HospitalInspections.org

Based on document review and interview, the governing body failed to ensure all contracted services at the facility were provided in accordance with all applicable conditions of participation and practice standards for 2 of 8 clinical services (laboratory and radiology services).

Findings include:

1. Review of the Bowen Center Performance Improvement Plan Fiscal Year 2018 (approved 9-17) indicated the following: "19.2 Contracted Services Evaluation: All contracted services will be evaluated at least annually to determine the effectiveness of the contract and assure competency of the provider. Each contract will have performance indicators assigned during the writing of the contract..."

2. On 3-9-18 at 1100 hours and on 5-11-18 at 0945 hours, the Senior Vice President of Performance & Compliance, staff A2 and the Vice President of Risk Management & Compliance, staff A3 were requested to provide documentation indicating the most recent annual review of performance indicators for the contracted laboratory and radiology services at the facility and none were provided prior to exit.

3. On 5-11-18 at 1435 hours, staff A2 confirmed the facility lacked documentation indicating the identified services were evaluated and reviewed in 2017 or 2018 and no other documentation was available.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided, for 7 of 198 contracted services (biomedical engineering, document disposal, emergency generator fuel, medical laboratory testing, organ and tissue procurement, pharmacy and radiology services).

Findings include:

1. Review of the policy/procedure Contracts and Cooperative Agreements (approved 7-12) indicated the following: "Contract Listing Report: A report prepared by the Accounts Payable Specialist that lists all contracts the Bowen Center has and the pertinent information in regard to each contract..."

2. Review of the list of contracted services received on 5-9-18 from the Senior Vice President of Performance & Compliance, staff A2 lacked documentation indicating a provider for biohazardous waste disposal, biomedical engineering, document disposal, emergency generator maintenance, generator fuel, fire extinguishers, fire alarm monitoring and certification, fire sprinkler maintenance and certification, housekeeping, medical laboratory testing, organ and tissue procurement, pharmacy, radiology and trash disposal services.

3. On 5-10-18 at 1050 hours, the Senior Vice President of Performance & Compliance, staff A2 and the Facilities Manager, staff A8 confirmed the listing failed to indicate a provider for the above services. The staff A8 indicated the facilities department maintained a list of agreements for all environment of care and life safety services and staff A2 and A8 were requested to provide any other list(s) of agreements that indicated a provider(s) for the services identified above.

4. Review a list of contracted services provided on 5-10-18 by staff A8 lacked documentation indicating a provider for biomedical engineering, document disposal, generator fuel, medical laboratory testing, organ and tissue procurement, pharmacy services and/or radiology services.

5. Review of facility administrative documentation indicated the following: medical laboratory testing was provided by CS11, pharmacy services by CS12, and radiology services by CS13.

6. On 5-11-18 at 1400 hours, staff A2 confirmed the lists of contracted services lacked documentation indicating a provider for the various services identified above and confirmed no other documentation was available.

Based on document review and interview, the quality assessment and performance improvement (QAPI, or PI) program failed to ensure documentation of quality indicator monitoring was maintained for 1 of 3 quality indicators selected for review.

Findings include:

1. Review of the Bowen Center Performance Improvement Plan Fiscal Year 2018 (approved 9-17) indicated the following: "11.14 Assure that quality of client care is monitored and evaluated according to established, continuously improving data... [and]... that the data needed to identify problems and opportunities for improvement in client care is generated..."

2. Review of the policy/procedure Inpatient Individualized Treatment Plan (approved 3-15) indicated the following: "5.12 It will be the responsibility of the Registered Nurses, Social Worker and Medical Director for ensuring that the treatment plans is (sic) accurate, up-to-date, and reviewed regularly. The Unit Director and/or designee will monitor the process at least weekly and the Performance Improvement Department will monitor at least 20% of admissions... 5.22 The development, implementation and review of treatment plans and related documents and documentation (sic) will be reviewed by supervisory personnel and the Performance Improvement staff at least monthly. "

3. On 5-11-18 at 0945 hours, the Senior Vice President of Performance & Compliance, staff A2 and the Vice President of Risk Management & Compliance, staff A3 were requested to provide documentation of recent PI data sampling to confirm that 20% of the Inpatient Individualized Treatment Plans (between 12 and 14 plans/month) were being monitored in accordance with the policy/procedure and none was provided prior to exit.

4. On 5-11-18 at 1140 hours, staff A2 confirmed the PI program lacked documentation indicating recent Inpatient Treatment Plan monitoring was performed in accordance with policy requirements and confirmed no other documentation was available.

Based on document review and interview, the Governing Body failed to follow its Governing Body Bylaws and ensure its quality assessment and performance improvement (QAPI, or PI) program maintained documentation indicating all inpatient and outpatient services were periodically monitored and reviewed for 1 of 4 quarters in 2017 and 2018 (1st quarter 2018).

Findings include:

1. Review of the Governing Body Bylaws, Rules and Regulations (approved 5-18) indicated the following: "The Board shall review results of performance improvement activities at least quarterly."

