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Based on record reviews, contract reviews and interview the hospital failed to ensure the hospital's contracted services were performed to allow the hospital to demonstrate independent compliance with Conditions of Participation.
This was evidenced by Iberia General and Medical Center (IGMC) signing a contract to provide, and then providing laboratory and blood gas services, radiology & imaging services, medical staff services, emergency and code blue services (Cardiac/Respiratory Arrest), pharmacy services, and telemetry services to HWH (hospital in a hospital) long term acute care hospital "a".
Findings:

Review of the "Purchased Services Agreement", dated 6/1/10, and presented to the surveyor as the most current agreement between host hospital Iberia General and Medical Center and HWH long term acute care hospital "a". This agreement revealed host hospital Iberia General and Medical Center is providing laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response services, pharmacy services, and telemetry services to HWH long term acute care Hospital "a".
This agreement further stipulated that Iberia General and Medical Center would respond to any code blue or emergency situations in long term care hospital "a" with physicians support staff handling the emergency and code blue situations along with HWH- long term acute care hospital "a" as support staff.

In an interview on 10/09/12 at 2:10 p.m. with S30RN, ER Director, he stated that the ER Physician on duty at Iberia General Hospital and Medical Center and a Supervisor (nursing) respond to Code Blue in the HWH-long term acute care hospital "a". S30RN, ER Director, further stated that a Code Blue in the HWH-long term care hospital "a" is announced through the overhead paging system in Iberia General Hospital and Medical Center.

In an interview on 10/09/12 at 2:15 p.m. with S25MD, on duty in the ER at Iberia General Hospital and Medical Center, he stated that the ER Physician from Iberia General Hospital does respond to Code Blue in the HWH-long term acute care hospital "a".

In an interview on 10/09/12 at 2:30 p.m. with S26RRT, Director of Respiratory Services, she stated that Respiratory Therapist's (RT) who are on duty at Iberia General Hospital and Medical Center do respond to Code Blue in the HWH-long term acute care hospital "a".

Based on observation, record review, and interview the Hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by Iberia General Hospital and Medical Center physically placed a computer owned by the hospital inside of another hospital. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the HWH (hospital within a hospital) long term acute care hospital "a" being on a list of current Iberia General Hospital and Medical Center patients provided to surveyor's and through interview with staff. (see findings at A0143)

2) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by the name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (hospital "a") being presented to surveyor's on a list of Iberia General Hospital and Medical Center's current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the HWH-long term acute care hospital "a". (see findings at A0143)

3) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by having a Telemetry logbook where the HWH (hospital "a") patients' name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log maintained inside Iberia General Hospital and Medical Center. (see findings at A0143)

Based on observation, record review, and interview the hospital failed to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by:

1) Iberia General Hospital and Medical Center physically placed a computer owned by the hospital inside of another hospital. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the HWH-long term acute care hospital "a" being on a list of current Iberia General Hospital and Medical Center patients provided to surveyor's and through interview with staff.

2) the name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (hospital "a") being presented to surveyor's on a list of Iberia General Hospital and Medical Center's current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the HWH.

3) having a Telemetry logbook where the HWH-long term acute care hospital "a" patients' name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log maintained inside Iberia General Hospital and Medical Center.

Findings:

1)

In an interview on 10/08/12 at 11:00 a.m. with S2DON and S29HIM Director both confirmed that a computer owned by Iberia General Hospital was located within the "hospital within a hospital" (HWH) (hosp "a").S2DON and S29HIM Director stated that the computer is used by hospital "a" to enter orders for ancillary services contracted from the host hospital. It was confirmed during the same interview that the HWH (hospital "a") had access to all patient demographic, lab orders and results, and Radiology orders and results on all current patients and past patients of Iberia General Hospital and Medical Center.

In an interview on 10/08/12 at 11:15 a.m. with S28IT (Information Technology), he confirmed the computer located in the HWH- long term acute care hospital "a" belonged to Iberia General Hospital. He further confirmed that the computer has access to patient information for patients of Iberia General Hospital. S28IT stated that the computer program used by Iberia General Hospital had no capability to limit the access of the HWH-long term acute care hospital "a" to only patients admitted to the HWH-long term acute care hospital "a".

In an interview on 10/09/12 at 8:55 a.m. with S27Quality and S28IT both stated that the computer owned by Iberia General Hospital that is located in the HWH-long term acute care hospital "a" can access any lab result, radiology report, and demographic information from Iberia General Hospital and Medical Center.

