HospitalInspections.org

Based on observations, interviews, and record review, the hospital failed to ensure that patients received care in a safe setting by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for geriatric psychiatric patients as evidenced by the presence of ligature risks and safety risks.
Findings:

Observations on 06/15/16 at 12:00 p.m. with S3HIM revealed 8 double occupancy patient rooms with at least 1 (one) patient assigned to each room. Beds on the unit were noted to have upper and lower metal side rails resulting in safety and ligature risks.

In an interview on 06/15/16 at 12:30 p.m., S1ADM verified that the bedrails were a ligature risk and a safety risk for patients. S1ADM indicated the hospital had a policy on Bedrail Use in their Risk for Falls guidelines for geriatric psychiatric patients that identified bedrail risks, but he was not aware if the policy identified how bedrail use would be monitored for patient safety.

In an interview on 06/15/16 at 1:45 p.m., S2DON indicated that the hospital had no policy for the monitoring of side rails while in use.

On 06/16/16 at 2:00 p.m. S2DON presented a Policy titled "Safe Use of Hospital Beds" (revised 01/11/16) as being a policy which was used by other hospitals and not implemented at the hospital.

Review of the Hospital's Policy and Procedure titled " Bedrails" PC-1019 (01/01/13) revealed a 1 page document. There was no documented evidence that the hospital's current policy addressed how bedrail use would be monitored for patient safety.

Based on record reviews and interviews, the hospital failed to ensure patients were free from all forms of abuse as evidenced by the hospital's neglect in having Patient #1 who exhibited combative behavior evaluated by a qualified practitioner before transporting her back to the nursing home for 1 (#1) of 1 patient record reviewed for abuse/neglect from a total sample of 5 patients.
Findings:

Review of the PHP's policy titled "Alleged Patient Abuse During Hospitalization", presented as a current policy by S8PD, revealed abuse is defined as the infliction of physical or mental injury to other parties. Criteria for defining abuse or neglect of a patient shall include physical or verbal abuse. Further review revealed no documented evidence that failure to have a patient who experienced decompensation or combative behavior evaluated by a practitioner included in the criteria defining abuse or neglect. A detailed statement from the alleged victim will be documented. After the alleged victim has given his/her version of the story, the interviewed should ask for relevant information that was omitted. This statement should be summarized, using the patient's words, in the Multidisciplinary Notes of the alleged victim's chart.

Review of the PHP's policy titled "Child/Adult Neglect and / or Abuse", presented as a current policy by S8PD, revealed that observation leading to suspicions of abuse or neglect as well as allegations or reports of abuse or neglect shall be documented in the Progress Notes.

Review of the "Hospital Abuse/Neglect Initial Report", presented by S8PD, revealed it was prepared on 05/13/16 by S8PD for an alleged physical abuse that occurred on 05/13/16 at 10:40 a.m. Further review revealed the description of the alleged incident included the following: patient became verbally aggressive during group therapy session and was escorted out by the therapist who attempted to calm her down and provide redirection; this was ineffective and patients' behavior became more aggressive and physical in nature; patient began trying to jump out her wheelchair and became more combative, swinging her arms and trying to hit staff; staff held patient in the chair, loaded her onto bus, and secured the wheelchair via safety belts; patient continued to fight against staff while she was being secured causing the seat belt to rub back and forth against her neck; patient was transported by 2 MHTs to the nursing home; upon arrival patient was noted to be calmer and controlled; patient reported to nursing home staff that she was choked by the staff at the PHP; bruises were noted to patient's neck, which appear to be from the seat belt, along with abrasions to bilateral arms. Further review of the investigation conducted by the hospital revealed a review of video footage that included the following: Patient #1 was wheeled (in her wheelchair) down the hall by S11PLPC; while S11PLPC was attempting to wheel patient out the door for transport, Patient #1 began fighting and swinging at staff as they approached the door; S17MHT came to assist S11PLPC while Patient #1 continued to be combative towards staff; Patient #1 was wheeled to the bus and continued to be combative towards staff; Patient #1 was placed on bus lift and raised into bus. Further review of the report revealed the following interviews:

S6LPC reported going to a vacant room after hearing a patient yelling to find that S11PLPC had brought Patient #1 to an empty room in an attempt to calm her down; when this was ineffective, S11PLPC closed the door with the patient in the room to allow her to "gather herself"; client came out the room within 1 minute.

S7LPN reported Patient #1 became agitated and began swinging at the staff and remembered a struggle to get Patient #1 onto the bus.

S14MHT reported Patient #1 was uncooperative with staff requiring multiple people to assist with loading her onto the bus. S14MHT indicated she and S15MHT secured the wheelchair into place on the bus while Patient #1 continued to yell and swing her arms as if she would hit S14MHT and S15MHT. S17MHT wrapped her arm around Patient #1's chest with one arm and held her hands down with the other hand. S17MHT rode with Patient #1 in this position during transport to the nursing home. S14MHT reported she recalled looking through the rear view mirror and seeing S17MHT whispering to Patient #1, but she (S14MHT) was unable to hear what was being said.

S15MHT reported as she was attempting to secure the front wheelchair restraints, Patient #1 began to swing at her. S17MHT grabbed Patient #1 with her left arm around Patient #1's upper chest and neck with her (S17MHT) right arm around patient #1's hands.

S11PLPC reported that at the end of her group session, Patient #1 became very upset and was yelling and screaming. As the wheelchair approached the exit door, Patient #1 swinging at S11PLPC. S17MHT came to assist and was observed to hold Patient #1's hands down to prevent her from harming herself or staff. She reported remembering seeing Patient #1 tussle with the seat belt while on the bus and getting caught up in it.

Further review of the report revealed a chart review was done that revealed there was documentation from multiple staff relating to Patient #1's outburst/yelling. S8PD and S13LPN met with Patient #1 and staff at the nursing home regarding the incident. Patient #1 was assessed and with pictures reviewed that were taken by the nursing home staff. Bruising was noted to Patient #1's right side of her neck along with multiple scratches/abrasions to bilateral upper extremities. The summary of the investigation revealed that "it is the opinion of these investigators after reviewing all evidence that the allegation of physical abuse cannot be substantiated at this time. However it is our belief that both S17MHT and S11PLPC acted inappropriately in their dealings with the client. S11PLPC should not have attempted to calm client by placing client in empty room and improper EDGE techniques were used by S17MHT and S11PLPC with an "acting out" client."

Review of Patient #1's medical record revealed no documented evidence of the above observations in the progress notes, and there was no documented evidence of multidisciplinary notes in the record. There was no documented evidence that Patient #1 was evaluated by a practitioner prior to being sent back to the nursing home in a hospital van with 2 MHTs in attendance.

