, in a walk in freezer for 1 of 1 freezers.

Findings:

1. On July 17, 2019 at approximately 9:45 AM, the area identified as the "Negative Pressure Room", in the ED was observed. There was an approximately 1.5 inch gap between the bottom of the entrance door and the floor.

A negative pressure room is a room that has a lower pressure than the rooms adjacent so any potential pathogens would remain in the designated room and not escape to the adjacent rooms. The gap at the bottom of the door of the "Negative Pressure Room" failed to ensure that the proper ventilation (i.e.: lower pressure) was maintained in the room identified as the "Negative Pressure Room".

On July 17, 2019 at approximately 10:00 AM, the Infection Control Officer was interviewed. The Infection Control Officer stated, "The hospital has an identified Negative Pressure Room and there is an inch and a half gap under the entrance door so it's not really effective ... I was not consulted on the design of the room when they built it". The Infection Control Officer added that patients identified as having an airborne disease were transferred to another hospital.

On July 17, 2019 at approximately 10:15 AM, the Infection Control Officer and the surveyor observed the "Negative Pressure Room" and the Officer confirmed the above finding.


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2. The hospital's "Food Storage" policy and procedure, indicated that "Refrigerator/Freezer facilities shall be constructed, insulated, and installed as to ensure the maintenance of a temperature range 28° to 41° F [Fahrenheit] (-2.2° C [Celsius] to 5.0° C) and 0° to -10° F (-17.8°C to -23.3°C), respectively" and "The temperature of all cool storage equipment shall be checked and logged on the appropriate form, at least once every 24 hours, with deviation from the norm reported, and action recommended or taken recorded."

On July 17, 2019 at approximately 11:30 AM, the temperature log for the walk-in freezer was reviewed. This log sheet indicated "freezers should read 30 degrees F or below" and "if the temperatures are not within the normal range please document what actions you took to ensure food safety". It was noted that the temperatures were recorded as follows: 4.3 on July 5, 2019; 7.9 on July 6, 2019; 3.9 on July 7, 2019; 6.8 on July 16, 2019; 4.7 on July 17, 2019. Additionally, the log did not have any documentation of any actions taken on these five days in which the freezer temperature was outside the range of 0° to -10° F (-17.8°C to -23.3°C).

This finding was confirmed by the Dietary Staff present at the time of the temperature log review.

Based observations, document reviews, and interviews conducted by the life safety code surveyors, the hospital failed to ensure that life safety code requirements were met. One of these failures included having an insufficient water supply available for the fire suppression system (sprinkler system).

Findings:

1. The water supply for the hospital's fire suppression system comes directly from a 9,000 gallon capacity tank located in an adjacent building to the hospital. There is another tank that supplies water to this 9,000 gallon capacity tank; however, the additional water supply is only available if facility personnel manually activate it within the building during an active sprinkler event which NFPA 13 does not allow. Since NFPA 13 does not allow this manual activation, the only stored water supply that can be considered available for the hospital's fire suppression system would be from the 9,000 gallon capacity tank.

On 7/16/19 between 1:30 PM and 3:00 PM, the gauge on the 9,000 gallon capacity tank was observed and indicated the tank was approximately half full. This meant approximately 4,500 gallons of water were available to supply water to the entire fire suppression system if it were to be fully activated.

The hospital's architectural life safety drawings were reviewed and indicated the hospital consisted of four different occupancy types: healthcare, hazardous (Boiler room, Laundry, storage, etc.), business, and assembly. The exact amount of water for the entire hospital's fire suppression system cannot be accurately calculated as a calculation plate for the new extended sprinkler coverage for the basement was not attached to the sprinkler riser. This calculation plate would have indicated the amount of water required for this area. However, calculations that can be made based on available information, indicated that a minimum of 25,920 gallons of water were needed to be available based on NFPA 13 requirements (432 gallons per minute for 60 minutes). Based on available information, the amount that is required to be available far exceeds the amount of water observed available on 7/16/19. In addition, the minimum number of gallons needed, based on available information, far exceeds the amount of water that can be stored in the 9,000 gallon capacity tank.

