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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure compliance with all applicable Federal and State laws and regulations.

The facility was determined to be non-compliant with the following Federal Regulation:

482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

Based on a review of facility documents, medical records (MR) and staff interviews (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" prior to discharge for three of three medical records reviewed (M22, MR23 and MR29).

Findings include:

Review of facility policy "Medicare and Medicare Advantage Notice of Hospital Discharge and Appeal Rights" dated September 24, 2014, revealed "Responsibilities of the Discharging Nurse - Delivery of Second Notice 1. All patients with Medicare, Medicare Advantage and Medicare Secondary Insurance must receive information about their discharge rights. 2. The Case Manager will make every effort to obtain the patients signature with date and time at least 48 hours prior to discharge. if not already signed, it will be the responsibility of the discharge nurse to verify that a second copy of the signed IM has been given to the patient before discharge. 3. If the patient has not received the second copy of the signed IM the discharge nurse will then be responsible to deliver the second copy to the patient."

1. Review of MR22, MR23 and MR29 indicated the patient was admitted to the facility and had a length of stay greater than 48 hours. Further review revealed MR22, MR23, and MR29 had an IMM signed at the time of admission, but there was no evidence of a signed IMM within two days prior to discharge.

2. On August 27, 2015, at approximately 10:15 AM, EMP15 confirmed the above findings and revealed "It [Medicare and Medicare Advantage Notice of Hospital Discharge and Appeal Rights] is not there."

Based on review of the facility documents and staff interview (EMP), it was determined the facility failed to follow the written fire control plan for their hospital based outpatient centers.

Findings include:

1) Review of facility document, "Life Safety Management Plan" , dated December 2011, revealed, "The following processes will be utilized to carry out the components of the Life Safety Management Plan: ... 4. Fire Drills: Fire drills are held monthly for the hospital. Frequency: Monthly. Fire drills are held periodically at all Highlands Hospital off-site facilities. Frequency: Quarterly."

2) Review of off-site facilities locations revealed the hospital has five off-site facilities. Further review of "Off-site Fire Drill Report," dated January 5, 2015, revealed one fire drill was completed at one off-site center in the first quarter. No other documentation of off-site fire drills was provided.

3) Interview with EMP11 on August 26, 2015, at approximately 10:00 am, revealed, "I didn't know we had to do it [fire drills] quarterly in outpatient facilities."

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to follow their policy to ensure a system was in place to control infections.

Findings include:

Review of facility policy "Airborne/Contact Isolation" dated March 5, 2008, revealed "Airborne and Contact Precautions in addition to Standard Precautions prevent transmission of infectious agents over long distances when suspended in the air and by contact with the patient and/or their environment. ... The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with special air handling and ventilation capacity that meet the American Institute of negative pressure relative to the surrounding area) A minimum of 6 air exchanges per hour is required. Also required is appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas of the hospital."

1. During an interview on August 26, 2015, EMP11 was asked if air exchanges were checked in the negative pressure rooms. EMP11 stated, "No we do not."