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Based on interview, document review, and interview, the governing board failed to ensure that a contractor of services appropriately provided those services for 1 of 17 contracted services reviewed as part of the facility's quality assurance performance improvement (QAPI) program.

Findings include:

1. In interview on 12-04-2017 at 11:15 am, employee #A1, President and Chief Executive Officer, indicated the hospital contracted for 17 specific services.

2. At the above-stated date and time, employee #A1 was requested to provide documentation of QAPI activities for the 17 services.

3. Review of QAPI program documents indicated the contracted service of nursing had no monitor, standards or report to the governing board.

4. In interview on 12-07-2017 at 3:00 pm, employee #A4, Vice President Quality, Risk, Infection Control, confirmed the contracted service of nursing had no monitor, standards or report to the governing board, and no further documentation was provided prior to exit.

Based on document review and interview, the facility failed to maintain a list of contracted services in which 13 of 17 contracted services were not included on the list.

Findings include:

1. In interview on 12-04-2017 at 11:15 am, employee #A1, President and Chief Executive Officer, indicated the hospital contracted for 17 specific services, as indicated on a document titled HOSPITAL DOCUMENT REQUEST - QA/PI MONITORS CERTIFICATION/RE-CERTIFICATION.

2. At the above-stated date and time, employee #A1 was requested to provide a list of all contracted services.

3. Review of a facility document titled NeuroPsychiatric Hospital of Indianapolis Facility Contracts, updated 7/30/17, was compared to the document titled HOSPITAL DOCUMENT REQUEST - QA/PI MONITORS CERTIFICATION/RE-CERTIFICATION.

4. The comparison indicated the contracted services of Bioengineering, Biohazard Waste Hauler, Computer Tomography Scanner, Laboratory Service, Laundry, Nursing, Occupational Therapy, Pharmacy, Physical Therapy, Radiology, Speech Pathology, Transcription, and Ultrasound, were not on the document titled NeuroPsychiatric Hospital of Indianapolis Facility Contracts, updated 7/30/17.

4. In interview on 12-07-2017 at 4:45 pm, employee #A1, confirmed the above-stated document titled NeuroPsychiatric Hospital of Indianapolis Facility Contracts, updated 7/30/17, was the most current list prior to the beginning of the survey, and no other documentation was provided prior to exit.

Based on interview and document review, the governing board failed to ensure that a contractor of services appropriately provided those services for 1 of 17 contracted services reviewed as part of the facility's quality assurance performance improvement (QAPI) program.

Findings include:

1. In interview on 12-04-2017 at 11:15 am, employee #A1, President and Chief Executive Officer, indicated the hospital contracted for 17 specific services.

2. At the above-stated date and time, employee #A1 was requested to provide documentation of QAPI activities for the 17 services.

3. Review of QAPI program documents indicated the contracted service of nursing had no monitor, standards or report to the governing board.

4. In interview on 12-07-2017 at 3:00 pm, employee #A4, Vice President Quality, Risk, Infection Control, confirmed the contracted service of nursing had no monitor, standards or report to the governing board, and no further documentation was provided prior to exit.

Based on on document review, observation and interview, the facility failed to ensure proper storage of medications in one (300 unit medication room) of three medication rooms.

Findings include:

1. Review of facility policy, DRUG STORAGE UNIT INSPECTION, Policy II-F.21, Issued 5/2015, page 1, c. Drugs for external use in liquid, tablet, capsule or powder form shall be segregated from drugs for internal and injectable use.

2. On observation 12/4/2017, at approximately 1:58pm, on the 300 unit with N2 (Quality/Risk/Infection Control) the following was observed, Glucerna (specialize nutrition), Dorzolamide ophthalmic (eye) drops, Flecainide tablets (oral) and Rid lice treatment kit (harmful if absorbed through skin), stored together on same shelf in cabinet (shelf approximately 9 inch tall, by 12 inches deep and 12 inches wide).