Based on the above information, the hospital has an insufficient water supply to ensure the required minimum amount of water was available for the fire suppression system. If a fire were to break out, the local fire department is a volunteer fire department; therefore, would not be readily available to assist with fire control making it imperative that a sufficient amount of water was available.

2. Multiple regulations were identified as being in non compliance with the life safety code requirements. Please see the CMS Form 2567 for Event ID 7W2T21 for details.

Based on documents reviewed and interviews, the Condition of Participation (CoP) for Organizational Structure was not met as evidenced by the failure of the Governing Body to ensure hospital policies were implemented in relation to reporting freezer temperatures outside identified ranges, confidentiality of medical records, and visitation policies. In addition the Governing Body failed to ensure policies were reviewed annually as required.

Finding:

Standard: §485.627(a) Governing Body or Responsible Individual also known as C-0241 - Based on record reviews and interviews, the Governing Body failed to ensure hospital policies were implemented in relation to reporting freezer temperatures outside identified ranges, confidentiality of medical records, and visitation policies. In addition the Governing Body failed to ensure polices were reviewed annually.

The cumulative effect of this deficient practice resulted in this Condition of Participation being out of compliance.

Based on record reviews and interviews, the Governing Body failed to ensure hospital policies were implemented in relation to reporting freezer temperatures outside identified ranges, confidentiality of medical records, and visitation policies. In addition the Governing Body failed to ensure polices were reviewed annually.

Findings:

The Governing body is responsible to ensure hospital policies are implemented and monitored. Based on observations, document reviews, and interviews, the Governing Body has failed to ensure the hospital's policies are implemented and monitored as evidenced by the following:

1. The hospital's hospital's "Food Storage" policy and procedure, in relation reporting and documentation of any action taken for temperatures outside the range identified in the policy, was not implemented. Please see C-0226, finding 2, for details.

2. The hospital was unable to provide evidence that policies were reviewed annually as required. Please see C-0272 and C-0334 for details.

3. The hospital failed to ensure that medical records were not accessible for possible unauthorized use. Please see C-0308 for details.

4. The hospital's "Visitation Policy" was not implemented as there was no documented that a patient was informed of his/her visitation rights. Please see C-1001 for details.

5. The hospital's "Restraints and Seclusion" policy indicated "employees required to demonstrate competency include but is not limited to the following: Nursing Staff (RN [Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants]. This includes contracted employees. Physicians/[Licensed Independent Practitioners ]" and "education is part of the orientation, annual education and competency evaluation of designated employees". In addition, the policy indicated "employees required to demonstrate competency include but is not limited to the following: Nursing Staff (RN [Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants]. This includes contracted employees. Physicians/[Licensed Independent Practioners]" and "education is part of the orientation, annual education and competency evaluation of designated employees".

On July 17, 2019 at 12:25 PM, the Chief Medical Officer, confirmed four of 20 Providers (medical staff) had not completed required annual training related to restraints.

On July 17, 2019 at 1:46 PM, the Vice President of Nursing and Patient Services confirmed 14 of 69 nursing staff had not completed or were past due with required annual restraint training and competency.

Based on the above information, 18 staff members failed to have annual education and competency evaluations related to restraints annually in accordance to hospital policy; therefore, the personnel records would not contain documentation that the training and demonstration of competency were successfully completed.

Based on document review and interviews, the facility failed to ensure that all policies were reviewed at least annually by members of the hospital's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff.

Finding:

The facility did not carry out or arrange for a total Program Evaluation for Fiscal Year (FY) 18 and FY 19, therefore, there was no evidence through documentation that the policies were reviewed annually by members of the hospital's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed in writing and verbally that the current electronic policy platform could not produce a report that provided evidence of the annual review of policies for FY 18 and FY 19.

