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Based on interview and record review, it was determined that the governing body failed to conduct the hospital in a manor to ensure that the hospital operations were separate from the skilled nursing facility that was in the same facility.

Findings include:

The governing body did not ensure that services were contracted specifically for the hospital. Refer to tag A 0084

The governing body did not ensure that the hospital nursing services were under the direction of one registered nurse. Refer to tag A 0385

The governing body did not ensure that the facility had a medical record system that was separate from the skilled nursing facility. Refer to tag A 0431

The governing body did not ensure that the hospital had contract specifically for the hospital for pharmacy services. Refer to tag A 0490

The governing body did not ensure that the hospital had a contract specifically for the hospital for radiological services. Refer to tag A 0528

The governing body did not ensure that the hospital had a contract specifically for the hospital for laboratory services. Refer to tag A 576

The governing body did not ensure that the hospital had a contract specifically for the hospital for dietary services. Refer to tag A 0618

The governing body did not ensure that the hospital had a contract specifically for the hospital for environmental services including but not limited to maintenance, housekeeping, laundry services and the general provision of supplies. Refer to tag A 0700

The governing body did not ensure that the hospital had a contract specifically for the hospital for rehabilitation services. Refer to tag A 1123

The governing body did not ensure that the hospital had a contract specifically for the hospital for respiratory services. Refer to tag A 1151

Based on interview and review of the organizational chart of the facility, it was determined that the hospital did not have designated nursing staff that had been employed just for the hospital area of the facility, including the chief nursing officer.

Findings include:

The facility did not have a chief nursing officer that had been hired by the hospital for the hospital. Refer to tag A 0386

The facility did not have nursing staff that had been hired by the hospital for the hospital. Refer to tag A 0392.

Based on interview it was determined that the facility did not have a medical record system that was separate from the skilled nursing facility.

Findings include:

An interview was held with the chief nursing officer (CNO) on 3/22/2013. The CNO stated that the medical records were hybrid. He stated that most of the record was electronic. He stated that the electronic records were password protected. He stated that any employee with a password could access the records, so skilled nursing employees could access hospital records and hospital employees could access skilled nursing patient records. There was no separation in the system. He also stated that the medical record personnel were employed by the facility and not specifically for the hospital.

Based on interview and record review it was determined that the facility did not have a contract for radiologic services that was specific for the hospital.

Findings include:

The hospital did not have a contract in place for radiological services that was specific for the hospital. Refer to tag A0529

Based on interview and record review, it was determined that the hospital did have a contract in place for laboratory services.

Findings include:

The hospital did not have a contract in place for laboratory services that was specific for the hospital and the needs of the hospital patients. Refer to tag A 0582

Based on interview, it was determined that the facility did not have a contract with anyone for dietary services.

Findings include:

An interview was held with the chief nursing officer on 3/20/2013. He stated that the facility had a dietary department that provided meals for all the patients in the entire building. He stated that the dietary services were organized and met the necessary requirements to provide the nutritional services for the patients. However, there was not a formal contract for the hospital to receive the dietary services available in the facility. It was also noted that there was a contract for a consulting dietitian that was not specific for the hospital.

Based on interview, it was determined that the facility did not have a maintenance program to ensure that the facility was maintained and provided a safe environment for the patients.

Findings include:

The hospital did not have maintenance services that were specific to the hospital. Refer to tag A 0701

Based on interview and record review it was determined that the hospital did not have a contract for rehabilitation services.

Findings include:

The hospital did not ensure that there was a contract in place for rehabilitation services for the hospital. Refer to tag A1124

Based on interview and record review it was determined that the hospital was providing respiratory services to the patients but none of the respiratory staff were employees of the hospital.

Findings include:

The hospital was providing respiratory services to hospital patients with non hospital personal. Refer to tag A 1152.

Based on interview and record review, it was determined that the facility did not ensure that contracted services were specific for the hospital and did not have a mechanism to evaluate the quality of each contracted service.

Findings include:

A review of the contracted services for the facility was completed on 3/20/2012. The contracts were between the contracted entity and the entire facility which included the skilled nursing facility and the hospital.

An interview was held with the facility chief nursing officer on 3/20/2013. He stated that the contracts were for the whole facility, not just the hospital. He also stated that there was no formal process to evaluate the quality of the contracted services by the quality assurance or the governing body.

Based on interview and record review, it was determined that the facility did not have a list of contracted services that were specific to the hospital.

Findings include:

The surveyor requested to review the contracted services for the hospital. The surveyor was given a large binder containing contracts between the "facility" and contracted services.

A review of the contracts was completed on 3/20/2013. The contracts did not identify if the contract was for the skilled nursing facility or the hospital.

An interview was held with the chief nursing officer on 3/20/2012. He stated that the contracts were for the entire facility not just the hospital. He also stated that there was no formal process to evaluate the quality of the contracted services by the quality assurance or the governing body of the hospital.

Based on review of 6 credentialing files and interview it was found that individual medical staff appraisals were not completed and reported to the governing body.

Findings include:

The committee of the whole is considered the medical staff meeting and governing board meeting. In the committee of the whole meeting for January 2013 a yearly summary is detailed. In that summary the number of medical staff on service at the facility is listed but does not specifically indicate which physician is up for re-appraisal and the granting of privileges.