In an interview on 06/16/16 at 9:10 a.m., S6LPC indicated earlier the day of the incident Patient #1 was seated and kept hollering to a man for him to get out of her f ... face, which she did often. At end of group she went off again. S6LPC indicated she saw S11PLPC take Patient #1 out of group room and bring her by wheelchair to another room across the hall, and S11PLPC closed the door. S6LPC indicated it was not seclusion, because there was no camera in the room. Surveyor clarified she wasn't asking if it was a seclusion room but was asking if placing Patient #1 in a room alone and closing the door was considered seclusion, and she said " yes ... more of a time-out." She further indicated a few seconds after being in the room, Patient #1 opened the door and came out the room. A procession down the hall continued with Patient #1 being taken to the van for transport back to the nursing home. She further indicated she saw the staff having trouble loading Patient #1 into the van, but she never saw any of the staff put their hands on Patient #1. S6LPC indicated she saw pictures of the marks on Patient #1's neck and arms. Patient#1 was trying to throw herself out the wheelchair while they were loading her. She further indicated she heard them say someone had to ride in the back with Patient #1, and S17MHT sat to the right of the patient in the van.

In an interview on 06/16/16 at 9:35 a.m., S13LPN indicated the Nursing home called to inform them that Patient #1 reported that someone at the PHP choked her. She further indicated she and S8PD went to the nursing home and spoke with Patient #1, the DON of the nursing home, and others who were present at the nursing home. Patient #1 told them that "the big lady" grabbed her (assumed it was S17MHT) from behind. S13LPN indicated Patient #1 placed her arms across her neck as demonstration of what happened. She further indicated she and S8PD looked at Patient #1's skin, and both lower arms had red marks, one looked like the result of a hold, and one looked like a skin tear like maybe a nail. She further indicated Patient #1's right neck had a red mark and said at the time it looked like it went with the story Patient #1 was reporting. S13LPN indicated Patient #1's memory is "pretty good." S13LPN indicated they didn't take any pictures, but the DON at the nursing home showed them some pictures that they (nursing home) had taken.

In an interview on 06/16/16 at 9:45 a.m., S14MHT indicated she was outside smoking, and S17MHT told her to get the van. She further indicated she saw S11PLPC, S6LPC, and S17MHT come out the door with Patient #1. S11PLPC was pushing the wheelchair with one hand and had a coffee cup in the other hand. S17MHT was on one side trying to keep Patient #1 from getting up from the wheelchair. Patient #1 had her arms on the building door to try to stay in building. When they loaded her on van, Patient #1 was combative. S17MHT came to restrain Patient #1 by placing one arm across Patient #1's chest with her (S17MHT) hand at Patient #1's opposite shoulder and one hand down holding Patient #1's hand that was not restrained. She indicated they tried to put the seat belt on Patient #1, but the seat belt wouldn't reach, so they put the latch around her waist (connected to the straps of the lock). She (S14MHT) got into the driver's seat, and S17MHT rode in back with the patient. While driving, Patient #1 was combative (yelling, calling S17MHT a fat b .....). S17MHT continued to hold Patient #1 as such: back of the wheelchair faced the back door of the van; S17MHT was leaning on the hump (where tire is) to support herself and was on the right side of patient with her arms wrapped around patient with her hands holding patient's hands. S14MHT indicated she didn't like what she was seeing. When asked what she meant by this statement, S14MHT indicated she couldn't hear anything, but when she looked in the rear view mirror, she saw S17MHT bent down telling Patient #1 something. She further indicated S17MHT's face looked " mean and evil." S14MHT indicated she never heard Patient #1 say she was being choked, but she did hear her say "get off my hand you b ...."

In an interview on 06/16/16 at 10:00 a.m., S11PLPC indicated both holds explained by S14MHT (in the above interview) and demonstrated by the surveyor were not appropriate holds in accordance with EDGE training. She further indicated she saw Patient #1's wheelchair tipped, and S17MHT grabbed Patient #1 from the side to bring her back up while at the door when they were trying to leave the facility. S11PLPC indicated she didn't see S17MHT hold the patient down at any time while at the facility. She further indicated she stood there while Patient #1 was being loaded in the van, and S17MHT didn ' t hold her like that. S11PLPC indicated at one point the seat belt was wrapped around Patient #1's neck, and she told them the patient would get hurt. She further indicated the MHTs didn't remove the seat belt right away, it remained like that for more than a minute. After reviewing Patient #1's medical record, S11PLPC confirmed the record had no documentation related to this incident.

In an interview on 06/16/16 at 10:55 a.m., S15MHT indicated Patient #1 was irate, screaming, and crying. She further indicated S14MHT pulled the van up, S7LPN and S11PLPC were standing and watching, and S17MHT put Patient #1 on the lift and rode on the lift with the patient. S15MHT indicated she got inside on the passenger side and secured the front of the wheelchair while patient was trying to get up reaching for S15MHT. S15MHT indicated S17MHT was saying "evil" things to her (explained as saying Patient #1 "needs to stop and she's doing too much for a black woman"). She further indicated S17MHT was holding her down with her arms behind Patient #1, had her left arm around the patient's neck across her shoulder and her right arm across the patient holding both arms down in Patient #1's lap). The seat belt wouldn't reach, and S17MHT indicated she'd stay in the back and hold her down. S15MHT indicated the type of hold she observed was not an appropriate EDGE hold. She further indicated she wasn't on the van during the transport. S15MHT indicated Patient #1 was still crying and trying to lift herself out the wheelchair when she (S15MHT) exited the van.

In an interview on 06/16/16 at 12:15 p.m., S8PD indicated Patient #1 was assessed at the nursing home. She further indicated that Patient #1 told her she was trying to not leave, and they were trying to get her to leave. She further indicated when she asked Patient #1 if she was choked, Patient #1 said the lady held her from behind, and they were doing it because she was acting up. During the interview S8PD provided pictures of Patient #1's neck and bilateral arm bruises recorded on her personal cell phone. A red mark was noted to the right side of Patient #1's neck and to both arms. S8PD indicated S17MHT refused to come in to be interviewed, and she is no longer employed at the hospital or PHP. S8PD indicated S15MHT, S14MHT, and Patient #1 confirmed the manner in which S17MHT was holding the patient, and she thinks that's how the patient was scratched. She further indicated she doesn't think it was intentional abuse, but it was abuse. She confirmed the demonstrated hold was not an approved hold taught in EDGE training. When asked if an unapproved hold in accordance with EDGE was used by a staff member, how could it be determined that abuse was not substantiated, S8PD offered no answer to the question. S8PD indicated a patient being placed in room with the door closed is considered seclusion. She further indicated she didn't report to HSS (Health Standards Section) the substantiation of abuse. S8PD indicated the proper protocol would have been to call an ambulance or police to transport Patient #1 to the ED for evaluation and possible PEC (physician's emergency certificate). When asked why she wasn't sent to the main campus of the hospital, S8PD indicated they didn't have a physician on staff that day at the PHP to PEC her, so they would have to send her to an emergency department for PEC and clearance to admit.

In an interview on 01/16/16 at 1:15 p.m., S8PD confirmed there were no multidisciplinary notes documented for 05/13/16. She confirmed there was no documented evidence in Patient #1's medical record of the events that occurred on 06/16/16 regarding the allegation of and substantiation of abuse. S8PD confirmed that Patient #1 was not evaluated by the psychiatrist after exhibiting decompensation and combative behavior prior to being transported back to the nursing home.