Based on document review and interview, the hospital failed to ensure the dishwasher reached manufacturer's recommended temperatures to ensure proper sanitation in 1 of 1 dishwashers.

Findings:

The manufacturer's recommendation for the CLe-Series Dishwasher indicated the minimum temperature, using high-temperature sanitizing for Single-Tank Model, was 160 degrees Fahrenheit (F) for the wash tank and 180 degrees F for the final rinse.

The hospital's "Dish Machine Temperature Log" indicated, "The Wash Tank should read a minimum of 158 F and the Final Rinse should read a minimum of 180 F. Please document corrective action taken if temperatures are below the minimum. Enter a work order if needed."

On July 15, 2019, at approximately 12:00 PM, the "Dish Machine Temperature Log," from breakfast on July 1, 2019 through supper on July 16, 2019, was reviewed. The wash tank temperatures and/or the final rinse temperatures were noted to be below the minimum required temperature as follows:

- 156 degrees F during the wash cycle at the evening meal on July 1, 2019
- 157 degrees F during the wash cycle at the evening meal on July 2, 2019
- 153 degrees F during the wash cycle and 178 degrees during the final rinse at the evening meal on July 3, 2019
- 155 degrees F during the wash cycle and 179 degrees during the final rinse at the evening meal on July 4, 2019
- 154 degrees F during the wash cycle at the evening meal on July 5, 2019
- 157 degrees F during the wash cycle at the breakfast meal on July 6, 2019
- 156 degrees F during the wash cycle at the evening meal on July 8, 2019
- 155 degrees F during the wash cycle at the evening meal on July 9, 2019
- 176 degrees F during the final rinse at the evening meal on July 14, 2019

There was no evidence of any documentation, provided to the surveyor, that indicated any corrective action taken when the temperatures were below the minimum required temperature.

The failure to proper sanitize dishes creates the potential for food borne illnesses.

The above findings were confirmed, by Dietary Staff, on July 17, 2019, at 9:00 AM.

Based on record reviews and interviews, the hospital failed to ensure that medications were administered as ordered by the authorized practitioner for 1 of 20 patients reviewed (Patient #13).

Finding:

Patient #13 had an order, dated July 2, 2019, for Progesterone to be administered daily. There was no evidence in the patient's record to indicate that Progesterone was administered on July 2, 2019, July 3, 2019, and July 4, 2019.

This finding was confirmed by the Director of Medical/Surgical, Special Care Unit, and Emergency Department on July 17, 2019 at 11:00 AM. The Director indicated that this medication was not brought in by the patient during the hospitalization; therefore was not available.

A review of the hospital's "Patient's Own Medication" policy and procedure, dated August 24, 2017, the "Medication Error Reporting and Follow Up" policy and procedure, or the "General Nursing Policies and Procedures for Pharmaceuticals" did not direct what staff were to do when a medication is not brought in by the patient.

On July 17, 2019 at 3:15 PM, the Director of Nursing Services confirmed the "Patient's Own Medication" policy and procedure did not address what the nurses must do if the patient does not bring in their medications.

It would be expected that if a medication was ordered by a practitioner that the medication would be available for administration to the the patient.

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Based on policy review, observations, and interviews, the hospital failed to ensure medical records were kept in a location to prevent unauthorized use for 2 of 3 inpatient units (Medical/Surgical Unit and the Special Care Unit) and 1 of 7 outpatient areas (the Wound Clinic).

Findings:

The hospital's "Overview of the Confidentiality of Healthcare Information" policy stated "It is EMHS policy that PHI will not be Used or Disclosed by Member Organization Workforce Members except as permitted or required by HIPAA and applicable state laws. Whenever required by the HIPAA Privacy Rule, all Workforce Members will make reasonable efforts to limit the Use and Disclosure of PHI to the Minimum Necessary to accomplish the intended purpose of the Use, Disclosure, or request. Each Member Organization must reasonably safeguard PHI: (i) from any intentional or unintentional Use or Disclosure that violates EMHS or Member Organization HIPAA policies; and (ii) to limit Incidental Uses or Disclosures." Additionally the hospital's "Medical Records Responsibility" policy stated, "Procedure. I. The Medical Record on the Inpatient Unit. a. All personnel on the inpatient unit share the responsibility for maintaining the integrity and confidentiality of the medical record."