2)

During the Entrance Conference at Iberia General Hospital & Medical Center on 10/08/12 at 10:00 a.m. a request was made for a list of current patients. Review of the list provided by S2DON revealed it contained the full names, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (hospital "a") being presented to surveyor's on a list of Iberia General Hospital and Medical Center's current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the HWH. This was confirmed by S2DON on 10/08/12 at 11:00 a.m.

3)

On 10/09/12 at 9:15 a.m., a face-to-face interview was conducted with S33 Telemetry Technician and an observation was made of the cardiac monitors. S33 stated she received patient information from HWH-long term acute care hospital "a" by telephone when telemetry monitoring was initiated. S33 stated the nurse in hospital "a" provided the patient's name, diagnosis, code status, age, room number, and the physician's name of the patient to be monitored. An observation of the long term acute care hospital "a" monitor revealed the patient's name, room number, age and physician's name were displayed on the screen. S33 stated she printed rhythm strips for all patients every 8 hours, documented the rhythm, posted the rhythm on a form to be filed in the patient's record, and delivered the strips to the patient's unit for filing. S33 verified long term acute hospital "a" was included in this process. S33 stated there is a log book for telemetry and all patients on telemetry, including long term acute care hospital "a" patients, are logged in. Review of the Telemetry Log book revealed the patient's name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log. S33 stated if she needed to compare strips, or needed other information, she went to long term acute care hospital "a" and reviewed the patient's record. S33 verified she had access to long term acute care hospital "a" patient records.

Based on observation, record review, and interview the Hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the Nursing Services had one well organized service with a plan of administrative authority and clear delineation of patient care responsibilities and failing to allow the hospital to demonstrate independent compliance of Conditions of Participation as evidenced by the hospital and the HWH (hospital within a hospital)-long term acute care hospital "a" using the same staff for Telemetry monitoring. Iberia General Hospital monitored patients from the HWH-long term acute care hospital "a", thereby co-mingling staff between Iberia General Hospital and the HWH-long term acute care hospital "a". (see findings at A0386)

Based on observation, record review and interview the hospital failed to ensure the Nursing Services had one well organized service with a plan of administrative authority and clear delineation of patient care responsibilities and failing to allow the hospital to demonstrate independent compliance of Conditions of Participation as evidenced by the hospital and the HWH (hospital within a hospital)-long term acute care hospital "a" using the same staff for Telemetry monitoring. Iberia General Hospital monitored patients from the HWH-long term acute care hospital "a", thereby co-mingling staff between Iberia General Hospital and the HWH-long term acute care hospital "a".

Findings:

On 10/08/12 at 3:30 p.m. a face-to-face interview was conducted with S32 CCU Manager and observations were made of the unit. S32 indicated the CCU was also responsible for telemetry monitoring for the long term acute care hospital "a". S32 stated the hospital had telemetry capability of 46. S32 stated they had 40 telemetry units for the hospital and 6 for long term acute care hospital "a". S32 stated the CCU has a telemetry technician who monitors the telemetry and CCU patient cardiac rhythms 24 hours a day, 7 days a week. S32 stated long term acute care hospital "a" had a remote display, but no one sits at the monitor in the long term acute care hospital "a". S32 stated the telemetry tech was responsible to monitor the long term acute care hospital "a" patients on telemetry as well as telemetry patients throughout the hospital. Observation of the CCU revealed the cardiac monitors were located in a room to the rear of the nurse's station. S33 Telemetry Technician stated CCU patients were on the first monitor, long term acute care hospital "a" patients were on the second monitor, and the other 2 monitors were for telemetry patients throughout the hospital. Observation of the long term acute care hospital "a" monitor revealed 2 patients from long term acute care hospital "a" were currently being monitored by S33 Telemetry Technician.

On 10/09/12 at 9:15 a.m., a face-to-face interview was conducted with S33 Telemetry Technician and an observation was made of the cardiac monitors. S33 stated she received patient information from long term acute care hospital "a" by telephone when telemetry monitoring was initiated. S33 stated the nurse in long term acute care hospital "a" provided the patient's name, diagnosis, code status, age, room number, and the physician's name of the patient to be monitored. An observation of the long term acute care hospital "a" monitor revealed the patient's name, room number, age and physician's name were displayed on the screen. S33 stated she printed rhythm strips for all patients every 8 hours, documented the rhythm, posted the rhythm on a form to be filed in the patient's record, and delivered the strips to the patient's unit for filing. S33 verified long term acute care hospital "a" was included in this process. S33 stated there is a log book for telemetry and all patients on telemetry, including long term acute care hospital "a" patients, are logged in. Review of the Telemetry Log book revealed the patient's name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log. S33 stated if she needed to compare strips, or needed other information, she went to long term acute care hospital "a" and reviewed the patient's record. S33 verified she had access to the long term acute care hospital "a" patient records.