Based on record reviews and interviews, the hospital failed to ensure patients were free from inappropriately-implemented restraint as evidenced by S17MHT physically holding Patient #1 during transport from the hospital to the nursing home using a hold that was not an approved EDGE hold for 1 (#1) of 1 patient record reviewed in which the patient was restrained from a total sample of 5 patients.
Findings:

Review of the hospital policy titled "Restraints and seclusion Use", presented as a current policy by S8PD, revealed that the hospital uses restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. Restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.


Review of the "Hospital Abuse/Neglect Initial Report", presented by S8PD, revealed it was prepared on 05/13/16 by S8PD for an alleged physical abuse that occurred on 05/13/16 at 10:40 a.m. Further review revealed the description of the alleged incident included the following: patient became verbally aggressive during group therapy session and was escorted out by the therapist who attempted to calm her down and provide redirection; this was ineffective and patients' behavior became more aggressive and physical in nature; patient began trying to jump out her wheelchair and became more combative, swinging her arms and trying to hit staff; staff held patient in the chair, loaded her onto bus, and secured the wheelchair via safety belts; patient continued to fight against staff while she was being secured causing the seat belt to rub back and forth against her neck; patient was transported by 2 MHTs to the nursing home; upon arrival patient was noted to be calmer and controlled; patient reported to nursing home staff that she was choked by the staff at the PHP; bruises were noted to patient's neck, which appear to be from the seat belt, along with abrasions to bilateral arms. Further review of the report revealed the following interviews:
S6LPC reported going to a vacant room after hearing a patient yelling to find that S11PLPC had brought Patient #1 to an empty room in an attempt to calm her down; when this was ineffective, S11PLPC closed the door with the patient in the room to allow her to "gather herself"; client came out the room within 1 minute.
S7LPN reported Patient #1 became agitated and began swinging at the staff and remembered a struggle to get Patient #1 onto the bus.
S14MHT reported Patient #1 was uncooperative with staff requiring multiple people to assist with loading her onto the bus. S14MHT indicated she and S15MHT secured the wheelchair into place on the bus while Patient #1 continued to yell and swing her arms as if she would hit S14MHT and S15MHT. S17MHT wrapped her arm around Patient #1's chest with one arm and held her hands down with the other hand. S17MHT rode with Patient #1 in this position during transport to the nursing home.
S15MHT reported as she was attempting to secure the front wheelchair restraints, Patient #1 began to swing at her. S17MHT grabbed Patient #1 with her left arm around Patient #1's upper chest and neck with her (S17MHT) right arm around patient #1's hands.
S11PLPC reported that at the end of her group session, Patient #1 became very upset and was yelling and screaming. As the wheelchair approached the exit door, Patient #1 swinging at S11PLPC. S17MHT came to assist and was observed to hold Patient #1's hands down to prevent her from harming herself or staff. She reported remembering seeing Patient #1 tussle with the seat belt while on the bus and getting caught up in it.
The summary of the investigation revealed that S11PLPC should not have attempted to calm client by placing client in empty room and improper EDGE techniques were used by S17MHT and S11PLPC with an "acting out" client."

Review of Patient #1's medical record revealed no documented evidence of the above observations in the progress notes, and there was no documented evidence of multidisciplinary notes in the record.

In an interview on 06/16/16 at 9:10 a.m., S6LPC indicated earlier the day of the incident Patient #1 was seated and kept hollering to a man for him to get out of her f ... face, which she did often. At the end of group she went off again. S6LPC indicated she saw S11PLPC take Patient #1 out of the group room and bring her by wheelchair to another room across the hall, and S11PLPC closed the door. S6LPC indicated it was not seclusion, because there was no camera in the room. Surveyor clarified she wasn't asking if it was a seclusion room but was asking if placing Patient #1 in a room alone and closing the door was considered seclusion, and she said " yes ... more of a time-out. " She further indicated a few seconds after being in the room, Patient #1 opened the door and came out the room. A procession down the hall continued with Patient #1 being taken to the van for transport back to the nursing home. She further indicated she saw the staff having trouble loading Patient #1 into the van, but she never saw any of the staff put their hands on Patient #1. S6LPC indicated she saw pictures of the marks on Patient #1's neck and arms. Patient#1 was trying to throw herself out the wheelchair while they were loading her. She further indicated she heard them say someone had to ride in the back with Patient #1, and S17MHT sat to the right of the patient in the van.

In an interview on 06/16/16 at 9:35 a.m., S13LPN indicated the Nursing home called to inform them that Patient #1 reported that someone at the PHP choked her. She further indicated she and S8PD went to the nursing home and spoke with Patient #1, the DON of the nursing home, and others who were present at the nursing home. Patient #1 told them that "the big lady" grabbed her (assumed it was S17MHT) from behind. S13LPN indicated Patient #1 placed her arms across her neck as demonstration of what happened. She further indicated she and S8PD looked at Patient #1's skin, and both lower arms had red marks, one looked like the result of a hold, and one looked like a skin tear like maybe a nail. She further indicated Patient #1's right neck had a red mark and said at the time it looked like it went with the story Patient #1 was reporting. S13LPN indicated Patient #1's memory is "pretty good." S13LPN indicated they didn't take any pictures, but the DON at the nursing home showed them some pictures that they (nursing home) had taken.

In an interview on 06/16/16 at 9:45 a.m., S14MHT indicated she was outside smoking, and S17MHT told her to get the van. She further indicated she saw S11PLPC, S6LPC, and S17MHT come out the door with Patient #1. S11PLPC was pushing the wheelchair with one hand and had a coffee cup in the other hand. S17MHT was on one side trying to keep Patient #1 from getting up from the wheelchair. Patient #1 had her arms on the building door to try to stay in building. When they loaded her on van, Patient #1 was combative. S17MHT came to restrain Patient #1 by placing one arm across Patient #1's chest with her (S17MHT) hand at Patient #1's opposite shoulder and one hand down holding Patient #1's hand that was not restrained. She indicated they tried to put the seat belt on Patient #1, but the seat belt wouldn't reach, so they put the latch around her waist (connected to the straps of the lock). She (S14MHT) got into the driver's seat, and S17MHT rode in back with the patient. While driving, Patient #1 was combative (yelling, calling S17MHT a fat b .....). S17MHT continued to hold Patient #1 as such: back of the wheelchair faced the back door of the van; S17MHT was leaning on the hump (where tire is) to support herself and was on the right side of patient with her arms wrapped around patient with her hands holding patient's hands. Once they were back at the building, S17MHT said " if she was at (name of another psychiatric hospital), she would flip her one good time." S14MHT indicated she assumed S17MHT meant she'd flip the wheelchair. S14MHT indicated she never heard Patient #1 say she was being choked, but she did hear her say "get off my hand you b ...."