2. Review of the Bowen Center Performance Improvement Plan Fiscal Year 2018 (approved 9-17) indicated the following: "11.0 Responsibilities of the Sr. Vice President, Performance and Compliance: ...11.10 Prepare and submit quarterly reports on Infection Control, Physician Services, Nursing Services, Dietary Services, Pharmacy Services, Clinical Staff Organization, Safety and Risk, Outcome Evaluation, and Implementation of the Strategic Plan to the Board of Directors, Executive Team and Management Council..."

3. Review of the 1-17-18, 2-21-18 and 3-21-18 Board of Directors Minutes lacked documentation indicating a quarterly review of performance measures for inpatient services of Dietetics, Infection Control, Laboratory services, Nursing services, Pharmacy services, Psychiatry services, Radiology services, Social services and Outpatient services were presented and reviewed.

4. On 5-11-18 at 1435 hours, the Senior Vice President of Performance & Compliance, staff A2 confirmed the 2018 Board of Directors Minutes lacked documentation indicating quarterly QAPI performance metrics for inpatient and outpatient services were presented and reviewed.

Based on document review and interview, the governing body, medical staff and executive leadership failed to ensure adequate resources were provided for the quality assessment and performance improvement (QAPI, or PI) program to measure, assess and improve patient services at the facility for one occurrence.

Findings include:

1. On 5-11-18 at 0945 hours, staff A2 indicated they and the Manager of Accreditation and Licensure, staff A7 were the two staff most directly involved with the PI performance indicators and program review of inpatient and outpatient services. Staff A2 confirmed that 65 to 80 clients are admitted each month for acute inpatient treatment and approximately 15,000 appointments are scheduled each month for outpatient services.

2. On 5-11-18 at 1435 hours, the Senior Vice President of Performance & Compliance, staff A2 confirmed the 2018 Board of Directors Minutes lacked documentation indicating quarterly QAPI performance metrics for inpatient and outpatient services were presented and reviewed.

3. On 5-11-18 at 1140 hours, staff A2 confirmed the PI program lacked documentation indicating recent Inpatient Treatment Plan monitoring was performed in accordance with the Inpatient Treatment Plan policy requirements.

4. On 5-11-18 at 1435 hours, staff A2 confirmed the facility lacked documentation indicating the contracted laboratory and radiology services were evaluated and reviewed in 2017 or 2018 and confirmed that additional resources and personnel are needed to support and adequately maintain the PI program documentation related to the inpatient and outpatient services at the facility.

Based on document review and interview, the facility failed to ensure a Registered Nurse provided assessment of pain on admission, and followed facility policy related to pain assessments for 13 of 24 patients (patients #2, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19 and 24's) and nursing assessments/re-assessments related to skin for 4 of 24 patients (#2, 13, 17 and 24) respiratory complaints for 1 of 24 patients (#13) and urinary tract infections for 1 of 24 patients (#13).

Findings include;

1. Review of facility policy titled "Pain Assessment & Response ...IV-558(R 03)" last reviewed/revised 4/17/2006 indicated: " ...1.0 Policy: Bowen Center shall assess to identify the presence of pain and shall assist primary care providers to manage clients experiencing pain in accordance with standards developed by the Joint Commission on Accreditation of Health-care Organizations (JCAHO) and endorsed by the American Pain Society. 2.0 Purpose: 2.1 To provide guidelines for evaluating for the presence of pain. 2.2 To document Bowen Center's approach to pain management. ...4.0 Procedures: 4.1 Bowen Center staff and contractors shall evaluate clients to determine the presence and intensity of pain at the time of admission and when re-assessment is completed. ...2 Inpatient ...clients shall be screened by the admitting nurse. Additional evaluations may be completed by the psychiatrist and the licensed independent practitioner (LIP) who completes the history and physical examination. ...4.3 The right of the client to receive pain management shall be honored and facilitated. 4.4 Staff who assess shall be trained to evaluate clients for the existence and intensity of pain, including but not limited to: ...3 Recognizing that behavioral disorders cannot be adequately addressed unless the individual is as free as possible from physical distress, including pain. ...4.7 Management of temporary pain may be accomplished by Bowen Center physicians privileged to do so ...."

2. Review of facility policy titled "Medication Orders and Medical Practice Guidelines (Protocols) ...IV-522 ATTACHMENT #7.6" last reviewed/revised on 8/10/15 indicated: " ...USE OF INHALERS ...1. Inhaler: a medical device used for delivering medication into the lungs via inhalation. Indication for Use: 1. Administration of bronchodilator medications 2. To relieve the symptoms of an acute asthma attack or chronic pulmonary diseases. Administration of Medication via an Inhaler: ...3. Take the client's pulse, respirations, SPO2 [oxygen saturation] and auscultate lung sounds prior to administration to establish a baseline to measure effectiveness or detect an adverse outcome. ...7. Following administration, retake client's pulse, respiration, SPO2, and auscultate lung sounds assessing effectiveness of medication and assessing for adverse effects. 8. Document pre and post administration on Inhalation Medication Assessment Log ...which shall be kept behind the clients current MAR ...."

3. Review of patients #2, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 22 and 24's closed medical records beginning at 1:00 p.m. on 5/10/18 indicated the records lacked a pain assessment on admission, therefore it could not be determined if a pain assessment was completed on the patients' nursing admission assessments to the facility.