On 10/09/12 at 9:15 a.m., in a face-to-face interview, S32 CCU Manager stated long term acute care hospital "a" had a monitor screen and they are primarily responsible for monitoring the patient's cardiac rhythms. S32 stated the CCU staff was "back up" for long term acute care hospital "a" staff. S32 indicated there was no one staff member sitting at the monitor in long term acute care hospital "a". S32 indicated the CCU policy on Telemetry Monitoring included long term acute care hospital "a". S32 stated the CCU provided the same services to long term acute care hospital "a" as they did for any patient in the hospital on telemetry. S32 stated the CCU staff had access to long term acute care hospital "a", "They let us go look at their records if we need to." S32 stated she thought they could access long term acute care hospital "a" patient's labs in the hospital computer. S32 stated long term acute care hospital "a" and the hospital used the same laboratory and respiratory services. S32 stated she was told, "We have a contract to assist hospital "a" to monitor their telemetry patients as back up. They are primarily responsible."

Review of the hospital policy titled, Telemetry Monitoring, revised date of 08/10 and reviewed date of 09/12, provided by S32 as current CCU policy, revealed in part the following: "Telemetry Usage: Telemetry will be monitored on 2nd floor (Medical Inpatient), 3rd floor (Maternal/Child Health & hospital "a"), and 4th floor (Outpatient Surgery & Surgical Inpatient)...Procedure: 3. For admits to the floor or new orders for telemetry, the unit secretary or the nurse will go to ICU and obtain a telemetry box. Relay to ICU the patient's name, room number, diagnosis, physician, code status, IV infusions that are: antiarrhythmic (Lidocaine), vasoactive (Dopamine, Dobutrex), or cardiac effecting (Aminophylline) and any orders pertaining to Telemetry. 4. Telemetry Tech will record the above patient information in the Telemetry Log book. 8. Telemetry techs are responsible for continuously monitoring the patient's ECG (Electrocardiogram) pattern. They are also responsible for obtaining a rhythm strip every 8 hours or more frequently if indicated..."

Based on observation, record review, and interview the Hospital failed to meet the Condition of Participation for Medical Records as evidenced by:

1) Failing to ensure the confidentiality of patient information for all patients in Iberia General Hospital and Medical Center and the hospital within the hospital (HWH)-long term acute care hospital "a". Iberia General Hospital and Medical Center physically placed a computer owned by the hospital inside of another hospital. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the HWH- long term care hospital "a" being on a list of current Iberia General Hospital and Medical Center patients provided to surveyor's and through interview with staff. (see findings at A0441)

Based on record review and interview the hospital failed to ensure the confidentiality of patient information for all patients in Iberia General Hospital and Medical Center and the hospital within the hospital (HWH)-long term acute care hospital "a". Iberia General Hospital and Medical Center physically placed a computer owned by the hospital inside of another hospital. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the HWH-long term acute care hospital "a" being on a list of current Iberia General Hospital and Medical Center patients provided to surveyor's and through interview with staff.

Findings:

During the Entrance Conference at Iberia General Hospital & Medical Center on 10/08/12 at 10:00 a.m. a request was made for a list of current patients. Review of the list provided by S2DON revealed it contained the full names, age, and location/room number of 11 patients in the Long-Term Acute Care (hospital "a") located inside of Iberia General Hospital and Medical Center. This was confirmed by S2DON on 10/08/12 at 11:00 a.m.

In an interview on 10/08/12 at 11:00 a.m. with S2DON and S29HIM Director both confirmed that a computer owned by Iberia General Hospital was located within the "hospital within a hospital" (HWH) long term acute care hospital "a". S2DON and S29HIM Director stated that the computer is used by long term acute care hospital "a" to enter orders for ancillary services contracted from the host hospital. It was confirmed during the same interview that the HWH - long term acute care hospital "a" had access to all patient demographic, lab orders and results, and Radiology orders and results on all current patients and past patients of Iberia General Hospital and Medical Center.