1. On July 15, 2019, at approximately 1:00 PM, in the Wound Clinic, patient medical records were observed stored in a closet that was readily accessible to housekeeping personnel who clean the area when staff was not present.

This finding was confirmed by a staff nurse at the time of the observation. The Nurse stated, "Housekeeping has access to the (closet) door key to clean when we aren't here."

2. On July 16, 2019, at approximately 10:00 AM, on the Special Care Unit, the nurses' desk was observed unsupervised with a patient's medical record on the desk which was readily accessible to anyone in the area. Multiple hospital visitors were in the area of the desk at the time of this observation.

This finding was confirmed, by a Certified Nursing Assistant (CNA), who stated, "That area doesn't have its own clerical support. The nurse is covering down the hallway. The patient's chart is on the desk."

3. On July 15, 2019, at 3:00 PM, seven patient records were observed sitting in the nurses' station on a rolling rack on the Medical/Surgical Unit. The nurses' station had no doors or security to prevent access to the charts if staff were not present at all times.

This finding was confirmed, by Registered Nurse #16, on July 15, 2019 at 3:00 PM.

Based on document reviews and interviews, the Condition of Participation (CoP) for Periodic Evaluation and Quality Assurance Review was not met as evidenced by the hospital's failed to ensure there was a total program review and a quality assurance program was developed.

Findings:

1. Standard: §485.641(a) Standard: Periodic Evaluation also known as C-0331 - Based on document reviews and interview, the hospital failed to ensure that there was a total program review for fiscal year (FY) 2018 (10/1/17 to 9/30/18) and FY 2019 (10/1/18 to 9/30/19). Please see C-0331 for details.

2. Standard: §485.641(a)(1)(ii) also known as C-0333 - Based on document reviews and interview, the hospital failed to review a representative sample of both active and closed clinical records during FY 2018 and FY 2019. Please see C-0333 for details.

3. Standard: §485.641(a)(1)(iii) The CAH's health care policies also known as C-0334 - Based on document review and interview, the hospital failed to provide evidence of a yearly review of the hospital's health care policies. Please see C-0334 for details.

4. Standard: §485.641(a)(2) also known as C-0335 - Based on document reviews and interview, the hospital failed to ensure an annual evaluation was completed to determine whether the utilization of services was appropriate, the established policies were followed, and any changes were needed. Please see C-0335 for details.

5. Standard: §485.641(b) Standard: Quality Assurance also known as C-0336 - Based on document reviews and interview, the hospital failed to develop an effective quality assurance program for FY 2018 and FY 2019. Please see C-0336 for details.

6. Standard: §485.641(b)(1) also known as C-0337 - Based on document review and interview, the hospital failed to ensure an effective quality assurance program was developed that included the evaluation of all patient care services and other services affecting patient health and safety for FY 2019. Please see C-0337 for details.

7. Standard: §485.641(b)(5)(i) also known as C-0341 - Based on document review and interview, the hospital failed to have a quality assurance program therefore failed to ensure evaluations of the program, including any findings or recommendations of the QIO, and corrective action if necessary cannot be done. Please see C-0341 for details.

8. Standard: §485.641(b)(5)(ii) also known as C-0342 - Based on document review and interview, the hospital failed to have a quality assurance program; therefore, would be unable to take remedial action to address deficiencies found through the quality assurance program. Please see C-0342 for details.

