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Based on interview and document review, the facility failed to ensure their Quality Assurance/ Performance Improvement (QAPI) program had developed ongoing QA/PI projects for pharmacy.

Findings include:

During an interview on 12/11/18, at 11:48 a.m. the pharmacy manager stated she was unable to provide any current QAPI projects at the time of the interview.

The director of quality was interviewed on 12/12/18, from 8:30 a.m-10:15 a.m. during which she stated that pharmacy was not currently involved in any ongoing QAPI projects.

Based on interview and document review, the Behavioral Health Hospital failed to ensure verbal orders were used infrequently and not for provider convenience.

Findings include:

The Percent of Verbal Orders by Patient Department report for date range of 11/1/18 - 11/30/18, indicated there were a total of 392 telephone orders, and 301 verbal orders which totaled 693 orders out of the 1,945 orders received. 36% of the orders received were verbal and telephone orders.

During a joint interview with the director of nursing (DON) and Registered Nurse Manager (RNM)-A on 12/11/18, at 1:58 p.m. the DON stated the facility's practitioners had the ability to enter patient orders electronically from outside of the building and it was the expectation of the hospital's physicians and practitioners to enter patient orders. RNM-A stated she had been working with the hospital's primary psychiatrist in order to comply with provider entry or the orders.

During an interview on 12/12/18, at 11:03 a.m. RNM-A confirmed the facility received verbal telephone orders from the hospital's primary psychiatrist on a daily basis. However, RNM-A stated the hospital did not have access to run a report from the electronic medical record system (EPIC) therefore was unable to produce a report to review the verbal/telephone orders received. She indicated the hospital was working on obtaining access to the report but at present, had not been tracking the frequency of verbal and telephone orders received.

Review of the hospital policy titled, "verbal and/or telephone orders" revised 9/18/18, revealed it was the hospital's policy to use verbal and/or telephone orders infrequently and not for physician convenience.