3. Interview on 12/4/2017, at approximately 1:58pm, on the 300 unit with N2 the following was confirmed, Glucerna (specialize nutrition), Dorzolamide ophthalmic (eye) drops, Flecainide tablets (oral) and Rid lice treatment kit (harmful if absorbed through skin), stored together on same shelf in cabinet.

Based on document review, observation and interview, the facility failed to ensure outdated drugs unavailable for patient use in one (300 unit) of three crash carts.

Findings include:

1. Review of facility policy, ADULT CARDIOPULMONARY RESUSCITATION, Policy No.: II-C.108, Issued: 5/2015, indicated, Supply Check.

2. On observation 12/4/2017, at approximately 2:11 pm, on the 300 unit with N2 (Quality/Risk/Infection Control) the following was observed, sodium chloride bag expired on, October 2017, times 1 bag.

3. Interview on 12/4/2017, at approximately 2:11 pm, on the 300 unit with N2 the above was confirmed.

Based on document review and interview, it could not be determined the facility conducted a utilization review committee function for 1 of 1 hospital.

Findings include:

1. Review of hospital Policy No.: I-E.4, Issued 5/2015, titled UTILIZATION REVIEW PLAN, indicated the Utilization Review Committee will be responsible for execution of the Utilization Review Plan.

2. On 12-04-2017 at 11:15 am, employee #A1, President and Chief Operating Officer, was requested to provide documentation of the Utilization Review Committee minutes. No documentation was provided.

3. In interview on 12-06-2017 at 2:30 pm, employee #A1 confirmed there was no above-requested documentation and none was provided prior to exit.

A Life Safety Code Recertification Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41(b).

Survey Date: 12/4-7/17 and 12/28/17

Facility Number: 013116

At this Life Safety Code survey, Neuropsychiatric Hospital of Indianapolis, LLC was found not in compliance with Requirements for Participation in Medicare, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). Building 01 was surveyed using Chapter 19, Existing Health Care Occupancies.

This one story facility was determined to be of Type II (000) construction and was fully sprinklered except for three exterior fabric canopies which were documented as treated with fire retardant material during fabrication by the supplier. The facility has a monitored fire alarm system with smoke detectors located in activity rooms, nurse's stations and facility support rooms. The facility has fire alarm system duct detectors installed in HVAC return air units. The facility has a capacity of 50 and had a census of 47 at the time of this survey.

All areas where patients have customary access were sprinklered and all areas providing facility services were sprinklered.

Based on record review, observation and interview; the facility failed to maintain the 2-hour fire rated separation between the Hospital and the adjoining tenant in accordance with Section 19.1.3.4.1. This deficient practice could affect two staff and visitors in the main entrance lobby (see tag K132) and the facility failed to ensure 1 of 8 hazardous areas such as soiled linen rooms exceeding 64 gallons storage was separated from other spaces by smoke resistant partitions and doors. Doors shall be self closing or automatic closing in accordance with 7.2.1.8. This deficient practice could affect over 12 patients, staff and visitors in the vicinity of the soiled linen room by Room 1014 (see tag K321) and the facility failed to provide a complete written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all patients, staff and visitors (see tag K346) and the facility failed to ensure all private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2011 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Table 7.1.1.2 requires wet and dry barrel hydrants to be inspected annually and after each operation. This deficient practice affects all patients, staff and visitors (see tag K353) and the facility failed to provide a complete written policy containing procedures to be followed for the protection of 47 of 47 patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice affects all patients, staff and visitors (see tag K354) and the facility failed to ensure 3 of 3 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 18.3.7.8(4) states rabbets, bevels, or astragals shall be required at the meeting edges of pairs or doors and doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect all patients, staff and visitors (see tag K374) and the facility failed to ensure 3 of over 50 rooms was maintained in accordance with 18.7.5.6. 18.7.5.6 states combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:
(1) They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
(2) The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
(3) The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.
(4)*The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:
(a) Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 18.7.5.6(b), (c), or (d).
(b) Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
(c) Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.
(d) Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
This deficient practice could affect over five staff and visitors (see tag K753) and the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test for eleven months of the most recent twelve month period. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, staff and visitors in the facility (see tag K918) and the facility failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly secured from falling in 1 of 1 200 Hall Med Rooms. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.3 states storage for nonflammable gases with a total volume equal to or less than 300 cubic feet shall comply with the requirements in 11.3.3.1 and 11.3.3.2. Section 11.3.3.2 states precautions in handling cylinders specified in 11.3.3.1 shall be in accordance with 11.6.2. Section 11.6.2.3(11) states freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect 10 patients, staff and visitors in the vicinity of the 200 Hall Med Room see tag K923).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