9. Standard: §485.641(b)(5)(iii) also known as C-0343 - Based on document review and interview, the hospital failed to have a quality assurance program; therefore, would be unable to document the outcome of all remedial action. Please see C-0343 for details

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on document reviews and interview, the hospital failed to ensure that there was a total program review for fiscal year (FY) 2018 (10/1/17 to 9/30/18) and FY 2019 (10/1/18 to 9/30/19).

Finding:

The documentation, dated February 22, 2018, of the Board Retreat and the documentation, dated June 6, 2019, of the Senior Leadership Retreat was reviewed. The documentation, dated February 22, 2018, consisted mostly of the master facility planning. The documentation, dated June 6, 2019, consisted mostly of how the facility was going to decrease services at this hospital and increase services at another hospital. Neither of these documents contained documentation of a periodic evaluation of its total program.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, that the hospital felt that the Board Retreat and the Senior Leadership Retreat documentation would meet the requirement of an evaluation of their total program for FY 2017-2018 and FY 2018-2019.

Based on document reviews and interview, the hospital failed to review a representative sample of both active and closed clinical records during fiscal year (FY) 2018 (10/1/17 to 9/30/18) and FY 2019 (10/1/18 to 9/30/19).

Finding:

A representative sample of active and closed clinical records reviewed in FY 2018 and FY 2019 was requested. The hospital provided documentation of patient records that were reviewed through the peer review process only.

There was no evidence provided that a representative sample of both active and closed clinical records were reviewed in FY 2018 and FY 2019.

This finding was confirmed, by the Director Quality, on July 17, 2019 at 2:16 PM.

Based on document review and interview, the hospital failed to provide evidence of a yearly review of the hospital's health care policies.

Finding:

The hospital failed to ensure that there was a total program review for FY 2018 and FY 2019; therefore, the there was no evidence provided that indicated the hospital's health care policies were reviewed at least yearly.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, in writing and orally, that the hospital could not produce a report that would demonstrate an annual review of policies for FY 2017-2018 or FY 2018-2019.

Based on document reviews and interview, the hospital failed to ensure an annual evaluation was completed to determine whether the utilization of services was appropriate, the established policies were followed, and any changes were needed.

Finding:

The hospital was unable to provide evidence of an annual evaluation for fiscal year (FY) 2018 (10/1/17 to 9/30/18) and FY 2019 (10/1/18 to 9/30/19); therefore, there was no evidence of an evaluation that determined whether the utilization of services was appropriate, the established policies were followed, and any changes were needed.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, in writing and orally, the hospital's current electronic policy platform could not produce a report to determine that all policies had been reviewed for FY 2018 and FY 2019.

Based on document reviews and interview, the hospital failed to develop an effective quality assurance program for fiscal year (FY) 2018 (10/1/17 to 9/30/18) and FY 2019 (10/1/18 to 9/30/19).

Finding:

On July 17, 2019, the document, titled "Blue Hill Memorial Hospital Quality & Professional Affairs Committee", was reviewed. This document stated, "Responsibilities: In meeting its responsibilities, the Quality & Professional Affairs committee shall: approve and monitor a comprehensive quality plan".

On July 16, 2019, the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan, for FY 2018 was reviewed. It was noted that this plan was not signed as being approved and accepted and the hospital was unable to produce a signed copy of the plan upon request.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a signed copy of the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2018.

The hospital was unable to provide evidence that a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan had been developed for FY 19.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2019.

An effective quality assurance program, that includes the following, is required: ongoing monitoring and data collection; problem prevention, identification and data analysis; identification of corrective actions; implementation of corrective actions; evaluation of corrective actions; and measures to improve quality on a continuous basis.

Based on document review and interview, the hospital failed to ensure an effective quality assurance program was developed that included the evaluation of all patient care services and other services affecting patient health and safety for fiscal year (FY) 2019 (10/1/18 to 9/30/19).

Finding:

On entrance to the facility on July 15, 2019, a written request was made to review the hospital's quality assurance program. The hospital was unable to provide evidence that a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan had been developed for FY 19.