In an interview on 06/16/16 at 10:00 a.m., S11PLPC indicated both holds explained by S14MHT (in the above interview) and demonstrated by the surveyor were not appropriate holds in accordance with EDGE training. She further indicated she saw Patient #1's wheelchair tipped, and S17MHT grabbed Patient #1 from the side to bring her back up while at the door when they were trying to leave the facility. S11PLPC indicated she didn't see S17MHT hold the patient down at any time while at the facility. She further indicated she stood there while Patient #1 was being loaded in the van, and S17MHT didn't hold her like that. S11PLPC indicated at one point the seat belt was wrapped around Patient #1's neck, and she told them the patient would get hurt. She further indicated the MHTs didn't remove the seat belt right away, it remained like that for more than a minute. After reviewing Patient #1's medical record, S11PLPC confirmed the record had no documentation related to this incident.

In an interview on 06/16/16 at 10:55 a.m., S15MHT indicated Patient #1 was irate, screaming, and crying. She further indicated S14MHT pulled the van up, S7LPN and S11PLPC were standing and watching, and S17MHT put Patient #1 on the lift and rode on the lift with the patient. S15MHT indicated she got inside on the passenger side and secured the front of the wheelchair while patient was trying to get up reaching for S15MHT. S15MHT indicated S17MHT was holding her down with her arms behind Patient #1, had her left arm around the patient's neck across her shoulder and her right arm across the patient holding both arms down in Patient #1's lap). The seat belt wouldn't reach, and S17MHT indicated she'd stay in the back and hold her down. S15MHT indicated the type of hold she observed was not an appropriate EDGE hold. She further indicated she wasn't on the van during the transport. S15MHT indicated Patient #1 was still crying and trying to lift herself out the wheelchair when she (S15MHT) exited the van.

In an interview on 06/16/16 at 12:15 p.m., S8PD originally indicated they didn't have a policy for restraint and seclusion, because they don't use seclusion or use restraints. When told that they used physical holds, S8PD indicated "they're not supposed to" (during the interview S8PD produced a policy). She further indicated Patient #1 was assessed at the nursing home. She further indicated that Patient #1 told her she was trying to not leave, and they were trying to get her to leave. She further indicated when she asked Patient #1 if she was choked, Patient #1 said the lady held her from behind, and they were doing it because she was acting up. S8PD indicated S15MHT, S14MHT, and Patient #1 confirmed the manner in which S17MHT was holding the patient which was a restraint. She further indicated there was no physician's or nurse practitioner's order for Patient #1 to be restrained.

Based on record review and interview, the hospital failed to ensure each RN's nursing license was verified to be valid and current as evidenced by having the license verification conducted on 06/15/16 (the day the survey began) for the nursing license that could have expired on 01/31/16 for 1 (S8) of 3 (S2, S8, S19) RN personnel files reviewed.
Findings:

Review of the personnel file of S8PD revealed that her RN license was verified on 06/15/16, the day the complaint survey began. The license could have been expired on 01/31/16.

In an interview on 06/16/16 at 3:55 p.m., S1ADM confirmed S8PD's RN license wasn't verified until the day the survey began, and it could have been expired since 01/31/16. He indicated the license verification should be done prior to the date the license expires to assure that the RN's license is current and unrestricted.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure a RN assessed each patient at the time of admission as required by the LSBN's practice act for 2 (#1, #5) of 2 PHP patients' records reviewed for RN assessment from a total sample of 5 patients.
2) Failing to ensure the physician's orders were implemented as evidenced by failure to weigh patients weekly for 2 (#1, #5) of 2 PHP records reviewed for implementation of physician orders from a total sample of 5 patients.
Findings:

1) Failing to ensure a RN assessed each patient at the time of admission as required by the LSBN's practice act:
Review of the hospital's policy titled "Admission Procedures", effective 07/02/12 and presented as a current policy by S8PD, revealed that that the nursing staff performs the nursing assessment to include evaluation of the following: physical health, identification of relevant medical conditions, infectious diseases, and allergies. The Nursing Care Plan/Preliminary Treatment Plan is completed within one day, and presenting problems are listed on the master problem list. There was no documented evidence that the hospital policy required the admission nursing assessment of each patient to the PHP to be conducted by a RN.

Review of LSBN's "Chapter 39. Legal Standards of Nursing Practice 3901. Legal Standards" revealed that the Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the RN in the practice of nursing. The standards of nursing practice provides a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a RN or by a RN in conjunction with other licensed or unlicensed personnel.

Review of LSBN's "Chapter 37. Nursing Practice 3701. Duties of the Board Directly Related to Nursing Practice as cited in R.S. (revised statute) 37:918" revealed that assessing health status was defined as gathering information relative to physiologic, behavioral, sociologic, spiritual, and environmental impairments and strengths of an individual by means of the nursing history, physical examination, and observation, in accordance with the board's Legal Standards of Nursing Practice. Delegating nursing interventions was defined as entrusting the performance of selected nursing tasks by the RN to other competent nursing personnel in selected situations. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.

Review of Patient #1's and Patient #5's medical record revealed the admit nursing assessment was performed by S10LPN. There was no documented evidence that a RN assessed each patient to determine which tasks may be delegated to a LPN and the amount of supervision which will be required.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated he was aware the admit nursing assessment had to be done by a RN in the inpatient setting, but he thought in the outpatient setting, it could be done by a LPN.

2) Failing to ensure the physician's orders were implemented:
Review of Patient #1's and Patient #5's physician orders revealed an order by S9MD to weigh weekly. Review of the entire medical record for each patient revealed no documented evidence that a weight had been obtained.

In an interview on 06/16/16 at 12:15 p.m., S8PD indicated patients in wheelchairs are not weighed, because the PHP does not have a wheelchair scale. She offered no explanation for not implementing physician orders and not informing the physician that weights were not obtained for Patients #1 and #5.

Based on record reviews and interviews, the hospital failed to ensure each patient had an individualized nursing care plan developed that included interventions for all diagnoses for which the patient was being treated for 3 (#1, #2, #5) of 5 patient records reviewed for nursing care plans from a total sample of 5 patients.
Findings:

Review of the outpatient policy titled "Treatment Planning", effective 07/02/12 and presented as a current policy by S8PD, revealed that the interdisciplinary treatment plan is a dynamic working document that directs the care of the patient throughout the continuum of care. It is individualized and based on the problems of the patient. The treatment plan is developed through an integrated process using the Psychiatric Evaluation, Psychosocial Assessment, and Nursing Assessment. The interdisciplinary treatment plan includes the following components: a list of problems including the date of their identification and designation of their status; goals which are specific, measurable, and patient-oriented expectations that are directly related to the identified problems and symptoms. Interventions are specific, staff-centered methods/modalities that are used to assist the patient in accomplishing the objectives. Interventions should include the specific staff responsible and frequency of the action. The treatment plan must be reviewed and updated/revised when appropriate.

Review of the hospital's policy titled "Admission Procedures", effective 07/02/12 and presented as a current policy by S8PD, revealed that that the nursing staff performs the nursing assessment to include evaluation of the following: physical health, identification of relevant medical conditions, infectious diseases, and allergies. The Nursing Care Plan/Preliminary Treatment Plan is completed within one day, and presenting problems are listed on the master problem list.

