HospitalInspections.org

This Condition is not met as evidenced by:

Based on utilization numbers, review of staffing schedules, and interviews, it was determined the facility failed to meet the requirements of 42 CFR 482.1 as evidenced by failing to be primarily engaged in providing inpatient services. The regulation at 42 CFR 482.1 implements the statutory requirement at Section 1861 (e) of the Social Security Act. The regulation requires that: (i) Hospitals participating in Medicare must meet certain specified requirements and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in the hospital.
The Act defines hospital as: an institution that " ... is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled or sick persons."

Findings follow:
A. Upon entrance to the facility at 11:15 AM on 07/09/18, the hospital's current census was two inpatients and one observation patient.

B. Review of the facility utilization report, received from the CNO/COO (Chief Nursing Officer/Chief Operating Officer) at 2:30 PM on 07/09/18 showed the ALOS (Average Length of Stay) for the last twelve months was 1.29 days. Information regarding the ADC (Average Daily Census) was also provided.

C. Review of the facility utilization report, received from the CEO (Chief Executive Officer) at 8:40 AM on 07/10/18 showed the total admissions for the last twelve months was 1293.
Further review of the utilization reports showed the following for the last twelve months:

1) # Inpatient # Outpatient
Proceudres Procedures
July 2017 81 422
August 2017 120 483
September 2017 98 419
October 2017 131 499
November 2017 121 559
December 2017 161 550
January 2018 104 489
February 2018 76 446
March 2018 91 428
April 2018 104 475
May 2018 93 512
June 2018 101 509

2) ALOS: ADC:
July 2017 1.47 4
August 2017 1.23 4.7
September 2017 1.29 4.2
October 2017 1.36 5.3
November 2017 1.19 5.1
December 2017 1.15 6.3
January 2018 1.34 4.2
February 2018 1.16 3.1
March 2018 1.06 3.4
April 2018 1.24 4
May 2018 1.3 4.4
June 2018 1.73 6.2

3) ADC by day of the week last twelve months:
Sunday 0.29
Monday 11.31
Tuesday 10.23
Wednesday 5.79
Thursday 3.49
Friday 0.77
Saturday 0.04

4) Averages by day of the week last twelve months for:
Admits Discharges
Sunday 0.06 0.02
Monday 8.62 0.56
Tuesday 8.27 6.08
Wednesday 4.63 8.21
Thursday 2.85 5.68
Friday 0.35 3.92
Saturday 0.04 0.29

D. A request for admission criteria to the hospital was made. During an interview with the CEO at 8:45 AM on 07/10/18 he stated the admission criteria was the same as what the physicians were credentialed and privileged for.

E. Review of the staffing schedules for the past twelve months showed twenty four hour staffing coverage for Saturday and Sunday for the laboratory and maintenance departments, one person on the day shift for housekeeping, one person from 7 AM to 5 PM for dietary, one person from 8AM to 8 PM in radiology, and pharmacy with contracted coverage after hours, weekends and holidays.

