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Based on interview and document review, the governing body did not ensure a quality assurance performance improvement (QAPI) plan was being implemented for 5 of 5 contracted services which included radiology, laboratory services, food and dietetic services, physical environment and occupational therapy services. This had the potential to affect 10 of 10 patients currently residing in the hospital.

Findings include:

The governing body did not ensure contracted services were evaluated as part of the hospital overall QAPI plan.

Radiological services, a contracted service with Rice Memorial Hospital, did not have a QAPI program. The Group Supervisor and Compliance Officer, who was responsible for the QAPI program for the hospital, was interviewed at 11:10 a.m. on 7/11/2012 and verified there was no QAPI program related to radiological services provided to patients at the Child Adolescent hospital.

Laboratory Services, a contracted service with Rice Memorial Hospital, did not have a QAPI program. The Group Supervisor and Compliance Officer, who was responsible for the hospital's QAPI program, was interviewed at 11:10 a.m. on 7/11/2012 and verified there was no QAPI program related to laboratory services provided to patients.

Food and Dietetic Services, a contracted service with A'viands, did not have a QAPI program. In an interview with the registered dietician at 10:00 a.m. on 7/11/12, she stated the department was currently monitoring and recording food temperatures. This has been done on a regular basis since 2006. She acknowledged this was a data collection activity but there was not a formal QAPI program that addressed this data.

The hospital's building had a lease arrangement (contracted service) with Kandiyohi county. The county provided contract services to maintain the physical structure of the building. The Administrator/Administrative Nursing Supervisor was interviewed at approximately 10:30 a.m. on 7/12/2012 and stated the county maintained the physical structure of the building such as wall repair and painting services. He stated there was no QAPI program related to the physical environment of the hospital, which was maintained by the county, under a contract agreement..

Occupational Therapy services, a contracted service with Rice Memorial Hospital, did not have a QAPI program. The Group Supervisor and Compliance Officer, who was responsible for the hospital's QAPI program, was interviewed at 11:10 a.m. on 7/11/2012. He verified there was no QAPI program related to occupational therapy services provided to patients.

A review of the "State of Minnesota Professional and Technical Services Master Contract", dated 5/23/2011, indicated the hospital had a contract with Rice Memorial Hospital for laboratory, radiological and occupational therapy services.

Review of the Child Adolescent Behavioral Health Services Governing Advisory Board Meeting for January, April, September and November 2011 and February 2012 only identified performance improvement activities which included "Strategic Plan and LIP Goal", monitoring patient acuity, grievances, falls, incidents, satisfaction survey and medication errors. Review of the State Operated Services Governing Board Meeting from January 2011 to January 26, 2012 identified different programs within the state system, appointments and policy approvals. There was no indication the governing board was evaluating the quality of each contracted service to ensure these services were provided in a safe and effective manner through the QAPI program nor did they direct the hospital to develop a QAPI program for these contracted services.

The Group Supervisor and Compliance Officer for the hospital, when interviewed at 11:10 a.m. on 7/11/2012, stated some data was collected from some of the contracted services, however, there were no QAPI programs for these services.

The Administrator/Administrative Nursing Supervisor was interviewed at approximately 9:30 a.m. on 7/12/2012. He stated the hospital had it's own governing body (the hospital advisory group) until February, 2012 which was responsible for reviewing QAPI activities which occurred at the hospital. The responsibilities of the governing body were then assumed by the State Operated Services division of the Department of Human Services, which then assumed responsibility for reviewing QAPI activities which occurred at the hospital. He stated the hospital sent a "dashboard" of performance improvement activities to the governing body but was unsure if they were reviewed.


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Based upon interview and policy review, the governing body did not ensure the medical staff had written policies and procedures for emergencies, initial treatment, and referrals. This had the potential to affect any patient who presented at the hospital with an emergency medical or psychiatric condition.

Findings include:

Although the hospital did not provide emergency services, the governing body did not ensure the medical staff had policies and procedures in place for addressing individual's emergency care needs 24 hours a day and 7 days per week.

Review of the facility policy did not identify any policies for emergency services, initial treatment and referrals.

The Administrator/ Administrative Nursing Supervisor was interviewed at approximately 9:30 a.m. on 7/12/2012. He stated the hospital did not provide emergency services and did not have any policies related to appraisal of patients presenting with an emergency medical condition, the initial treatment of these patients or a means to refer the patients, when appropriate.

Based on interview, record review and document review, the hospital failed to implement their grievance policy for one of one patient (P1) who filed a grievance.

Findings include:

During the entrance conference at 10:30 a.m. on 7/10/12, the Administrator/administrative nursing supervisor stated the hospital did not have any record of grievances since 4/24/12.

Upon review of P1's medical record, the nursing progress notes, dated 6/7/2012, indicated P1 claimed "sexual harassment" from another peer at 1900 hour. The progress notes indicated a registered nurse (RN)-B had discussed the incident with P1 and offered P1 an opportunity to file a grievance. The nursing progress note of 6/7/2012 indicated "offered a grievance form to fill out, which he (P1) did". There was no indication the facility responded to the grievance or complainant beyond the initial filing.