In an interview on 10/08/12 at 11:15 a.m. with S28IT (Information Technology), he confirmed the computer located in the HWH-long term acute care hospital "a" belonged to Iberia General Hospital. He further confirmed that the computer has access to patient information for patients of Iberia General Hospital. S28IT stated that the computer program used by Iberia General Hospital had no capability to limit the access of the HWH-long term acute care hospital "a" to only patients admitted to the HWH-long term acute care hospital "a".

In an interview on 10/09/12 at 8:55 a.m. with S27Quality and S28IT both stated that the computer owned by Iberia General Hospital that is located in the HWH-long term acute care hospital "a" can access any lab result, radiology report, and demographic information from Iberia General Hospital and Medical Center.

Review of a document titled "Purchased Services Agreement" revealed the following: "This Purchased Services Agreement (this "Agreement") is effective June 1, 2010 by and between Iberia Medical Center ("Hospital") and hospital "a" a long term acute care hospital. 17. HIPPA. Except as permitted or required by this Agreement or by law, each party will not use or disclose patient information in a manner that would violate the requirements of 45 CFR Section 165.504 and 164.506(c)(1) known as HIPPA Privacy and Security Standards contained in the Health Insurance Portability and Accountability Act of 1996..."

Based on observation, record review, and interview the Hospital failed to meet the Condition of Participation for Emergency Services as evidenced by:

1) Failing to ensure there was adequate staffing in the Emergency Room (ER) at all times by allowing the ER Physician on duty to respond to medical emergencies in the long term acute care hospital "a" that is located within Iberia General Hospital and Medical Center and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. The long term acute care hospital "a" is a separately licensed and certified hospital. (see findings at A1104)

Based on record review and interview the hospital failed to ensure there was adequate staffing in the Emergency Room (ER) at all times by allowing the ER Physician on duty to respond to medical emergencies in the long term acute care hospital "a" that is located within Iberia General Hospital and Medical Center and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. The long term acute care hospital "a" is a separately licensed and certified hospital.
Findings:

In an interview on 10/09/12 at 2:10 p.m. with S30RN, ER Director, he stated that the ER Physician on duty at Iberia General Hospital and Medical Center and a Supervisor (nursing) respond to Code Blue (Cardiac/Respiratory Arrest) in the HWH-long term acute care hospital "a". S30RN, ER Director, further stated that a Code Blue in the HWH-long term acute care hospital "a" is announced through the overhead paging system in Iberia General Hospital and Medical Center.

In an interview on 10/09/12 at 2:15 p.m. with S25MD, on duty in the ER at Iberia General Hospital and Medical Center, he stated that the ER Physician from Iberia General Hospital does respond to Code Blue in the HWH-long term acute care hospital "a".

In an interview on 10/09/12 at 2:30 p.m. with S26RRT, Director of Respiratory Services, she stated that Respiratory Therapist's (RT) who are on duty at Iberia General Hospital and Medical Center do respond to Code Blue in the HWH-long term acute care hospital "a".

In an interview on 10/09/12 at 2:40 p.m. with S2DON she stated the following on duty employee's from Iberia General Hospital and Medical Center respond to Code Blue in the HWH-long term acute hospital "a" : 1 RT, 1 Nursing Supervisor, and 1 ER MD. S2DON further stated that the ERMD responds even if there is only one Physician on duty in the ER.