4. Review of patient #2's medical record indicated the following:
(A) The patient was admitted inpatient on 12/13/17 at 11:11 p.m. and discharged on 12/15/17 at 2:35 p.m.
(B) The patient's skin was assessed by a Registered Nurse on 12/13/17 at 11:20 p.m. The nursing admission assessment indicated the following, which included, but was not limited to swelling and bruise on the patient's right hand.
(C) The MR (medical record) lacked documentation of additional skin re-assessments by the inpatient nursing staff.

5. Review of patient #13's medical record indicated the following:
(A) The patient was admitted inpatient on 1/24/18 at 8:19 p.m. and discharged on 1/27/18 at 4:30 p.m.
(B) The patient's diagnoses included but were not limited to urinary tract infection, diabetes, chronic obstructive pulmonary disease, asthma, neuropathy in feet and hypertension.
(C) The patient's skin was assessed by a Registered Nurse on 1/24/18 at 8:25 p.m. The nursing admission assessment indicated the following, which included, but was not limited to cracked bilateral heels.
(D) A history and physical (H&P) was completed by A11 (Nurse Practitioner - Inpatient and Outpatient) on 1/25/18 at 5:50 p.m. and indicated the patient's skin was free of lesions.
(E) The MAR (medication administration record) indicated the patient had physician orders, which included but were not limited to the following: Keflex 500 milligrams twice a day for seven days for UTI (urinary tract infection) with a start date of 1/25/18, Robitussin DM two teaspoons every four hours as needed for cough with a start date of 1/25/18 and Pro-Air 90 micrograms, two puffs every four hours as needed for shortness of breath with a start date of 1//24/18. The MAR indicated the patient was administered Robitussin DM on 1/26/18 at 11:13 a.m. and 3:19 p.m., on 1/27/18 at 8:40 a.m. and 2:48 p.m. for cough. The MAR indicated the patient was administered Pro-air on 1/26/18 at 11:13 a.m. and on 1/27/18 at 8:40 a.m. for S.O.B. (shortness of breath).
(F) The MR (medical record) lacked documentation of additional skin re-assessments by the inpatient nursing staff. The MR also lacked documentation of nursing assessments/re-assessments related to the patient's complaints of shortness of breath, coughing and a urinary tract infection such as the following assessments: pain, temperature, lung sounds, productive/nonproductive cough, respirations and oxygen saturation.

6. Review of patient #17's medical record indicated the following:
(A) The patient was admitted inpatient on 4/30/18 at 10:40 p.m. and discharged on 5/2/18 at 5:22 p.m.
(B) The patient's skin was assessed by a Registered Nurse on 4/30/18 at 10:45 p.m. The nursing admission assessment indicated the following, which included, but was not limited to an abrasion located at the center of the patient's forehead.
(C) A history and physical (H&P) was completed by A11 (Nurse Practitioner - Inpatient and Outpatient) on 5/1/18 at 7:30 a.m. and indicated the patient's skin was free of lesions.
(D) A nurse's progress dated 5/1/18 at 8:00 p.m. indicated the following: "Cl [client] came to counter saying her abrasion was bugging her as it is right on the center of her hairline/forehead. Ibuprofen given for pain and new order received for bacitracin which this RN [Registered Nurse] applied ...."
(E) The MR (medical record) lacked documentation of additional skin re-assessments by the inpatient nursing staff.

7. Review of patient #24's medical record indicated the following:
(A) The patient was admitted inpatient on 5/6/18 at 5:54 p.m. and discharged on 5/8/18 at 1:50 p.m.
(B) The patient's skin was assessed by a Registered Nurse on 5/6/18 at 6:00 p.m. The nursing admission assessment indicated the following, which included, but was not limited to a rash located on the patient's upper back.
(C) A history and physical (H&P) was completed by A11 (Nurse Practitioner - Inpatient and Outpatient) on 5/7/18 at 7:20 a.m. and indicated the patient's skin was free of lesions.
(D) The MR (medical record) lacked documentation of additional skin re-assessments by the inpatient nursing staff.

8. During an interview with A11 on 5/11/18 at 3:07 p.m., he/she indicated the room that was used for assessing newly admitted patients was occupied by the outside lab staff at the same time he/she was here in the mornings to assess patients for completing the patient's history and physical. A11 indicated there was not adequate light in the patients' rooms where he/she has to assess the patients or the patient has a roommate and is unable to undress the patient to do a complete head to toe assessment. A11 indicated he/she would document under the category of skin on the H&P as "free of lesions" due to he/she could only base the assessment on what was visible to assess on the patient, so if not visible he/she would not document on. A11 indicated he/she likes to assess the patients in his/her office, but feels he/she has to fight over the office with the lab staff who also use his/her office. A11 indicated he/she had notified A3 (Senior Vice President of Performance and Compliance) and A8 (Inpatient Unit Nurse Case Manager).

9. During an interview with A8 on 5/11/18 at 6:54 p.m., he/she indicated no specific policy related to nursing assessment and reassessment.

10. A5 (Director of Nursing and Infection Control Officer) and A3 also verified pain assessments should be assessed with PRN (as needed) pain medication administration, with any wounds/injuries and on admission. They indicated pain level assessment should be completed at least once in an eight hour shift by the nurse.