Patient #1
Review of Patient #1's "Nursing Home/Outpatient Psychiatric Evaluation" revealed his diagnoses included Depression, Anxiety, Diabetes, Congestive Heart Failure (CHF), Osteoporosis, Peripheral Vascular Disease (PVD), and Osteomyelitis.

Review of Patient #1's "Master Treatment Plan" revealed the identified problems were Mood Disturbance and Ineffective Coping for which a treatment plan was initiated. There was no documented evidence that the problems of Depression, Diabetes, CHF, Osteoporosis, PVD, and Osteomyelitis were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.

Patient #5
Review of Patient #5's "Admit Note/Psychiatric Evaluation" revealed her reason for admission included Depression, Insomnia, and Phantom Limb Pain (related to left above-the-knee amputation).

Review of Patient #5's "Master Treatment Plan" revealed the identified problems were Mood Disturbance and Ineffective Coping for which a treatment plan was initiated. There was no documented evidence that the problems of depression, Insomnia, and Phantom Limb Pain were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.

In an interview on 06/16/16 at 12:15 p.m., S8PD indicated "we don't handle medical diagnoses here, it's strictly a psychiatric facility." When informed that the policy she presented stated the Nursing Care Plan/Preliminary Treatment Plan is completed within one day, and presenting problems are listed on the master problem list, S8PD indicated "we've never done nursing medical care plans."

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/09/16 and was receiving medications to treat Diabetes. Further review revealed no documented evidence that a nursing care plan was developed and implemented for Diabetes.

In an interview on 06/16/16 at 11:30 a.m., S2DON indicated that the care plan did not include a plan for Diabetes.


31206

Based on record reviews and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available as evidenced by failure to have documented evidence of current CPR certifications, EDGE training, and/or competency evaluations by appropriately qualified staff for for 1 (S8) of 3 RN personnel files reviewed and 2 (S14, S17) of 5 MHT personnel files reviewed for competency from a total of 14 personnel files reviewed.
Findings:

Review of the hospital's "2016 Staff Development Plan", presented as the current plan by S8PD, revealed that elements of the competence assessment process begins upon hire and continues throughout the employee's tenure. An evaluation of each employee's competence is conducted during the orientation process, ninety days post employment, and annually thereafter. The evaluation includes an objective assessment of the individual's job performance which is made through daily observations, performance evaluations, job-specific competency skills check lists, direct observation, during treatment planning, and periodic age-specific testing/other testing. Within 30 days of hire, all staff will be oriented to the unit/department to which they have been assigned as evidenced by completion of the Unit-Specific Orientation Checklist. Within 60 days of hire, employees with direct patient care responsibilities will obtain and maintain current certification in EDGE and in Cardiopulmonary Resuscitation (CPR).

S8PD
Review of S8PD's personnel file revealed she was hired on 02/13/15 as the RN Program Director of the outpatient PHP. Further review revealed her EDGE certification had expired on 03/31/16. Her competency evaluation was completed by S1ADM who was not a RN and had no medical experience.

S14MHT
Review of S14MHT's personnel file revealed she was hired on 04/07/16. Further review revealed no documented evidence of EDGE and CPR certification as required by hospital policy within 60 days of employment.

S17MHT
Review of S17MHT's personnel file revealed she was hired on 08/25/10 and terminated on 05/19/16. Further review revealed her CPR certification had expired on 04/30/14, and she was not currently certified at the time of her termination.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated personnel have to have EDGE training within 60 days of hire. He further indicated after the event of 05/05/13/16 (related to Patient #1), they decided to wait to do EDGE training for everyone who was due when they did the refresher course for S11PLPC. He confirmed the expired EDGE training and CPR for the above-listed staff and that S14MHT had not been certified in EDGE and CPR within 60 days as required by hospital policy. S1ADM confirmed he did not have medical experience, and S8PD's competency evaluation should have been conducted by a qualified RN.

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to ensure the organization of the medical record service was appropriate to the scope and complexity of the services performed as evidenced by failure to have the outpatient PHP medical records incorporated with the inpatient medical records and under the responsibility of the HIM Director for the hospital (see findings in tag A0432).

2) Failing to ensure medical records were accurately written, promptly completed, and properly filed and retained as evidenced by:

a) Failing to develop a system to ensure that patient medical records were completed promptly after discharge but no later than 30 days after discharge as evidenced by having 74 discharged medical records from February 2016 to the current date of 06/16/16 that had not been reviewed for completion. Patient #1's medical record had no documented evidence of events on 05/13/16 when she she became combative and was held inappropriately by S17MHT, an order for discharge, and a discharge summary, and she was discharged on 05/16/16.

b) Failing to ensure all medical records stored at the outpatient PHP were protected from fire and water damage as evidenced by having multiple cardboard boxes containing patient medical records as far back as 2006 stacked on the floor and above shelving, close to the ceiling, in the medical room with no observation of a means to protect the records from fire or water damage (see findings in tag A0438).

3) Failing to ensure its policy and procedure for conducting an updated examination of the patient when a medical H&P examination was completed within 30 days before admission was specific and in accordance with regulatory requirements for outpatient services as evidenced by having the psychiatric evaluation modified to include H&P requirements with no policy developed to reflect the changes made. This resulted in Patient #1's "Traditional Out Patient Psychiatric Evaluation Update" not including whether there were changes in Patient #1's medical condition since her previous H&P had been done. This was evidenced in 1 (#1) of 1 patient record reviewed with an updated H&P from a total sample of 5 patient records (see findings in tag A0461).

Based on interviews, the hospital failed to ensure the organization of the medical record service was appropriate to the scope and complexity of the services performed as evidenced by failure to have the outpatient PHP medical records integrated with the inpatient medical records and under the responsibility of the HIM Director for the hospital.
Findings:

In an interview on 06/16/16 at 8:25 a.m., S8PD was asked who manages medical records at the outpatient PHP for completeness of records. She indicated that she audits discharge charts and sends them back to the personnel or physician if correction is needed. She further indicated once the corrections are complete, the administrative assistant files the record. She further indicated the nurse was auditing the January through March records, and what's on the table in her office is records from April to the current date. S8PD indicated she couldn't say how many patient records were incomplete or what the delinquency rate is. She confirmed that the Hospital's PHP and IOP (intensive outpatient program) medical records are not incorporated into the hospital's medical record department.

In an interview on 06/16/16 at 2:55 p.m., S3HIM indicated she was responsible for the hospital's medical record department. She further indicated she isn't involved with the outpatient's medical records. S3HIM indicated she doesn't include the outpatient records in tracking for delinquencies. She further indicated she hadn't checked the hospital's May 2016 patient records yet, because she doesn't check the May charts until the end of June. She confirmed this process could result in some of the medical records being almost 60 days delinquent when she actually reviews them, if the patient was discharged at the beginning of may. She further indicated she doesn't have a list of delinquent medical records. She keeps the records in a "cubbyhole" until she checks them.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated the corporate person is either a RHIT (registered health information tech) or a RHIA (registered health information administrator), but she doesn't come to the hospital regularly to oversee S3HIM's work. He further indicated they'll need to put processes in place to include outpatient services into the hospital's medical record processes.