F. During an interview with the CEO at 8:40 AM on 07/10/18 he stated PCU (Patient Care Unit) Nursing staff were on call and not actually on the unit up until May of 2018. During an interview with the DON (Director of Nursing) at 8:45 AM on 07/10/18 he stated PCU Nursing staff were on call and not actually on the unit up until May of 2018 at which time the facility started staffing a nurse on the PCU all shifts even when there were no inpatients. Review of the PCU Nursing staff schedules supported the above interview with the CEO and CNO. Examples follow:
1)
Sunday 11/12/17 no staff scheduled 6:30 PM to 6:30 AM
Saturday 11/18/17 (NAMED) on call 6:30 PM to 6:30 AM
Sunday 11/19/17 no staff scheduled 6:30 AM to 6:30 PM
Sunday 11/19/17 (NAMED) on call 6:30 PM to 6:30 AM
Saturday 11/25/17 (NAMED) on call 6:30 AM to 6:30 PM
Sunday 11/26/17 (NAMED) on call 6:30 AM to 6:30 PM
Sunday 11/26/17 (NAMED) on call 6:30 PM to 6:30 AM
Sunday 12/24/17 (NAMED) on call 6:30 AM to 6:30 PM
Sunday 12/24/17 (NAMED) on call 6:30 PM to 6:30 AM
Monday 12/25/17 (NAMED) on call 6:30 AM to 6:30 PM
Monday 12/25/17 (NAMED) on call 6:30 PM to 6:30 AM
Saturday 12/30/17 (NAMED) on call 6:30 PM to 6:30 AM
Sunday 12/31/17 (NAMED) on call 6:30 PM to 6:30 AM
Sunday 01/07/18 (NAMED) on call 6:30 AM to 6:30 PM
Sunday 02/04/18 (NAMED) on call 6:30 AM to 6:30 PM
Sunday 02/04/18 (NAMED) on call 6:30 PM to 6:30 AM
Saturday 03/03/18 (NAMED) on call 6:30 AM to 6:30 PM
Saturday 03/03/18 (NAMED) on call 6:30 PM to 6:30 AM
Friday, Saturday & Sunday 03/16/18 - 03/18/18 (NAMED) on call night shifts
Saturday 03/17/18 no staff scheduled on day shift
Sunday 03/18/18 (NAMED) on call day shift
Friday, Saturday & Sunday 4/06/18 - 04/08/18 (NAMED) on call night shifts
Friday, Saturday & Sunday 04/13/18 - 04/15/18 (NAMED) on call night shifts
Saturday & Sunday 04/14/18 - 04/15/18 (NAMED) on call day shifts
Saturday & Sunday 05/05/18 & 05/06/18 (NAMED) on call day shifts
Friday, Saturday & Sunday 05/04/18 - 05/06/18 (NAMED) on call night shifts

2) Review of the PCU staffing schedules showed that after 05/07/18 all shifts had a nurse assigned to be physically present no matter the census.

G. Review of the PCU crash cart check schedules received from the DCS (Director of Clinical Services) at 1:10 PM on 07/09/18, for September 2017, and January 2018 through June 2018 showed the following examples:

September 1st night shift through September 4th night shift the entry was "Closed."
January 13th day shift through January 14th night shift the entry was "Closed."
January 27th day shift through January 28th night shift the entry was "Closed."
February 3rd day shift through February 4th night shift there were no entries indicating the cart was checked or the unit was closed.
March 3rd day shift through March 4th night shift there were lines drawn through the signature areas.
March 17th day shift through March 18th night shift there were lines drawn through the signature areas.
April 8th day and night shift there was a line drawn through the signature areas.
April 14th day shift through April 15th night shift there was a line drawn through the signature areas.
May 5th and May 6th night shift the entry was "Closed."

H. Review of the Operating Room staffing schedules for the last twelve months showed staff were scheduled on call 24 hours per day, seven days a week.

I. During an interview with the DCS at 1:30 PM on 07/09/18 she stated the facility performed orthopedic, bariatric and back/spine procedures primarily.

J. Observation of patient care included the following:
1) Physical Therapy Assistant (PTA) #1 was observed walking Patient #2 from room #208B to the Nursing Station at 1:30 PM on 07/10/18.
2) Registered Nurse #1 was observed answering the call light for Patient #6 in room #202 at 1:30 PM on 07/10/18.
3) PTA #1 was observed in room #208B teaching Patient #2 leg exercises at 9:00 AM on 07/10/18.
4) DCS was observed bringing ice to Patient #3 at 9:00 AM on 07/10/18.
5) Ultrasound Technician #1 was observed performing an ultrasound on both lower extremities of Patient #4 at 9:15 AM on 07/10/18.

K. Patient Interview:
An interview was conducted with Patient #3 at 9:05 AM on 07/10/18. Patient #3 stated she "had a total knee replacement of the Left knee performed yesterday and would be going home today." Patient #3 was asked if she was told prior to the surgery she would be going home the day after surgery and she stated yes she was told. Patient #3 volunteered she "had a total knee replacement of the Right knee two months ago at this hospital."

L. Tours of the facility were conducted on 07/09/18 and 07/10/18. The Patient Care Unit has twenty beds and the Operating Suite has five surgical rooms.