Based upon document review, observation and interview, the facility failed to follow their policy/procedures and ensure that confidential medical records (MR) were not accessible to unauthorized individuals for 5 of 6 off-site locations.

Findings include:

1. Review of the policy/procedure Client Health Record Security (approved 9-14) indicated the following: "The client record is considered the property of Bowen Center and safeguards from unauthorized use, access, loss or destruction shall be in place... Client records in paper format shall be stored in locked rooms or filed in lockable files."

2. During a visit to the offsite #1 on 5-09-18 at 1657 hours, in the company of the County Director of Outpatient Services, staff A13 and the Addictions Team Leader, staff A14, MR folders containing confidential patient information were observed in storage on the open-faced shelves of a floor to ceiling storage unit in a room connected to the staff side of the patient reception area at the outpatient location.

3. On 5-09-18 at 1658 hours, the staff A13 and A14 confirmed that a contracted housekeeping service provided cleaning services in the building during the evening/night hours when the clinical and office staff were not present. Staff A13 and A14 confirmed that housekeeping personnel had a set of keys to access the locked room for cleaning and confirmed the MR were not secured in locked files when housekeeping services were provided.

4. During a visit to the offsite #2 on 5-09-18 at 1753 hours, in the company of the County Director of Outpatient Services, staff A15 and the Office Manager, staff A16, MR folders containing confidential patient information were observed in storage on open-faced shelves of 4 floor to ceiling storage units located in a MR storage room at the outpatient location.

5. On 5-09-18 at 1754 hours, the staff A15 and A16 confirmed that a contracted housekeeping service provided cleaning services in the building during the evening/night hours when the clinical and office staff were not present. Staff A15 and A16 confirmed that housekeeping personnel had a set of keys to access the locked room for cleaning and confirmed the MR were not secured in locked files when housekeeping services were provided.

6. During a visit to the offsite #3 on 5-09-18 at 1846 hours, in the company of the Client Services staff A17, MR folders containing confidential patient information were observed in storage on open-faced shelves of five (5) floor to ceiling storage units located in a MR storage room at the outpatient location.

7. On 5-09-18 at 1847 hours, staff A17 confirmed that a contracted housekeeping service provided cleaning services in the building during the evening/night hours when the clinical and office staff were not present. Staff A17 confirmed that housekeeping personnel had a set of keys to access the locked room for cleaning and confirmed the MR were not secured in locked files when housekeeping services were provided.

8. During a visit to the offsite #4 on 5-10-18 at 0905 hours, in the company of the [offsite #4] Director of Outpatient Services, staff A18 and Business Office Manager, staff A19, MR folders containing confidential patient information were observed in storage on open-faced shelves of seven (7) floor to ceiling storage units located in a MR storage room at the outpatient location.

9. On 5-10-18 at 0905 hours, the staff A18 and A19 confirmed that a contracted housekeeping service provided cleaning services in the building during the evening/night hours when the clinical and office staff were not present. Staff A18 and A19 confirmed that housekeeping personnel had a set of keys to access the locked room for cleaning and confirmed the MR were not secured in locked files when housekeeping services were provided.

10. During a visit to the offsite #5 on 5-10-18 at 1130 hours, in the company of the [offsite #5] Business Office Manager, staff A12, MR folders containing confidential patient information were observed in storage on open-faced shelves of seven (7) floor to ceiling storage units located in a MR storage room at the outpatient location.

11. On 5-10-18 at 1130 hours, staff A12 confirmed that a contracted housekeeping service provided cleaning services in the building during the evening/night hours when the clinical and office staff were not present. Staff A12 confirmed that housekeeping personnel had a set of keys to access the locked room for cleaning and confirmed the MR were not secured in locked files when housekeeping services were provided.

A Life Safety Code Recertification Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41(b).

Survey Date: 05/10/18

Facility Number: 005179

At this Life Safety Code survey, Otis Bowen Center for Human Services was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.482,41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This one story facility was determined to be of Type II (000) construction and was fully sprinklered except above the drop ceiling. The facility is separated between health care occupancies and a mix occupancy of business, storage, and assembly. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors and patients rooms. The facility has a capacity of 16 and had a census of 12 at the time of this survey.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 occupancy separation wall was protected (see tag K132), the facility failed to ensure the means of egress through 1 of 9 exits were accessible (see tag K222), the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained ( see tag K353), the facility failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks (see tag K918), the facility failed to ensure 1 of 1 emergency diesel powered generator was allowed a 5 minute cool down period after a load test (see tag K918), the facility failed to ensure staff were instructed in the use of the UL 300 hood system in 1 of 1 Kitchen (see tag K324), the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained (see tag K341), the facility failed to ensure staff were instructed in the use of the UL 300 hood system in 1 of 1 Kitchen (see tag K712), the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained (see tag K712), the facility failed to conduct quarterly fire drills for 2 of 4 quarters (see tag K712), the facility failed to ensure 1 of 1 UL 300 manual activation pull station was readily accessible (see tag K712), the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal and simulation of emergency fire conditions for the last 4 quarters (see tag K712), the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained (see tag K345), the facility failed to ensure annual inspection and testing of 2 of 2 fire door assemblies were completed (see tag K 761).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 occupancy separation wall was protected in accordance with 19.1.3.3. LSC 19.1.3.3 states sections of health care facilities shall be permitted to be classified as other occupancies, provided they meet all the of following conditions: (2) they are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect all occupants, the facility failed to ensure the means of egress through 1 of 9 exits were accessible. This deficient practice could affect staff and up to 8 patients, the facility failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks. Chapter 8.3.7 of NFPA 99 requires storage batteries, including electrolyte levels or battery voltage, used in connection with essential electrical systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 requires defective batteries shall be repaired or replaced immediately upon discovery of defects. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:


1. Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 between 10:34 a.m. and 11:53 a.m., the facility site plans indicated a two hour occupancy separation wall near the nurse's station. Based on observation the following was discovered:
a) the rolling steel door is held open with a fusible link
b) the Kitchen door does not have a fire resistive label on the door nor on the door frame
c) the Doctor Evaluation room does not have a self-closure
d) seven separate penetrations in the barrier near Office Room 200 above the drop ceiling
e) nine separate penetrations in the barrier near Office Room 114 above the drop ceiling
f) four separate penetrations in the barrier near Office Room 130 above the drop ceiling
g) four separate penetrations in the barrier near the Kitchen above the drop ceiling
Based on interview at the time of each observation, the Maintenance Technician #1 and the Director of Facilities Management confirmed the rolling steel door does not release with the fire alarm, confirmed the lack of a self-closure, was unable to locate the two fire ratings on the Kitchen door and frame, and confirmed the lack of fire stopping material in the barrier.

2. Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 9:34 a.m., the Director of Operations was unable to open the exit door by patient room 306. Based on interview at the time of the observation, the Director of Operations and the Compliance Manager confirmed the door lock would not release with the key.

3. Based on record review with the Director of Operations and the Compliance Manager on 05/11/18 at 11:06 a.m., no weekly inspection documentation was available for review. Based on an interview at the time of record review, the Director of Operations and the Compliance Manager contacted their staff member who maintains the generator and confirmed no weekly inspection is documented.

4. Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 11:06 a.m., the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Director of Operations and the Compliance Manager acknowledged the lack of documentation.

Based on observation and interview, the facility failed to ensure staff were instructed in the use of the UL 300 hood system in 1 of 1 Kitchen. NFPA 96, 11.1.4 states instructions for manually operating the fire extinguishing system shall be posted conspicuously in the kitchen and shall be reviewed with employees by management. This deficient practice could affect staff only, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.3.1.2 requires the location and spacing requirements shall be based on six factors. (2) Ceiling height. (5) Compartment ventilation. NFPA 72 17.7.3.2.1 spot-type smoke detectors shall be located on the ceiling, or, if on a sidewall, between the ceiling and 12 inches down from the ceiling to the top of the detector. This deficient practice could affect staff and any patients in the waiting area, the facility failed to conduct quarterly fire drills for 2 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice affects all occupants, the facility failed to ensure 1 of 1 UL 300 manual activation pull station was readily accessible. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition at 10.5.1 states, a readily accessible means for manual activation shall be located between 42 inches and 48 inches above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. This deficient practice was not in a resident area but could affect kitchen staff, the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal and simulation of emergency fire conditions for the last 4 quarters. This deficient practice affects all occupants.

Findings include:

1. Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 10:04 a.m., the Kitchen contained a UL 300 hood system. Based on interview, the Patient Supported Technician was asked what she would do if there was a grease fire underneath the hood. She replied she would turn off the burner, tell staff, and grab a K class fire extinguisher. She failed to indicate pulling the Ansul hood pull station. Based on interview, the Director of Operations and the Compliance Manager acknowledged her response and were unaware of the Ansul pull station requirement.

2. Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 10:04 a.m., a cooking appliance was directly in front of the UL 300 manual activation pull station. Based on interview at the time of observation, the Director of Operations and the Compliance Manager confirmed the method of pulling manual activation pull stations directly back would be difficult.

3. Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 9:14 a.m., the Main Entry waiting area contained two smoke detectors seventeen feet from the peak of the ceiling. Based on interview at the time of observation, the Director of Operations and the Compliance Manager acknowledged the smoke detectors location and provided the measurement from the peak of the slanted ceiling to the smoke detectors on each side.

4. Based on record review of the "Fire Drill Evaluation" forms with the Director of Operations and the Compliance Manager on 05/10/18 at 10:47 a.m., there was no documentation for a first shift fire drill in the first quarter of 2018. Additionally, there was no documentation for a first, second, or third shift fire drill in the fourth quarter of 2017. Based on interview at the time of record review, the Director of Operations and the Compliance Manager were unable to provide further documentation.

5. Based on record review of titled "Fire Drill Evaluation" with the Director of Operations and the Compliance Manager on 05/10/18 at 10:46 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Director of Facilities confirmed verification of the transmission of the fire alarm signal is not performed.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, Table 14.4.5(15)(e) Testing Frequencies indicates that heat detectors be tested annually. This deficient practice could affect all occupants, the facility failed to ensure annual inspection and testing of 2 of 2 fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all patients.