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Based on document review, observation and interview, the facility failed to maintain a safe environment in 3 of 3 instances and the facility failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly secured from falling in 1 of 1 200 Hall Med Rooms. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.3 states storage for nonflammable gases with a total volume equal to or less than 300 cubic feet shall comply with the requirements in 11.3.3.1 and 11.3.3.2. Section 11.3.3.2 states precautions in handling cylinders specified in 11.3.3.1 shall be in accordance with 11.6.2. Section 11.6.2.3(11) states freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect 10 patients, staff and visitors in the vicinity of the 200 Hall Med Room (see tag K923).

Findings include:

1. Review of facility policy, Food Storage, Policy No.: III-E. 22, Issued 5/2015, page 1, 1. Food & nonfood items will be stored separately.

2. On observation 12/4/2017, at approximately 1:21 pm, with N2 (Quality/Risk/Infection Control) on the 300 unit in the activities room, the following was observed, three containers of cereal, two containers of juice and one container of pudding stored with Good Sense Odor Counteractant, label indicated the following; hazardous.

3. Interview on 12/4/2017, at approximately 1:21 pm, with N2 on the 300 unit in the activities room, the above was confirmed.

4. Review of facility policy, MEDICATION REFRIGERATION/FREEZER STORAGE, Policy No.: II-F.57, Issued 5/2015, indicated, 2. Temperature Checks, a. Daily temperature checks of medication refrigerators and storage rooms are the responsibility of the Pharmacy Services and the nursing staff. b. Refrigerator temperatures are recorded on a log.

5. Observation on 12/4/2017, at approximately 1:42 pm, with N2 on the 300 unit in the medication room, the following was observed, Refrigerator logs for November missing recordings on the following dates, 1, 2, 3, 4, 5, 8, 11, 12, 13, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 30.

6. Interview on 12/4/2017, at approximately 1:42 pm, confirmed the above.

7. Review of facility policy, ADULT CARDIOPULMONARY RESUSCITATION, Policy No.: II-C.108, Issued: 5/2015, indicated, Supply Check, unable to determine when contents of crash cart checked.

8. Review of facility document, Crash Cart Contents, indicated Drawer 3 Ambu Bag 1 (resuscitation bag).

9. Observation on 12/4/2017, at approximately 2:29 pm, with N4 (Registered Nurse) on the 300 unit, the following was observed, crash cart lacked a ambu bag (resuscitation bag) in the third drawer.

10. Interview on 12/4/2017, at approximately 2:29 pm, with N4 (Registered Nurse) on the 300 unit, the above was confirmed.

11. Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, one of one 'E' type oxygen cylinders in the 200 Hall Med Room was freestanding on the floor and was not properly chained or supported in a proper cylinder stand or cart. Based on interview at the time of the observations, the CDPO stated a nurse had probably left it in the room without a stand or cart and agreed the aforementioned 'E' type oxygen cylinder was not properly chained or supported in a proper cylinder stand or cart.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test for eleven months of the most recent twelve month period. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, staff and visitors in the facility (see tag K918).