Based on record reviews, observations, and interviews, the hospital failed to ensure medical records were accurately written, promptly completed, and properly filed and retained as evidenced by:

1) Failing to develop a system to ensure that patient medical records were completed promptly after discharge but no later than 30 days after discharge as evidenced by having 74 discharged medical records from February 2016 to the current date of 06/16/16 that had not been reviewed for completion. Patient #1's medical record had no documented evidence of events on 05/13/16 when she she became combative and was held inappropriately by S17MHT, an order for discharge, and a discharge summary, and she was discharged on 05/16/16.

2) Failing to ensure all medical records stored at the outpatient PHP were protected from fire and water damage as evidenced by having multiple cardboard boxes containing patient medical records as far back as 2006 stacked on the floor and above shelving, close to the ceiling, in the medical room with no observation of a means to protect the records from fire or water damage.
Findings:

1) Failing to develop a system to ensure that patient medical records were completely promptly after discharge but no later than 30 days after discharge:
Review of the hospital policy titled "Documentation Completion Time", presented as a current policy by S8PD, revealed that each medical record shall be completed within 30 days after discharge of the patient or the record becomes delinquent. HIM Director will review on a continuous basis incomplete records. Physicians will be notified of any incomplete or delinquent charts by phone, mail, or fax. If records are still delinquent two weeks after being notified, he/she shall automatically suffer suspension of admitting or consulting privileges. HIM Director will notify the physician in writing of such suspension.

Patient #1
Review of the "Hospital Abuse/Neglect Initial Report", presented by S8PD, revealed it was prepared on 05/13/16 by S8PD for an alleged physical abuse that occurred on 05/13/16 at 10:40 a.m. Further review revealed the description of the alleged incident included the following: patient became verbally aggressive during group therapy session and was escorted out by the therapist who attempted to calm her down and provide redirection; this was ineffective and patients' behavior became more aggressive and physical in nature; patient began trying to jump out her wheelchair and became more combative, swinging her arms and trying to hit staff; staff held patient in the chair, loaded her onto bus, and secured the wheelchair via safety belts; patient continued to fight against staff while she was being secured causing the seat belt to rub back and forth against her neck; patient was transported by 2 MHTs to the nursing home. Review of Patient #1's medical record revealed no documented evidence of this event in her medical record.

In an interview on 06/16/16 at 8:25 a.m., S8PD was asked who manages medical records at the outpatient PHP for completeness of records. She indicated that she audits discharge charts and sends them back to the personnel or physician if correction is needed. She further indicated once the corrections are complete, the administrative assistant files the record. She further indicated the nurse was auditing the January through March records, and what's on the table in her office is records from April to the current date. S8PD indicated she couldn't say how many patient records were incomplete or what the delinquency rate is. She confirmed that the Hospital's PHP and IOP (intensive outpatient program) medical records are not incorporated into the hospital's medical record department.

In an interview on 06/16/16 at 11:45 a.m., S8PD and S16AA indicated they had no system in place for tracking delinquent medical records. S16AA indicated there were 74 patient medical records from February 2016 to the current date of 06/16/16 that have not been reviewed for completion or have been reviewed and need to be re-reviewed to assure corrections were made.

In an interview on 06/16/16 at 12:15 p.m., S8PD offered no comment when informed that the record review of Patient #1's medical record revealed no documented evidence of a physician's order to discharge her on 05/16/16, and no discharge summary was documented.

In an interview on 01/16/16 at 1:15 p.m., S8PD confirmed there were no multidisciplinary notes documented for 05/13/16 related to the event that occurred on 05/13/16 when Patient #1 became combative..

In an interview on 06/16/16 at 2:55 p.m., S3HIM indicated she was responsible for the hospital's medical record department. She further indicated she isn't involved with the outpatient's medical records. S3HIM indicated she doesn't include the outpatient records in tracking for delinquencies. She further indicated she hadn't checked the hospital's May 2016 patient records yet, because she doesn't check the May charts until the end of June. She confirmed this process could result in some of the medical records being almost 60 days delinquent when she actually reviews them, if the patient was discharged at the beginning of may. She further indicated she doesn't have a list of delinquent medical records. She keeps the records in a "cubbyhole" until she checks them.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated the corporate person is either a RHIT (registered health information tech) or a RHIA (registered health information administrator), but she doesn't come to the hospital regularly to oversee S3HIM's work. He further indicated they'll need to put processes in place to include outpatient services into the hospital's medical record processes.

2) Failing to ensure all medical records stored at the outpatient PHP were protected from fire and water damage:
Review of the hospital policy titled "Patient Records", presented as a current policy by S8PD, revealed that all patient charts are to be filed in locked areas according to medical record number. There was no documented evidence that the policy addressed the storage of medical records.

Observation of the medical record room at the outpatient PHP on 06/16/16 at 9:00 a.m. revealed no fire extinguisher was located in the room, and the room was not sprinklered. Further observation revealed multiple cardboard boxes containing patient medical records as far back as 2006 stacked on the floor and above shelving, close to the ceiling, in the medical room with no observation of a means to protect the records from fire or water damage. This observation was confirmed by S8PD who was present during the observation.

Based on record reviews and interviews, the hospital failed to ensure all patient medical record entries were completed, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures as evidenced by failure to have physician psychiatric evaluations timed when written by the physician, have physician verbal orders authenticated within 10 days in accordance with hospital policy, have a completed and authenticated physician order for discharge, and have a completed discharge summary documented within 30 days of discharge for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for completion from a total of 5 sampled patients.
Findings:

Review of the hospital policy titled "Verbal/Phone Orders", presented by S8PD as a current policy, revealed that all phone orders are to be signed during the next physician's or licensed independent practitioner's face-to-face with the patient or within 10 days.

Review of the hospital policy titled "Discharge Summaries", presented as a current policy by S8PD, revealed that the attending physician will develop a discharge summary to be included in the patient's record within 30 days of discharge. The discharge summary shall give an account of the patient's inpatient treatment. All discharge summaries shall be authenticated by the responsible practitioner which will include signature, date, and time.

Review of the hospital policy titled "Discharge of Patient", presented as a current policy by S8PD, revealed that discharges may be initiated only on the order of a physician.

Review of the hospital's policies titled "Documentation Completion Time" and "Patient Records" revealed no documented evidence that all medical record entries were to be completed, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided.

Review of Patient #1's "Nursing Home/Outpatient Psychiatric Evaluation" documented by S9MD on 04/04/16 revealed no documented evidence of the time the evaluation was documented. Review of her "Physician Orders" revealed a telephone order was received from S9MD on 05/11/16 at 3:30 p.m. There was no documented evidence that the telephone order had been authenticated by S9MD as of the review of Patient #1's medical record on 06/15/16 (35 days since it was received and written).