During an interview with RN-B at 4:30 p.m. on 7/10/12, he stated he had forwarded the patient's grievance to the "officer of the day" and was unaware of further follow up.

The patient refused to be interviewed at 3:35 p.m. on 7/10/2012 in regards to the grievance.

Review of the hospital's policy and procedure titled "Grievance and Complaint Process
#6450", dated 4/26/2010, indicated....."the grievance or complaint is presented to any staff member; if unresolved, the grievance or complaint is presented to an appropriate program supervisor; if still unable to resolve, the grievance or complaint is then presented to the local authority for resolution".

During an interview at 9:03 a.m. on 7/12/2012, the Administrator/administrative nursing supervisor stated he was unaware of this grievance. He was not able to track the location of the grievance form, therefore an investigation was not completed.

No further information was available.

Based on interview and document review, the hospital failed to have a Quality Assurance and Performance Improvement (QAPI) program for the conditions of Patient Rights, Discharge Planning, Radiological services, Laboratory services, Occupational Therapy services and the physical plant, which had the potential of affecting 10 of 10 patients who were currently residing at the hospital.

Findings include:

Review of the QAPI program did not identify that a QAPI plan for patient rights or discharge planning had been implemented.

During an interview with the clinical social worker and RN-A at 1:30 p.m. on 7/11/2012, she stated there wasn't any form of a QAPI program being conducted at this time in the areas of patient rights or discharge planning.

The Food and Dietetic Services, a contracted service with A'viands, did not have a QAPI program. In an interview with the registered dietician at 10:00 a.m. on 7/11/12, she stated the department was currently monitoring and recording food temperatures. This has been done on a regular basis since 2006. She acknowledged this was a data collection activity but there was not a formal QAPI program that addressed this data.

The hospital's building had a lease arrangement (contracted service) with Kandiyohi county. The county provided contract services to maintain the physical structure of the building. The Administrator/Administrative Nursing Supervisor was interviewed at approximately 10:30 a.m. on 7/12/2012 and stated the county maintained the physical structure of the building such as wall repair and painting services. He stated there was no QAPI program related to the physical environment of the hospital, which was maintained by the county, under a contract agreement..

Review of the QAPI program indicated that radiology was a contracted service with Rice Memorial Hospital, there was no QAPI program.

The Laboratory Services, a contracted service with Rice Memorial Hospital, did not have a QAPI program.

The Occupational Therapy services, a contracted service with Rice Memorial Hospital, also did not have a QAPI program.

A review of the "State of Minnesota Professional and Technical Services Master Contract", dated 5/23/2011, indicated the hospital had a contract with Rice Memorial Hospital for laboratory, radiological and occupational therapy services.


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The Group Supervisor and Compliance Officer, who was responsible for the QAPI program for the hospital, was interviewed at 11:10 a.m. on 7/11/2012. He verified there were no QAPI programs related to radiological services, laboratory services and occupational therapy services, which were contracted services, provided to patients.

Based on medical record review and interview, the facility failed to act upon a nutritional assessment for 1 of 2 patients (P2) in the sample who were diagnosed with obesity.

Findings include:

P2 had a nutritional screening conducted on 6/27/2012 by a registered nurse. It identified P2 was obese with a Body Mass Index (BMI) of 34.8, a weight of 178 pounds and a height of 60 inches. The screening indicated a dietary consult was needed and the physician would write the order. The documentation did not reflect that a physician's order had been written and P2 remained on a regular diet.

In a interview with the registered dietician (RD) at 10:20 a.m. on 7/11/12, she stated she was unaware of any referral or order for a dietary consult for the patient.

Review of the current physician orders at 4:00 p.m. on 7/11/2012, with a registered nurse (RN)-A confirmed P2 was currently on a regular diet and did not have a reduced calorie diet even though he was obese.

In an interview with RN-C at 9:30 a.m. on 7/12/2012, she stated, although she had authored the nutritional screening, she was not aware there wasn't a follow through on obtaining a physician's order for the dietary consult.

No further information was available.

The hospital was found out of compliance with the Condition of Participation, Physical Environment (42 CFR 482.41), as evidenced by deficiencies issued as a result of a Life Safety Code inspection completed as a full survey after removal or deemed status.

Findings include:

Refer to Life Safety Code deficiencies K17, K18, K25, K50, K52, K54, K62, and K147 for additional information.

Based on observation and documentation review, the hospital failed to ensure infection control practices were implemented related to food handling for 2 of 3 observations. This would have the potential of affecting 10 of 10 patients who were in the hospital.