Findings include:

Based on review of "Monthly Generator" documentation with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, emergency generator load testing documentation for monthly load tests for the eleven month period of January 2017 through November 2017 did not include the cool down time period for the load test. Based on interview at the time of record review, the CDPO stated the aforementioned documentation records the total time the generator operated during the test which is generally greater than 30 minutes and includes a cool down time period but acknowledged documentation of the cool down time period for each of the monthly load tests was not available for review. Based on observations with the DPO at 2:45 p.m. on 12/28/17, the diesel fired emergency generator for the facility is rated at 100 kW.

Based on record review, observation and interview; the facility failed to maintain the 2-hour fire rated separation between the Hospital and the adjoining tenant in accordance with Section 19.1.3.4.1. This deficient practice could affect two staff and visitors in the main entrance lobby (see tag K132) and the facility failed to ensure 1 of 8 hazardous areas such as soiled linen rooms exceeding 64 gallons storage was separated from other spaces by smoke resistant partitions and doors. Doors shall be self-closing or automatic closing in accordance with 7.2.1.8. This deficient practice could affect over 12 patients, staff and visitors in the vicinity of the soiled linen room by Room 1014 (see tag K321) and the facility failed to provide a complete written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all patients, staff and visitors (see tag K346) and the facility failed to ensure all private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2011 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Table 7.1.1.2 requires wet and dry barrel hydrants to be inspected annually and after each operation. This deficient practice affects all patients, staff and visitors (see tag K353) and the facility failed to provide a complete written policy containing procedures to be followed for the protection of 47 of 47 patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice affects all patients, staff and visitors (see tag K354) and the facility failed to ensure 3 of 3 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 18.3.7.8(4) states rabbets, bevels, or astragals shall be required at the meeting edges of pairs or doors and doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect all patients, staff and visitors (see tag K374) and the facility failed to ensure 3 of over 50 rooms was maintained in accordance with 18.7.5.6. 18.7.5.6 states combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:
(1) They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
(2) The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
(3) The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.
(4)*The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:
(a) Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 18.7.5.6(b), (c), or (d).
(b) Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
(c) Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.
(d) Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
This deficient practice could affect over five staff and visitors (see tag K753).

Findings include:

1. Based on review of facility blueprint information with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, a two hour fire rated wall separates the facility, Suite 100, from the adjoining tenant, a call center. A portion of the two hour tenant separation wall consists of the west wall of the main entrance lobby. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, a three inch in diameter hole was noted in the west wall of the main entrance lobby above the suspended ceiling near a support truss for the roof deck above which did not maintain the two hour fire resistance rating of the tenant separation wall which consisted of four layers of five-eighths inch thick drywall. Based on interview at the time of the observations, the DPO agreed the aforementioned hole in the tenant separation wall did not maintain the two hour fire resistance rating of the wall.

2. Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the corridor door to the soiled linen room by Room 1014 was not equipped with a self closing device. The room contained soiled linen in three separate 32 gallon capacity trash bags in wheeled support carts. Based on interview at the time of the observations, the CDPO and DPO stated soiled linen is not normally stored in the room but agreed the door to the room was not equipped with a self closing device.

3. Based on review of "Interim Life Safety Measures" and "Fire Watch" documentation with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the fire watch plan for fire alarm system impairment was incomplete. The plan stated to contact the Mental Health Division of the Indiana State Department of Health. The plan failed to include contacting the Indiana State Department of Health (ISDH) via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview at the time of record review, the CDPO agreed the fire watch documentation for fire alarm system impairment stated to contact the Indiana State Department of Health but not via the ISDH Gateway link or at the e-mail address listed above.

4. Based on record review with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, documentation of fire hydrant inspection within the most recent twelve month period was not available for review. Based on observations with the DPO at 2:45 p.m. on 12/28/17, one red fire hydrant was noted in the facility parking lot by the emergency generator. Based on interview at the time of record review, the DPO stated he has worked at the facility for less than one year, did not know if the fire hydrant was maintained by the facility and stated documentation of fire hydrant inspection within the most recent twelve month period was not available for review.

5. Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors.

6. Based on review of USAutomatic Fire & Security's "Report of Inspection" documentation dated 03/06/17, 06/23/17, 09/20/17 and 12/18/17 with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, monthly wet sprinkler system gauge inspection documentation for 8 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 8 months of the most recent 12 month period was also not available for review. Based on interview at the time of record review, the CDPO and DPO stated the facility checks sprinkler gauges and valves but sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was not available for review. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the facility has supervised wet sprinkler systems.

7. Based on record review, observation and interview; the facility failed to ensure the sprinkler system was maintained in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 13.6.2.1 states all backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate. Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors.

8. Based on review of USAutomatic Fire & Security's "Backflow Prevention Assembly Test and Maintenance Report" documentation dated 08/24/17 with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the Watts Model 975XL2 backflow prevention device was listed as "Failed" testing. No replace or repair documentation on or after 08/24/17 was available for review. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, USAutomatic Fire & Security had affixed a hanging tag to the facility's wet sprinkler system riser documenting annual wet sprinkler system backflow prevention testing on 08/24/17 but it was also listed as "Fail." Based on interview at the time of the observations, the CDPO and DPO stated repair to the backflow preventer has not been performed yet because replacement parts are on order.

9. Based on review of "Interim Life Safety Measures" and "Fire Watch" documentation with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the facility fire watch plan for automatic sprinkler system impairment was incomplete. The plan stated to contact the Mental Health Division of the Indiana State Department of Health. The plan failed to include contacting the Indiana State Department of Health (ISDH) via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. In addition, the written fire watch policy also did not include notification of the insurance carrier, the alarm monitoring company and the property owner or designated representative. Based on interview at the time of record review, the CDPO stated the fire watch documentation for automatic sprinkler system impairment stated to contact the Indiana State Department of Health but not via the ISDH Gateway link or at the e-mail address listed above and agreed the policy also did not include notification of the aforementioned three entities.

10. Based on review of facility blueprint information with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the facility suite measures 28,156 square feet in size. Based on interview at the time of record review, the VPQ stated the facility had two separate renovations in 2016 and 2017 to expand their suite size within the existing structure and had to construct or reconstruct a smoke barrier wall within the suite from outside wall to outside wall in order to have two separate smoke compartments within the suite. Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the set of corridor smoke barrier doors at the entrance to the 100 Hall near the main entrance for the facility had a one half inch gap in between the meeting edges of the door set and was not equipped with a rabbet, bevel, or astragal. The smoke barrier corridor door set at the exit of the 100 Hall into the 200 Hall was also not equipped with a rabbet, bevel, or astragal. In addition, the smoke barrier corridor door set at the exit of the 300 Hall into the administrative office area by the tenant separation wall was also not equipped with a rabbet, bevel, or astragal. Based on interview at the time of the observations, the CDPO and the DPO stated the aforementioned corridor smoke barrier door sets were not equipped with a rabbet, bevel, or astragal.

11. Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the corridor door to Room 117, Room 127 and Room 174 each were covered 100 percent with holiday wrapping paper. Based on interview at the time of the observations, the CDPO stated the fire resistance rating of the wrapping paper was not available for review, the paper was not treated with fire retardant material and agreed the surface of each door was entirely covered with wrapping paper.

Based on document review, observation and interview, the facility failed to maintain a sanitary environment in one facility.

Findings include:

1. Review of facility policy, Cleaning Central Supply, Policy No.: III-C.8, Issued 5/2015, Mop floors using a hospital approved germicidal solution according to procedure.

2. On observation 12/4/2017, at approximately 1:30 pm, with N2 (Quality/Risk/Infection Control) in the 300 unit supply closet, the following was observed, dirty, sticky, dried foot prints on the floor.

3. Interview on 12/4/2017, at approximately 1:30 pm, with N2 (Quality/Risk/Infection Control) in the 300 unit supply closet, the above was confirmed.