Findings include:

1. Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 10:58 a.m., the last fire alarm report dated 09/06/17 by Cottage Watchman Security Systems indicated "Fire doors released upon alarm but east doors do not close all the way and are locked. West doors do not close all the way." Based on interview at the time of record review, the Director of Operations and the Compliance Manager acknowledged the issues and was unable to show documentation showing repairs have been made.

2. Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 10:58 a.m., the last fire alarm report dated 09/06/17 by Cottage Watchman Security Systems indicated "Heat detectors tested every 5 years." Based on interview at the time of record review, the Administrator and the Maintenance Director acknowledged the aforementioned condition and confirmed no other documentation was available for review.

3. Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 11:40 a.m., the site plans indicated the 2 hour occupancy separation wall. The two hour wall traveled down two sides of the Kitchen. Based on interview at the time of record review, the Director of Operations and the Compliance Manager provided fire door assembly inspections on all doors except the two doors in the Kitchen.

Based on document review and interview, the facility failed to ensure the infection control officer maintained their qualifications through ongoing education and training for 2 of 2 Infection Control Officers. (A5 and A10)

Findings include;

1. Review of facility policy titled "Infection Control Teaching and Competency...#III-431 (R 03)" last reviewed/revised 8/21/12 indicated the following: "...1.0 Policy: The Center shall insure staff competence in infection control practices and techniques. The Center shall provide staff with both initial and ongoing training. The Center shall measure staff performance and evaluate them for competency in this area. 2.0 Purpose: 2.1 To establish a procedure insuring staff competence in infection control practices. ...

2. Review of A5's (Director of Nursing and Infection Control Officer) training transcript indicated he/she lacked
bi-annual ongoing infection control training which included the following: .1 Modes of transmission, including Tuberculosis, Hepatitis B, HIV. .2 Use of Standard Precautions. .3 Handwashing basics. .4 Food safety - temperature of refrigerators. .5 Food/drug interactions. .6 Drug/drug interactions. .7 Blood-borne disease, epidemiology, symptoms and transmission. .8 Hepatitis B vaccine information. .9 Procedure to follow if exposure occurs. .10 Information on post-exposure and follow-up. .11 TB [Tuberculosis] testing.

3. Review of A10's (Transitional Living Nurse and Infection Control Nurse) training transcript indicated he/she lacked bi-annual ongoing infection control training which included the following: .1 Modes of transmission, including Tuberculosis, Hepatitis B, HIV. .2 Use of Standard Precautions. .3 Handwashing basics. .4 Food safety - temperature of refrigerators. .5 Food/drug interactions. .6 Drug/drug interactions. .7 Blood-borne disease, epidemiology, symptoms and transmission. .8 Hepatitis B vaccine information. .9 Procedure to follow if exposure occurs. .10 Information on post-exposure and follow-up. .11 TB [Tuberculosis] testing.

4. During an interview with A5 on 5/11/18 at 3:55 p.m., he/she indicated they as well as A10 (infection control officers) are not completing enough education related to infection control.

5. During an interview with A3 (Senior Vice President of Performance and Compliance) on 5/11/18 at 5:53 p.m., he/she indicated/verified a concern related to infection control officers' education and the need for additional education and training.

6. During an interview with A2 (Vice President of Risk Management and Compliance) on 5/11/18 at 5:59 p.m., he/she verified based on standards there was not enough contining education and training related to infection control for the Infection Control Officers.

Based on document review and interview, the facility failed to develop policies and procedures to address its organ procurement responsibilities (see tag 885), to obtain and maintain an agreement with an organ procurement organization (see tag 886) and ensure the family of each potential donor is informed of their options to donate or decline to donate organs, tissue, and/or eyes (see tag 888).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Organ, Tissue and Eye Procurement requirements were met.

Based on document review and interview, the facility failed to establish and maintain policies and procedures to address its organ procurement responsibilities for one occurrence.

Findings include:

1. On 5-09-18 at 1100 hours, the Senior Vice President of Performance & Compliance, staff A2 and the Vice President of Risk Management & Compliance, staff A3 were requested to provide organ donation documentation including a process for requesting organ, tissue and/or eye donation from the family of each potential donor and for evaluating the medical suitability of each potential donor and none was provided prior to exit.

2. On 5-11-18 at 1450 hours, staff A2 confirmed the facility lacked policies and procedures to address its organ donation responsibilities and confirmed no other documentation was available.

Based on document review and interview, the facility failed to establish an agreement with an Organ Procurement Organization (OPO) to address its organ procurement responsibilities for one occurrence.

Findings include:

1. On 5-09-18 at 1100 hours, the Senior Vice President of Performance & Compliance, staff A2 and the Vice President of Risk Management & Compliance, staff A3 were requested to provide documentation indicating an agreement with an OPO and none was provided prior to exit.

2. On 5-11-18 at 1450 hours, staff A2 confirmed the facility failed to establish an agreement with an Organ Procurement Organization and confirmed no additional documentation was available.

Based on document review and interview, the facility failed to ensure the family of each potential donor was informed of its options for organ, tissue and/or eye donation including the option to decline for one occurrence.