Findings include:

During the noon meal observation at 11:12 a.m. on 7/11/2012, Human Service Technician (HST)-A was observed with gloves on placing a patient's meal in the refrigerator because the patient was still asleep. HST-A proceeded to look for a food covering to preserve the bread stick. In her search for a covering, she opened two drawers, three cupboards and the refrigerator door with the same gloved hands. Without first changing her gloves, she picked up the bread stick, placed it into a paper towel and then into the refrigerator for patient consumption later.

In a second observation at 11:20 a.m. on 7/11/2012, HST-B was asked by a P8 to make some toast. HST-B, who was wearing food handling gloves, took two slices of bread from the patient's hands, unlocked the door to the kitchenette with her gloved hands, and placed the bread into the toaster. While the bread was toasting, she opened two cupboard doors, placed a bottle of liquid cleaner under the kitchen sink and opened two drawers with the same gloved hands. After the bread was toasted, HST-B without first changing her soiled gloves removed the toast from the toaster and proceeded to hand the toast to P8.

The above observations were discussed with the Registered Dietician (RD) at 11:33 a.m. on 7/11/12, she agreed the gloves should have been changed between handling the various surfaces in the kitchen and the direct handling of the food.

Review of the facility A'viand's (food contractor) policy for hand washing titled "Washing Hands" (undated), stipulated "food employees shall clean their hands...immediately before engaging in food preparation including working with exposed food,...after touching dirty dishes, equipment or utensils."

Based on interview and document review the facility failed to ensure that occupational therapy services had been reevaluated and changed when patients refused services for 2 of 5 patients (P4, P15) who received occupational therapy services.

Findings include:

P4 was admitted to the hospital on 6-11-12 with diagnoses that included Asperger's disorder and social anxiety disorder.

Occupational Therapy (OT) was ordered by the physician and an assessment was completed on 6-13-12. The 6-13-12 OT summary identified P4 "...demonstrates sensory processing difficulty which is impacting his ability to participate in daily activities." The objective was for P4 to "...be able to participate in sensory strategies 50% of the time offered." P4 would also "...be able to identify one benefit of sensory strategies."

The June 2012 treatment activity record identified the following activities of: "brushing every two hours." Out of 24 opportunities P4 refused this activity 11 times. A treatment of "shoulder compressions x10 immediately following brushing" indicated out of 23 opportunities P4 refused this activity 10 times. Exercise bike 1-2 times a day identified out of 12 opportunities P4 refused this activity 8 times. Rocking chair 1-2 times per day for 15 minutes identified out of 10 opportunities this activity was refused 5 times. Weighted blanket 1-2 times per day for 15 minutes also at night for sleep identified out of 4 opportunities, this was refused 2 times. Ball bounce 1-2 times per day for 10 minutes identified out of 6 opportunities this activity was refused 4 times.

A 6-20-12 OT note identified "review of sensory date tracker" and P4 "...has not participated in sensory strategies consistently when offered over the last week." The note also identified "(P4) identifies the following benefits (s) from the daily participation in sensory strategies unable to identify benefits this date." The OT plan was to "Continue with current daily sensory strategies and weekly OT to assist with organizing sensory information to facility improved performance in daily activities and social interactions." The plan was to also add "body sox 1-2 x day for 15 minutes." There was no indication in the record the "body sox" was ever implemented.

Even though P4 was not participating in the OT sensory strategies consistently, and had not reached the goal of 50% participation, the OT continued the same sensory program as P4 was initially assessed.

P15 was admitted to the facility on 5-8-12 and then discharged on 6-22-12 with diagnoses that included disruptive behaviors, reactive attachment disorder, and attention deficit hyperactivity disorder.

Occupational therapy (OT) was ordered by a physician and an initial evaluation was completed on 6-4-12. The 6-4-12 OT evaluation summary identified P15 "has difficulty processing auditory, oral , touch and multisensory stimuli. She would benefit from more intensity in daily sensory experiences in order to fulfill patient sensory needs as demonstrated by her more than other scores in sensation seeking and registration quadrants." The objectives were for P15 to "participate in sensory strategies 50% of time offered." P15 would also "be able to identify one benefit of sensory strategies."

The June 2012 treatment activity record identified trampoline 1-2 times per day for 10 minutes. Out of 25 opportunities P15 refused the treatment 19 times. A ball bouncing activity was identified to be competed 1-2 times per day for 10 minutes. Out of 24 opportunities, this activity was refused 17 times. There were other activities of brushing, shoulder compression, body sox and swinging which P15 consistently participated in.

An occupational therapy note on 6-20-12 indicated they reviewed "sensory date tracker" and P15 "has participated in sensory strategies consistently when offered over the last week." The note indicated they spoke with staff and P15 did not like the trampoline or ball bouncing so these "can be discontinued." Although P15 had consistently refused the trampoline and ball bouncing, over the past 15 days, these refusals were not addressed until 6-20-12, two days before P15 was discharged from the hospital.


During interview with Administrator/Administrative Nursing Supervisor at approximately
2:30 p.m. on 7-12-12, he stated that OT comes into the hospital every week to evaluate the patients progress and makes changes at that time.


No additional information was provided.