4. Review of facility policy, Patient Equipment And Medical Devices Cleaning, Policy No.: III-D.7, Issued 5/2015, indicated, when patient discharges return equipment to clean utility room and place clear bag over.

5. On observation 12/4/2017, at approximately 1:39 pm, with N2 in the 300 unit Medication Room, the following was observed, Oxygen concentrator machine, with yellow drippings on side of machine. The machine had a nearly empty bottle fluid attached to unit.

6. Interview on 12/4/2017, at approximately 1:39 pm, with N2 in the 300 unit Medication Room, confirmed the Oxygen concentrator was dirty.

7. Review of facility policy, Bloodborne Pathogen Exposure Control Plan, Policy No.: III-D.44, Issued: 5/2015, indicated, page 13,d. Sharps containers shall be readily available in areas where sharps waste may be generated. They must remain upright throughout use and be replaced as necessary to avoid overfilling.

8. On observation 12/4/2017, at approximately 1:47 pm, with N2 and N4 (Registered Nurse) in the 300 unit medication room, the following was observed, sharps box filled above the fill line indicated on container.

9. Interview on 12/4/2017, at approximately 1:47 pm, with N4 confirmed the above.

10. Manufacture booklet TRUE METRIX SELF MONITORING BLOOD GLUCOSE SYSTEM, indicated page 4, The TRUE METRIX Self Monitoring Blood Glucose System is for one person use ONLY. DO NOT share your meter or lancing device with anyone, including family members. Do not use on multiple patients!

11. On observation 12/5/2017, at approximately 10:14 am, with N2, on the 300 unit, the following was observed, TRUE METRIX SELF MONITORING BLOOD GLUCOSE SYSTEM.

12. Interview on 12/5/2017, at approximately 10:14 am, with N2 confirmed TRUE METRIX SELF MONITORING BLOOD GLUCOSE SYSTEM, used. The TRUE METRIX Self Monitoring Blood Glucose System is used on multiple patients. Confirmed same type used on all units.

13. Review of facility policy, PATIENT EQUIPMENT AND MEDICAL DEVICE CLEANING-GLUCOMETER CLEANING, Policy No.: III-D.7a, Issued 5/2015, indicated use an EPA-registered disinfectant effective against HBV, HCV and HIV.

14. On observation 12/5/2017, at approximately 11:25 am, with N2, on the facility units the following was observed, glucometer wiped with alcohol pad after use.

15. Interview on 12/5/2017, at approximately 11:25 am, with N2, confirmed, glucometer wiped with alcohol pad after use.

Based on document review and interview, there was no evidence of education of patient and/or support persons on admission versus discharge medications, highlighting changes, for 1 of 5 medical records reviewed.

Findings include:

1. Review of 5 patient medical records indicated Patient/Record #2 had no evidence of education of patient and/or support persons on admission versus discharge medications, highlighting changes.

2. In interview on 12-02-2017 at 11:15 am employee #A5, Corporate Social Services Compliance, confirmed the above-stated finding and no other documentation was provided prior to exit.

Based on medical record review and staff interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, B1, B2, B3 and B4) the Psychiatric Evaluations failed to contain a description of patient assets in descriptive not interpretive fashion. This failure to describe achievements, interests, or other personal attributes results in other members of the multidisciplinary team not knowing what patient attributes might be utilized in the selection of treatment modalities.

Findings include:

I. Medical Record Review:

1. Patient A1: This 67-year-old patient was admitted 11/22/2017 with the diagnosis of Chronic Paranoid Schizophrenia, with acute exacerbation. The Psychiatric Evaluation dated 11/23/2017 stated "Patient can return to Lakeview Manor when [his/her] symptoms improve." as the sole patient asset.

2. Patient A2: The Psychiatric Evaluation dated 11/26/2017 stated "Patient's nephew is [his/her] Healthcare Power of Attorney and is supportive. Patient agrees that [he/she] may not be ready to go home at this time but is hopeful [he/she] can in the future."