Findings include:

1. On 5-09-18 at 1100 hours, the Senior Vice President of Performance & Compliance, staff A2 and the Vice President of Risk Management & Compliance, staff A3 were requested to provide documentation how a family is to be approached and informed of its organ and tissue donation options and none was provided prior to exit.

2. On 5-11-18 at 1450 hours, staff A2 confirmed the facility lacked documentation indicating how a family is to be informed of its donation options and confirmed no other documentation was available.

Based on record review and interview, the facility failed to:

I. Ensure the Psychiatric Evaluations included an estimation of patients' intellectual functioning, or memory with supporting clinical evidence for four (4) of eight (8) active sample patients (A2, A3, A4, and A6). This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate. (Refer to B116)

II. Ensure that the Master Treatment Plans (MTPs) included Goals/Objectives written in Behavioral, Measurable and Observable terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This lack of patient-specific goals hampers the treatment team's ability to assess the changes in a patient's condition as a result of treatment interventions and may contribute to failure to modify plans in response to a patient's needs. (Refer to B121)

III. Ensure that the MTPs included specific treatment interventions that addressed patients' identified problems and goals, including frequency and modality of the interventions for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure results in MTPs that are not able to guide the staff in providing active treatment that is purposeful and goal oriented. Such failure potentially results in treatment that is inconsistent or ineffective as well as prolonged hospitalization. (Refer to B122)

IV. Ensure that all treatment team staff had documented evidence in the progress/treatment notes, pertaining to active treatment interventions from the MTPs to show comprehensive information about treatments provided for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, documentation did not consis

Based on record review and staff interview, the facility failed to assess and estimate memory or intellectual functioning in a sufficiently descriptive manner to establish baseline parameters for four (4) of eight (8) active sample patients (A2, A3, A4, and A6). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review:

The following Psychiatric Evaluations/ mental status evaluations (dates of evaluation in parenthesis) contained no assessment of the patient's memory or intellectual functions with supportive clinical evidence:

1. Patient A2 (6/19/18), under "Intellect and centration" - "Fair" and "Memory Recall - deferred." No explanation or reasons for deferring given and no follow up noted.

2. Patient A3 (6/20/18), under "Intellect and concentration" - "Poor" and "Memory Recall - Limited."

3. Patient A4 (6/19/18), under "Intellect and concentration" - "Poor."

4. Patient A6 (6/20/18), under "Intellect and concentration" - "Fair" and "Memory - Fair."

B. Staff interview:

In a meeting and review of a sample of the above psychiatric assessments/mental status evaluations with the Medical Director on 6/22/18 at 9:30 a.m., he did not dispute the above deficiencies and further stated, "I am in agreement."

Based on policy review, record review, and interview, the facility failed to develop Master
Treatment Plans (MTPs) which included patient goals written in observable, measurable patient behaviors to be achieved for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The facility used identical pre-printed treatment plan forms which resulted in the selection of identical treatment goals [Treatment Objective] for 8 (eight) of 8 (eight) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) regardless of their unique problems called "Clinical Needs" by the facility. These deficient goal statements hinder the ability of the team to individualize treatment and to measure the change in the patient consequent to treatment interventions.

Findings include:

A. Policy/Document Review:

1. The facility's policy IV-581 titled "Inpatient Individualized Treatment Plan (R02)" Approval date March 3, 2015, stipulated under "5.11.4"; "Each treatment goal will be measurable."

B. Record Review:

1. Patient A1- Master Treatment Plan had the following "Clinical Need" stated as "At risk for compromised level of functioning and panic attacks, client reports mood is at an intolerable level - manic behavior."

a. Short-term goal [STG]: "Client will participate in 50 % of groups and activities while on IPU [Inpatient Unit] exhibiting improved socialization skills by discharge." The goal was staff expectation/treatment compliance statement rather than a measurable goal.

b. Short-term goal: "Client will verbalize understanding of discharge plan with intent to comply with medications and treatment recommendations after discharge by discharge." The goal was staff expectation rather than a measurable goal.

c. Short-term goal: "Client will reality test with

Based on policy review, record review and interview, the facility failed to develop Master Treatment Plans that identified physician, nursing and social work interventions that were individualized and specific, based on the unique psychiatric symptoms of each patient needs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). The Master Treatment Plans were composed of problem template, with pre-printed interventions, which were not individualized but instead were routine, generic discipline functions that lacked focus for treatment. MTPs also included several intervention statements that failed to identify the frequency and a method of delivery (individual or group sessions). These deficiencies result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment and potentially lead to inconsistent or ineffective treatment.

Findings include:

A. Policy Review:

The facility's policy IV-581 titled "Inpatient Individualized Treatment Plan (R02)" Approval date March 3, 2015, stipulated under "5.11.7"; "Individualized therapeutic interventions will be adapted for clients with special programming needs as applicable."