Review of the "PHP Admission / Discharge Log", presented by S8PD, revealed that Patient #1 was admitted on 05/02/16 and discharged on 05/16/16. Review of her "Physician Orders" on 06/15/16 revealed no documented evidence that a discharge order was written by S9MD. Review of the "Discharge Summary" contained in Patient #1's medical record revealed the form was blank. There was no documented evidence that a discharge summary had been documented by S9MD as of 06/16/16 (31 days after discharge).

In an interview on 06/16/16 at 12:15 p.m., S8PD offered no comment when informed that the record review of Patient #1's medical record revealed no documented evidence of a physician's order to discharge her on 05/16/16, the telephone order was not authenticated by S9MD within 10 days, and there was no discharge summary documented.

Based on record reviews and interviews, the hospital failed to ensure its policy and procedure for conducting an updated examination of the patient when a medical H&P examination was completed within 30 days before admission was specific for outpatient services as evidenced by having the psychiatric evaluation modified to include H&P requirements with no policy developed to reflect the changes made. This resulted in Patient #1's "Traditional Out Patient Psychiatric Evaluation Update" not including whether there were changes in Patient #1's medical condition since her previous H&P had been done. This was evidenced in 1 (#1) of 1 patient record reviewed with an updated H&P from a total sample of 5 patient records.
Findings:

Review of the hospital policy titled "History and Physical Examination", presented as a current policy by S8PD, revealed that every patient has a H&P examination performed and included as part of their medical record within 24 hours of admission in order to establish medical necessity for partial hospitalization services. If the patient has had a H&P within the past 30 days, that, with appropriate update, is acceptable. Further review revealed the "1997 E/M (evaluation and management) Documentation Guidelines" define a problem-focused physical exam as including 1 to 5 bullets (guidelines below indicated at least 10 organ systems must be reviewed) from one or more of the following organ systems: constitutional; eyes; ears, nose, mouth and throat; neck; respiratory; cardiovascular, chest (breasts), gastrointestinal; genitourinary; lymphatic; musculoskeletal; skin; neurologic; psychiatric. The procedure included that the physician will perform a H&P examination (as defined by the 1997 E/M Documentation Guidelines indicated above) within 24 hours of admission or a copy of a recent (within past 30 days) H&P will be placed on the chart within 24 hours. The admitting physician will review all H&P examinations. Review of the entire policy revealed no documented evidence that the psychiatric evaluation could be used as the H&P or the H&P update.

Review of the "1997 Documentation Guidelines For Evaluation And management Services", referred to in the hospital's "History and Physical Examination" policy revealed a review of systems is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized: constitutional symptoms ( such as fever, weight loss); eyes; ears, nose mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; allergic/immunologic. At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.

Review of Patient #1's medical record revealed her "Nursing Home/Outpatient Psychiatric Evaluation" was documented on 04/04/16 by S9MD. Further review revealed 6 organ systems were included in the "review of systems and medical problems."

Review of Patient #1's "Traditional Out Patient Psychiatric Evaluation Update", documented by S9MD on 05/02/16 at 11:00 a.m., revealed the following statement had a check mark in the box located on the form before the statement: "I have reviewed the patient's most recent psychiatric evaluation." There was no documented evidence that a physical examination was performed and whether there was any change in Patient #1's medical condition since her previous "Nursing Home/Outpatient Psychiatric Evaluation" was done on 04/04/16.

In an interview on 06/15/16 at 2:55 p.m., S8PD indicated their policy titled "History and Physical Examination" refers to the H&P requiring a review of systems that includes 1 to 5 of the organ systems. She further indicated the "Nursing Home/Outpatient Psychiatric Evaluation"had the organ systems added to it, so it could be used as the H&P. When it was brought to S8PD's attention that the "Traditional Out Patient Psychiatric Evaluation Update" didn't include a review of systems, and S9MD did not document that Patient #1 had no change in her medical condition, S8PD made no comment.

In an interview on 06/15/16 at 3:30 p.m. with S8PD and S12CCN present, neither S8PD nor S12CCN offered an explanation for the hospital's outpatient policy not addressing the use of the psychiatric evaluation and update as the H&P and H&P update.

In an interview on 06/16/16 at 3:55 p.m., S1ADM offered no explanation when informed that the outpatient psychiatric evaluation and the psychiatric evaluation update were being used as the H&P at the time of admission to the hospital's outpatient PHP.

Based on interviews, the hospital failed to meet the Condition of Participation of Outpatient Services as evidenced by:

1) Failing to ensure outpatient services were organized and integrated with inpatient services as evidenced by:

a) Failing to ensure outpatient services were integrated with inpatient Medical Record Services and Quality Assessment and Performance Improvement Services.

b) Failing to ensure the hospital developed a policy that addressed that if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available (see findings in tag A1077).


2) Failing to ensure that personnel providing outpatient services in the PHP were qualified and evaluated for competency to provide services as evidenced by failure to have documented evidence of current CPR certifications, EDGE training, and/or competency evaluations by appropriately qualified staff for 1 (S8) of 3 RN personnel files reviewed, 2 (S14, S17) of 5 MHT personnel files reviewed, and 2 (S6, S11) of 3 LPC/PLPC/LCSW personnel files reviewed for competency from a total of 14 personnel files reviewed (see findings in tag A1079).

Based on interviews, the hospital failed to ensure outpatient services were organized and integrated with inpatient services as evidenced by:

1) Failing to ensure outpatient services were integrated with inpatient Medical Record Services and Quality Assessment and Performance Improvement Services.

2) Failing to ensure the hospital developed a policy that addressed that if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available.
Findings:

1) Failing to ensure outpatient services were integrated with inpatient Medical Record Services and Quality Assessment and Performance Improvement Services:
In an interview on 06/16/16 at 8:25 a.m., S8PD was asked who manages medical records at the outpatient PHP for completeness of records. She indicated that she audits discharge charts and sends them back to the personnel or physician if correction is needed. She further indicated once the corrections are complete, the administrative assistant files the record. She further indicated the nurse was auditing the January through March records, and what's on the table in her office is records from April to the current date. S8PD indicated she couldn't say how many patient records were incomplete or what the delinquency rate is. She confirmed that the Hospital's PHP and IOP (intensive outpatient program) medical records are not incorporated into the hospital's medical record department.

In an interview on 06/16/16 at 2:55 p.m., S3HIM indicated she was responsible for the hospital's medical record department. She further indicated she isn't involved with the outpatient's medical records. S3HIM indicated she doesn't include the outpatient records in tracking for delinquencies. She further indicated she hadn't checked the hospital's May 2016 patient records yet, because she doesn't check the May charts until the end of June. She confirmed this process could result in some of the medical records being almost 60 days delinquent when she actually reviews them, if the patient was discharged at the beginning of may. She further indicated she doesn't have a list of delinquent medical records. She keeps the records in a "cubbyhole" until she checks them.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated the corporate person is either a RHIT (registered health information tech) or a RHIA (registered health information administrator), but she doesn't come to the hospital regularly to oversee S3HIM's work. He further indicated they'll need to put processes in place to include outpatient services into the hospital's medical record processes.