3. Patient A3: The Psychiatric Evaluation dated 11/13/2017 stated "Patient's family are [his/her] legal guardians and they are supportive. [He/she] lives in an Indiana Mentors Group Home where [he/she] receives structure, supervision." No achievements, interests or personal attributes listed.

4. Patient A4: The Psychiatric Evaluation dated 11/24/2017 stated "[His/her] nephew and [his/her] niece are involved in [his/ her] treatment and have been supportive." No achievements, interests or personal attributes listed.

5. Patient B1: The Psychiatric Evaluation dated 11/28/2017 had no description of assets.

6. Patient B2: The Psychiatric Evaluation dated 11/26/2017 stated "Patient's daughter and her husband appear to be supportive. [He/she], [himself/ herself], had been requesting to live in an assisted living facility prior to onset of [his/ her] current decline." No achievements, interests or personal attributes listed.

7. Patient B3: The Psychiatric Evaluation dated 11/10/2017 stated "Patient is pleasant, cooperative, and [he/she] is not agitated. [His/her] sister is supportive and [he/she] has lived successfully at the same skilled nursing facility for over 10 years. [He/she] can return to that facility after [his/her] treatment." No additional interests or personal attributes listed.

8. Patient B4: The Psychiatric Evaluation dated 11/30/2017 stated "Patient's sister is [his/her] healthcare power of attorney and is supportive and involved in [his/her] treatment. [He/she] can return to the skilled nursing facility once [his/her] treatment is complete." No additional interests or personal attributes listed.

II. Staff Interview:

On 12/05/2017 at 10:30a.m. the clinical director was interviewed. A partial focus of the interview was the findings described in Section I, above. After reviewing four (4) of the Psychiatric Evaluations the Clinical Director agreed that the assessment of assets was not a description of patient attributes that might be utilized in the treatment process.

Based on medical record review, facility policy review and staff interview it was determined that for six (6) of eight (8) patients (Patients A2, A3, A4, B1, B3 and B4) the Multidisciplinary Master Treatment Plan (MTP) was established before the completion of assessments by the various disciplines participating. The facility's timeframes for discipline assessments are as follows: the History and Physical within 24 hours, the Psychiatric Assessmentwithin 60 hours, the Psychosocial Assessment within 72 hours, the Nursing Admission Assessment within eight (8) hours and Activities Assessment within72 hours. This failure results in a selection of Problems that will be addressed before the Treatment Team has had an opportunity to collectively discuss their various findings and prioritize issues.

Findings include:

I. Medical Record Review:

1. Patient A2: The patient was admitted to the hospital on 11/25/2017. The "Multidisciplinary Plan of Care"(MTP) had established 3 Problems--Physical Aggression, Verbal Aggression and Sexually Inappropriate on 11/25/2017. This MTP described interventions for the disciplines of Social Services, Activities and Nursing for these Problems on that date. The Psychosocial Assessment was dated 11/30/2017.

2. Patient A3: The patient was admitted to the hospital on 11/13/2017. The "Multidisciplinary Plan of Care" (MTP) had established 5 Problems--Homicidal Ideation, Delusions, Hallucinations, Threatening, Physical Aggression and Verbal Aggression on 11/13/2017. This MTP described interventions for the disciplines of Social Service, Nursing and Activities on that date. The Psychosocial Assessment was dated 11/20/2017.

3. Patient A4: The patient was admitted 11/22/2017. The "Multidisciplinary Plan of Care" (MTP) had established 3 Problems--Paranoid delusions, Verbal Aggression and Refusing Medication on 11/22/2017. This MTP described interventions for Social Services, Nursing and Activities. The Psychosocial Assessment was dated 12/01/2017 and the Activity Assessment was dated 12/01/2017.