B. Record Review:

The Master Treatment Plans for the following active sample patients were reviewed (dates of plans in parentheses): A1 (6/17/18); A2 (6/19/18); A3 (6/20/18); A4 (6/19/18); A5 (6/20/18); A6 (6/20//18); A7 (6/18/18); and A8 (6/17/18). This review revealed the Master Treatment Plans did not include individualized specific interventions to assist patients to accomplish treatment goals but contained routine generic discipline functions (such as "evaluate," "order suicidal/self-harm precautions," "prescribe medication," "monitor," and "administer antipsychotics as ordered") written

Based on record review, policy review and interview, the facility failed to ensure that the treatment team staff adequately documented in the treatment notes, active treatment interventions from the Master Treatment Plan to show comprehensive information about treatment provided for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, and A8). Specifically, documentation did not consistently include if the interventions were carried out, and if so, the patients' response to the interventions, including the understanding of the information provided and specific comments if any. This failure hinders the treatment team in determining the patients' response to active treatment interventions, evaluating if there were measurable changes in the patients' condition and revising the treatment plan when the patient did not respond to treatment interventions.

Findings include:

A. Record Review

Staff was asked to copy all [average length of stay was three days] progress notes, for all disciplines since all active sample patients' admissions (A1, A2, A3, A4, A5, A6, A7, and A8) to review progress/treatment notes. From this review, the surveyors were not able to find any progress/treatment notes pertaining to treatment goals and interventions from any disciplines for all of the sample patients. The medical records did not include whether the interventions were held as assigned in the treatment plan, and if held, there were no reference to what was discussed and how the patient responded to the intervention.

B. Policy Review:

The hospital policy "Procedure: Clinical documentation Timeliness," Procedure #: V - 539 (R01), approved on January 20, 2016 stipulated under "Definitions: Documentation: "The narrative of a clinical contact that is written .... that explains... the interventions used by

Based on record review and staff interview the Medical Director failed to ensure that;

I. The Psychiatric Evaluations included an assessment of patients' memory and intellectual
functioning for four (4) of eight (8) active sample patients (A2, A3, A4, and A6). This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate. (Refer to B116).

II. The Master Treatment Plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) included; a) STGs that were observable, measurable and written in behavioral terms (Refer to B121) and b) Treatment interventions that were individualized and specific to each patients' unique psychiatric symptoms/problems. These deficiencies potentially result in treatment that is inconsistent or ineffective as well as prolonged hospitalization.

III. The progress/treatment notes written by all treatment team members refer to the implementation of treatment interventions identified in the MTPs and documented progress that patients were making towards accomplishing STGs for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This failure hindered the treatment team in determining the patients' response to active treatment interventions, evaluating if there were measurable changes in the patients' condition and revising the treatment plan if/when the patient is not responding to treatment interventions. (Refer to B124)

III. An adequate number of qualified Activity Therapy staff were employed to conduct Activity Therapy Assessments and provide sufficient numbers of structured therapeutic activities. This failure results in patients not receiving a full complement of therapies, patients not being assessed adequately regarding ne

Based on observation, record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. The identified short-term goals in MTPs for 8 (eight) of 8 (eight) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8)) were observable, measurable and addressed the individual patient presenting problems and needs. These deficient goal statements hinder the ability of the team to individualize treatment and to measure the change in the patient consequent to treatment interventions. (Refer to B121).

II. Active treatment interventions to be implemented by Registered Nurses for 8 (eight) of 8 (eight) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) were individualized to achieve specific goals. The listed nursing interventions were routine, generic discipline functions expected to be regularly provided by nursing staff for all patients. Interventions were also written as staff expectations/compliance statements. These failures to develop focused, individualized interventions can result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122).

Interview

In an interview with the Nursing Director, Director of Operations and RN 1 on 6/21/17 at 12:30 p.m., the Treatment Plans were reviewed. They agreed that the treatment plan goals were not written in observable, measurable patient behaviors to be achieved and that the nursing interventions lacked specific purpose/focus, the modality needed to be identified and that they were generic routine nursing functions.

Based on policy review, medical record review and interview; the facility failed to:

I. Employ a qualified Therapeutic Activities staff to provide and document active treatment for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Specifically, the facility failed to follow their own policy in providing a qualified and competent individual to complete therapeutic activities assessments to ensure appropriate input into the formulation of the Master Treatment Plans (MTPs), as well as to offer therapeutic activities. This failure results in patients not receiving a full complement of therapies, patients not being assessed adequately regarding needs and capabilities, and patients not receiving individualized and goal-directed therapeutic activities.

II. Provide documented evidence showing Patient Support Technicians (PSTs) competency to provide therapeutic activity groups. Specifically, PSTs provided most of the therapeutic activities titled "Intro/Safety Plan, Exercise/Outdoors, Movie/TV/Games groups." PSTs did not have documented evidence except for an orientation sheet "Shadow & help w/Group Day Three." This failure results in a lack of structured therapeutic activities provided by qualified staff, which potentially hampers patients' progress in obtaining their optimal level of functioning.

Findings include:

A. Policy Review

The facility policy titled "Activity Services; Procedure #: IV - 533 (R 04) Approval date: July 20, 2009" stated under 4.3, "A qualified competent individual shall be assigned to provide oversight for activity services."

B. Record Review

1. There were no Therapeutic Activities Assessments located in the medical records.

2. The Master Treatment Plans (MTPs) for the following patients were reviewed (dates of