Review of a document titled "Purchased Services Agreement" revealed the following: "This Purchased Services Agreement (this "Agreement") is effective June 1, 2010 by and between Iberia Medical Center ("Hospital") and Hospital "a" a long term acute care hospital. Witnesseth. Whereas, Hospital operates a general acute care hospital located at 2315 East Main Street, New Iberia, Louisiana 70560 ("Hospital Campus") at which it provides general hospital and medical services to residents of the surrounding communities; and Whereas, hospital "a" owns and operates a long-term care hospital ("LTCH"), as defined in 42 CFR 412.23(e), located within Hospital, through which hospital "a" offers long-term acute care services to medically complex patients in need thereof; and...Whereas, Hospital has agreed to make available to LTCH certain ancillary services and supplies requested by LTCH for use by LTCH in the delivery of Services during the period of time that the Lease Agreement is in effect. Now therefore, for and in consideration of the premises and the mutual covenants herein contained, Hospital and long term acute care hospital "a" agree that during the term of the Lease Agreement, and during any renewal, extension or modification thereof, Hospital will make available to LTCH, its successors or assigns, the following services if requested by LTCH: 1. Hospital Services in General. A. When requested, Hospital shall make available to LTCH the following services ("Service(s)"), as more fully described in more detail herein: 1) Laboratory and Blood Gas Services; 2) Radiology and Other Imaging Services; 3) Emergency Services; 4) Surgical Services; 5) Central Supply; 7) Coordinated Disaster Planning; 8) Respiratory Services; Telemetry Services; and 10) Other Services and Supplies. B.Long term care hospital "a" may purchase the Services listed above and Hospital shall provide the Services to LTCH patients "under arrangement" in the same manner and to the extent to which they are available to patients admitted to the Intensive Care Unit ("ICU") at Hospital. C. In addition to making the foregoing services available to LTCH, Hospital, shall permit LTCH physicians, staff and patients reasonable access to the physical facilities relating to the foregoing services...D. Whenever applicable to the foregoing Services, Hospital staff shall be responsible for transporting and accompanying LTCH patients to the physical facilities of Hospital for receipt of the foregoing Services; shall stay with LTCH patients during the foregoing Services; and shall return LTCH patients to the Leased Premises upon completion of the foregoing Services...C. Emergency Services...Hospital shall provide code blue emergency services to LTCH patients as needed twenty-four (24) hours a day. Code blue related to LTCH patients occurring in the physical facilities of Hospital located outside of the Leased Premises shall be handled by Hospital's medical staff physicians and support staff, with the assistance of LTCH staff. LTCH shall have policies and procedures in place for emergency situations and shall be responsible for notifying Hospital of code blues related to LTCH patients occurring in the Leased Premises. Once notified of a code blue by the LTCH, Hospital medical staff physicians and the LTCH staff shall be primarily responsible for responding to a code blue. Any Hospital staff member assisting and/or responding to code blues and performing emergency services for LTCH patients shall maintain a current and valid BLS (basic life support) certification. Upon request, records of each Hospital staff members' BLS certification, including competency and training/education documentation, will be provided in compliance with Medicare Conditions of Participation and the applicable standard of care...H. Telemetry Services. Hospital shall provide, upon request by LTCH, telemetry services as ordered by a member of LTCH's medical staff for a LTCH patient. Telemetry services shall include providing telemetry transmitters, to the extent available, and secondary monitoring. Hospital shall provide competent and qualified administrative and telemetry personnel for secondary monitoring of LTCH patients. LTCH staff shall be primarily responsible for telemetry monitoring of the LTCH's patients. I. Respiratory Services. Hospital may provide under arrangement and upon request by LTCH, such Respiratory Services as are available at Hospital as ordered by a member of LTCH's medical staff for an LTCH patient. The parties acknowledge that such Respiratory Services are intended by the parties to be available to LTCH patients if there is a need for such Respiratory Services and if the Hospital's staff, trained and responsible for providing Respiratory Services, are available and not otherwise engaged in providing patient care at the Hospital. When available, Hospital agrees to provide Respiratory Services in accordance with community standards of practice and federal and Louisiana law...6...B. Cooperation. Hospital and long term acute care hospital "a" understand that federal regulations governing the relationship between a "hospital within a hospital" and the "host hospital" found at 42 CFR 412.22(g) prohibit a co-located hospital from exercising direct or indirect control over LTCH. However, in order to encourage cooperation between the parties and ensure the highest quality patient care, Hospital shall provide LTCH current and updated policy and procedure manuals for each of the departments providing services to LTCH pursuant to this Agreement. Hospital and long term acute care hospital "a" agree to comply with all Medicare conditions of participation found at 42 C.F.R. 482, et. Seq. LTCH is responsible for keeping Hospital informed of LTCH's preparations for surveys. LTCH and Hospital will cooperate in order to ensure (i) attendance, at Hospital's request, at in-service presentations pertinent to patient care rendered, (ii) consistent and reasonable interaction between LTCH and Hospital management, and (iii) adequate staffing based on LTCH's and Hospital's needs...10. Independent Medical Staff. A. Long term acute care hospital "a" represents that it has established a separate and distinct medical staff independent of Hospital's medical staff, and that no physician shall be entitled to the privileges of medical staff membership at LTCH solely by virtue of their membership on the medical staff of Hospital. Long term acute care hospital "a" further represents that it has implemented credentialing policies and procedures intended to ensure that only qualified physicians are appointed to its medical staff and which otherwise meet applicable regulatory and credentialing standards regarding the same...17. HIPPA. Except as permitted or required by this Agreement or by law, each party will not use or disclose patient information in a manner that would violate the requirements of 45 CFR Section 165.504 and 164.506(c)(1) known as HIPPA Privacy and Security Standards contained in the Health Insurance Portability and Accountability Act of 1996..."