An interview with the CEO was held on 3/20/2013 where he indicated that the credentialing was done with the end of year summary. When questioned he explained this was done by indicating the number of medical staff and allied staff that were presently employed at the facility. There is no detail regarding the specific physicians being credentialed or re credentialed at that time.

Based on review of the medical staff Bylaws, it was determined that the Bylaws did not specify the duties and privileges of each category of medical staff.

Findings include:

A review of the current Medical Staff Bylaws dated 1/14/2013, was completed on 3/20/2013. The review revealed that the responsibilities of the Medical staff were to account for the quality and appropriateness of patient care rendered by all practitioners. This was to be accomplished by a ..."credentials program that included mechanism for appointment and reappointment and the matching of clinical privileges to be exercise or of specified services to be performed with the verified credential and current demonstrated performance of the applicant staff member of affiliate."

Further review of the Bylaws revealed that it was not detailed what the duties and scope of privileges were to be for each category or practitioner. For example, nurse practitioners and physicians assistants were not mentioned in the Bylaws. .

Based on interview and record review, it was determined that the hospital did not have a designated registered nurse that was responsible for the nursing services of the hospital only.

Findings include:

A review of the facility organizational chart that was given to the survey staff on 3/19/2013. It was noted that the chief nursing officer was responsible for the entire campus and not just the hospital area.

An interview was held with the chief nursing officer on 3/20/2013. He stated that he is over the entire campus. He stated that he has three assistant directors of nursing to provide all the necessary coverage for the hospital and the skilled nursing facility.

During the survey, the chief nursing officer provided the surveyors with 3 different organizational charts. The first one was provided on 3/19/2013, and the other 2 were provided on 3/20/2013.

Based on interview it was determined that the hospital did not have any nursing personnel that had been hired specifically for and assigned to the hospital.

Findings include:

The chief nursing officer was asked by the survey staff to provide a list of the employees hired to work in the hospital.

The chief nursing officer stated that all the staff were hired for the entire facility (hospital and skilled nursing facility) He stated that no one had been hired just for the hospital area of the facility.

Based on interview and record review, it was determined that the hospital did not have pharmacy services that were specific to the hospital.

Findings include:

A review of the facility contracts was completed on 3/20/2013. In the contract book was a contract with a local pharmacy and a pharmacy consultant to provide pharmacy services services. The contract was not specific for the hospital.

An interview was held with the chief nursing officer on 3/20/2013. He stated that the contract was for the whole facility and was not specific to the hospital.

Based on interview and record review, it was determined that the hospital did not have a contract with a provider of radiologic services to meet the needs of the patients.

Findings include:

A review of the facility contracts was completed on 3/20/2013. In the contract book was a contract with a local hospital for provide radiology services. The contract was not specific for the hospital.

An interview was held with the chief nursing officer on 3/20/2013. He stated that the contract was for the whole facility and was not specific to the hospital.

Based on record review and interview it was determined that the hospital did not have a contract in place for laboratory services for the hospital.

Findings include:

A review of the facility contracts was completed on 3/20/2013. In the contract book was a contract with a local laboratory company to provide laboratory services. The contract was not specific for the hospital.

An interview was held with the chief nursing officer on 3/20/2013. He stated that the contract was for the whole facility and was not specific to the hospital.

Based on record review there was no documentation indicating a written document detailing the description of laboratory services to be provided by the contracted lab for the facility.

Findings include: on 03/20/2013 a review of the committee of the whole minutes was done. On review of the minutes there was no documentation noted that the medical staff received information regarding the description of laboratory services that were to be provided.

Based on interview, it was determined that the facility did not have a maintenance program to ensure that the facility was maintained and provided a safe environment for the patients.

Findings include:

An interview was held with the chief nursing officer on 3/20/2013. He stated that the "facility" had a maintenance department that was responsible for the routine and preventative maintenance.

There was not a separate maintenance department that was responsible for the hospital area of the facility.

Based on interview and record review, it was determined that the hospital did not have a contract specific to the hospital for rehabilitation services.

Findings include:

A review of the contracts was completed on 3/20/2013. The review revealed that the "facility" had a contract with a local rehabilitation agency for services such as physical therapy, occupational therapy and speech therapy services. The contract was not specific to the hospital.

An interview was held with the chief nursing officer on 3/20/2013. He stated that the contract was for the entire facility and not just for the hospital area.

Based on interview and record review, it was determined that the hospital did not have an organized respiratory therapy department that was specific to the hospital.

Findings include:

An interview was held with the chief nursing officer on 3/20/2013. He stated that the facility had a respiratory therapy department that covered the entire facility, not just the hospital. He stated that the employees were not specific to the hospital and neither was the department.

A review of several facility documents revealed that the respiratory therapists were hired for the "facility", not just the hospital. They were involved in the hospital quality assurance program.

Based on interview and record review, it was determined that the facility did not have a designated director of respiratory services.

Findings include:

An interview was held with the chief nursing officer on 3/20/2013. He stated that the respiratory department did not have a specific a physician that was the director of the respiratory care services. He stated that there was a physician that was on the medical staff that the respiratory department obtained orders from and monitored patients, but was nor officially the director.

A review of the credentialing files was completed on 3/20/2013. The physician used for the respiratory services was credentialed and privileges at the hospital but had not been appointed as the director of respiratory services.