4. Patient B1: The patient was admitted 11/28/2017. The "Multidisciplinary Plan of Care" (MTP) had established 3 Problems--Physical Aggression, Paranoid Delusions and Auditory Hallucination on 11/30/2017. The Psychosocial Assessment was dated 12/01/2017.

5. Patient B3: The patient had been admitted 11/09/2017. The "Multidisciplinary Plan of Care" (MTP) had established 5 Problems--Delusions, Depression, Anxious, Physical Aggression and Placement on 11/09/2017. The Activities Assessment was dated 11/16/2017 and the Psychosocial Assessment was dated 11/16/2017.

6. Patient B4. The patient was admitted 11/30/2017. The "Multidisciplinary Plan of Care" (MTP) had established 4 Problems--Paranoid Delusions, Physical Aggression, Verbal Aggression and Hallucinations on 11/30/2017. The Activities Assessment was dated 12/05/2017 and the Psychosocial Assessment was dated 12/04/2017.

II: Hospital Policy Review:

The facility's "Plan of Care-Protocol for the use of the Multidisciplinary Format", Revised 8/20/2017, Policy No. I-C34 in the Section "Policy" states the following: "The initial multidisciplinary plan of care will be initiated within 24 hours of admission. This excludes weekends to allow each discipline their 72-hour timeframe for completing assessments." Thus,the findings described in Section I, above do not follow facility guidelines for the multidisciplinary creation of a Master Treatment Plan.

II. Staff Interview:

1. On 12/04/2017 at approximately 2:00p.m. the Director of Social Work was asked to explain how a Multidisciplinary Treatment Plan could be formulated before all disciplines had completed their assessments. "He said it was puzzling and did not dispute the findings."

2. On 12/05/2017 at 10:30a.m. the clinical director was interviewed. A partial focus was the findings described in Section I, above. He replied, "It's hard to explain that" and did not dispute the findings.

Based on record review and interview, the facility failed to include physician interventions on the Master Treatment Plans (MTPs) for six (6) of eight (8) active sample patients (A1, A2, A3, A4, B2 and B4). For two (2) of eight (8) active sample patients (A1 and A2), the problems of physical aggression and verbal aggression, the social work interventions were identical. For four (4) of eight (8) active sample patients (A2, B2, B3 and B4), some of the nursing interventions were discipline tasks, not interventions. Failure to include physician interventions on the MTP, individualize interventions by all disciplines based on specific behaviors, and clearly describe specific nursing interventions can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

I. Medical Record Review:

1. Six (6) of eight (8) active sample patients (dates of MTPS in parenthesis) did not have physician interventions: A1 (11/22/17), A2(11/25/17), A3(11/13/17), A4(11/22/17), B2(11/25/17)and B4(11/30/17).

2. Identical interventions for different patients: A1 (physical aggression) and A2 (verbal aggression)-- the social work intervention was, "Social work will meet with [name of patient] a minimum of five minutes weekly for two weeks to practice appropriate social communication." This is a generic discipline task.

3. Nursing discipline tasks written as interventions:

a. Patient A2 - For problem of physical aggression - "Nursing will document each incident that occurs with physical aggression and report to psychology for behavioral therapy and further interventions."

For problem of verbal aggression - "Nursing will report any verbal outbursts and threats to psychology and social services for further therapy."

b. Patient B2 - For the problem of hallucinations - "Nursing will observe [name of patient] for signs that [s/he] is responding to hallucinations to voices, and report to psychiatrist each shift for two weeks."

c. Patient B3 - For the problem of paranoid delusions - "Nursing will document each delusional thought and report to psychology for further interventions."

d. Patient B4 - For the problem of delusions - "Nursing will document each delusional thought and report to psychology for further interventions."


B. Staff Interviews:

1. In an interview with the Nursing Director on 12/5/17 at 11:00 a.m., the discipline tasks written as interventions were discussed. She did not dispute the findings.

2. In an interview with the clinical director on 12/05/17 at 10:30 a.m. the findings described in Section I, above were discussed. He did not dispute the findings.