A draft of a Medical Staff Quality Improvement Plan for FY 19, which ends on September 30, 2019, was provided. However, as of July 17, 2019, just over two months before the end of the FY, this draft plan had not been approved.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2019.

Based on document review and interview, the hospital failed to have a quality assurance program therefore failed to ensure evaluations of the program, including any findings or recommendations of the QIO, and corrective action if necessary cannot be done.

Finding:

On July 17, 2019, the document, titled "Blue Hill Memorial Hospital Quality & Professional Affairs Committee", was reviewed. This document stated, "Responsibilities: In meeting its responsibilities, the Quality & Professional Affairs committee shall: approve and monitor a comprehensive quality plan".

On July 16, 2019, the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan, for fiscal year (FY) 2018 (10/1/17 to 9/30/18) was reviewed. It was noted that this plan was not signed as being approved and accepted and the hospital was unable to produce a signed copy of the plan upon request.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a signed copy of the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2018.

The hospital was unable to provide evidence that a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan had been developed for FY 19 (10/1/18 to 9/30/19).

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2019.

The hospital failed to have a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan; therefore, evaluations of the program, including any findings or recommendations of the QIO, and corrective action if necessary cannot be done.

Based on document review and interview, the hospital failed to have a quality assurance program; therefore, would be unable to take remedial action to address deficiencies found through the quality assurance program.
Finding:

On July 17, 2019, the document, titled "Blue Hill Memorial Hospital Quality & Professional Affairs Committee", was reviewed. This document stated, "Responsibilities: In meeting its responsibilities, the Quality & Professional Affairs committee shall: approve and monitor a comprehensive quality plan".

On July 16, 2019, the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan, for FY 2018 (10/1/17 to 9/30/18) was reviewed. It was noted that this plan was not signed as being approved and accepted and the hospital was unable to produce a signed copy of the plan upon request.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a signed copy of the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2018.

The hospital was unable to provide evidence that a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan had been developed for FY 19 (10/1/18 to 9/30/19).

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2019.

The hospital failed to have a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan; therefore, would be unable to take remedial action to address deficiencies found through the quality assurance program.

Based on document review and interview, the hospital failed to have a quality assurance program; therefore, would be unable to document the outcome of all remedial action.

Finding:

On July 17, 2019, the document, titled "Blue Hill Memorial Hospital Quality & Professional Affairs Committee", was reviewed. This document stated, "Responsibilities: In meeting its responsibilities, the Quality & Professional Affairs committee shall: approve and monitor a comprehensive quality plan".

On July 16, 2019, the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan, for fiscal year (FY) 2018 (10/1/17 to 9/30/18) was reviewed. It was noted that this plan was not signed as being approved and accepted and the hospital was unable to produce a signed copy of the plan upon request.

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a signed copy of the Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2018.

The hospital was unable to provide evidence that a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan had been developed for FY 19 (10/1/18 to 9/30/19).

On July 17, 2019 at 2:16 PM, the Director of Quality confirmed, both verbally and in writing, the absence of a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan for FY 2019.

The hospital failed to have a Hospital-Wide Quality Management Program Performance Improvement and Safety Plan; therefore, would be unable to document the outcome of remedial action.

Based on observation and record review, the facility failed to ensure that all patients were informed of their visitation rights for 1 of 20 patients reviewed (Patient #1).

Finding:

The hospital's "Visitation Policy" indicated, "B. Each, patient or, if appropriate, the patient's support person, shall be informed of his/her visitation rights in advance of furnishing patient care whenever possible. Such notice will be documented in the patient's chart".

Patient #1's record was reviewed. The "Consent To Care, Guarantee of Payment and Assignment of Benefits, and Protected Health Information" form, that contained information regarding visitation rights, was not signed by Patient #1; therefore, there was no documented evidence that the patient was informed of his/her visitation rights.

This finding was confirmed, by the Director of Medical/Surgical, Special Care Unit, and Emergency Department, on July 17, 2019 at 11:30 AM.