Quality Assessment and Performance Improvement Services:
In an interview on 06/16/16 at 3:15 p.m., S2DON indicated she was responsible for QAPI. She further indicated quality data for the outpatient PHP does not integrate with the hospital's inpatient QAPI. S2DON indicated she didn't know the outpatient and inpatient quality data needed to be integrated together. She further indicated S8PD is over the staff at the PHP, so those employees (some of whom are nurses and MHTs) aren't under her direction.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated, when informed that the outpatient PHP's medical records and QAPI data were not integrated with the inpatient setting, he would have to put processes in place to include the outpatient services into the hospital processes.

2) Failing to ensure the hospital developed a policy that addressed that if an outpatient at the offsite campus required inpatient hospitalization, the patient would be required to send the patient to the main campus if the main campus had beds available:
In an interview on 06/16/16 at 12:15 p.m., S8PD indicated she didn't think a policy had been developed that addressed the transfer of decompensating outpatient PHP patients to the main campus since the event that occurred on 05/13/16 (Patient #1 was restrained during transport back to the nursing home after being combative at the PHP offsite campus). She further indicated in this particular instance, Patient #1 should have been sent by ambulance or police transport to the emergency department of an acute care hospital for evaluation and possible PEC (physician's emergency certificate), since they didn't have a physician on staff at the offsite to institute a PEC.

In an interview on 06/16/16 at 12:55 p.m., S8PD indicated the corporate office had a central intake who does patient placement. She further indicated she didn't know why patients who had to be admitted from the offsite went to other facilities. S8PD indicated S13LPN would keep a log of where the patient was transferred and the reason they were sent to the facility, such as inpatient, medical, psychiatric hospital. S8PD presented a "PHP Admission / Discharge Log" during the interview that listed 2 patients in June thus far and 4 patients in May who needed inpatient admission and were sent to hospitals other than Jennings Senior Care Hospital. She indicated she didn't know why these patients were not sent to Jennings Senior Care Hospital, and S13LPN was off for the day and not available to provide answers.

No policy was presented that addressed if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available as of the time of exit on 06/16/16 at 4:25 p.m.

Based on record reviews and interviews, the hospital failed to ensure that personnel providing outpatient services in the PHP were qualified and evaluated for competency to provide services as evidenced by failure to have documented evidence of current CPR certifications, EDGE training, and/or competency evaluations by appropriately qualified staff for 1 (S8) of 1 RN personnel file reviewed, 2 (S14, S17) of 2 MHT personnel files reviewed, and 2 (S6, S11) of 2 LPC/PLPC personnel files reviewed for competency from a total of 5 outpatient services personnel files reviewed.
Findings:

Review of the hospital's "2016 Staff Development Plan", presented as the current plan by S8PD, revealed that elements of the competence assessment process begins upon hire and continues throughout the employee's tenure. An evaluation of each employee's competence is conducted during the orientation process, ninety days post employment, and annually thereafter. The evaluation includes an objective assessment of the individual's job performance which is made through daily observations, performance evaluations, job-specific competency skills check lists, direct observation, during treatment planning, and periodic age-specific testing/other testing. Within 30 days of hire, all staff will be oriented to the unit/department to which they have been assigned as evidenced by completion of the Unit-Specific Orientation Checklist. Within 60 days of hire, employees with direct patient care responsibilities will obtain and maintain current certification in EDGE and in Cardiopulmonary Resuscitation (CPR).

Nurses and MHTs

S8PD
Review of S8PD's personnel file revealed she was hired on 02/13/15 as the RN Program Director of the outpatient PHP. Further review revealed her EDGE certification had expired on 03/31/16. Her competency evaluation was completed by S1ADM who was not a RN and had no medical experience.

S14MHT
Review of S14MHT's personnel file revealed she was hired on 04/07/16. Further review revealed no documented evidence of EDGE and CPR certification as required by hospital policy within 60 days of employment.

S17MHT
Review of S17MHT's personnel file revealed she was hired on 08/25/10 and terminated on 05/19/16. Further review revealed her CPR certification had expired on 04/30/14, and she was not currently certified at the time of her termination.

LPC/PLPC/LCSW:
S6LPC
Review of S6LPC's personnel file revealed she was hired on 10/24/14. Further review revealed no documented evidence that her LPC license was verified since 10/23/14 to determine that she had a current, unencumbered license to practice. S6LPC's EDGE certification had expired on 05/31/16. Further review revealed her competency was evaluated by S8PD, a RN and not an appropriately qualified LPC.

S11PLPC
Review of S11PLPC's personnel file revealed she was hired on 07/10/15. Further review revealed her skills competency was evaluated on 08/14/15 by S8PD, a RN and not an appropriately qualified LPC. Further review revealed an "Employee Conference Report" dated 05/19/16 that included a remediation plan for S11PLPC to receive a refresher course on EDGE. There was no documented evidence that S11PLPC had received a refresher course on EDGE as of the date of this review on 06/16/16.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated personnel have to have EDGE training within 60 days of hire. He further indicated after the event of 05/13/16 (related to Patient #1), they decided to wait to do EDGE training for everyone who was due when they did the refresher course for S11PLPC. He confirmed the expired EDGE training and CPR for the above-listed staff and that S14MHT had not been certified in EDGE and CPR within 60 days as required by hospital policy. S1ADM confirmed he did not have medical experience, and S8PD's competency evaluation should have been conducted by a qualified RN. He further indicated S6LPC and S11PLPC should have been evaluated for competency by a qualified LPC and not a RN.

Based on record reviews and interviews, the hospital failed to meet all special provisions applying to psychiatric hospitals as evidenced by:

1) Failing to meet the requirements of the Condition of Participation for the Special Medical Records Requirements For Psychiatric Hospitals (see findings in tag B0103).


2) Failing to meet the requirements for Condition of Participation for the Special Staff Requirements For Psychiatric Hospitals (see findings in tag B0136).

Based on record reviews, observations, and interviews, the psychiatric hospital failed to meet all Conditions of Participation specified in §§482.1 through 482.23 and §§482.25 through 482.57. by failing to meet the Condition of Participation for Outpatient Services (482.54). This is evidenced by:

1) Failing to ensure outpatient services were organized and integrated with inpatient services as evidenced by:

a) Failing to ensure outpatient services were integrated with inpatient Medical Record Services and Quality Assessment and Performance Improvement Services.

b) Failing to ensure the hospital developed a policy that addressed that if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available (see findings in tag A1077).


2) Failing to ensure that personnel providing outpatient services in the PHP were qualified and evaluated for competency to provide services as evidenced by failure to have documented evidence of current CPR certifications, EDGE training, and/or competency evaluations by appropriately qualified staff for 1 (S8) of 3 RN personnel files reviewed, 2 (S14, S17) of 5 MHT personnel files reviewed, and 2 (S6, S11) of 3 LPC/PLPC/LCSW personnel files reviewed for competency from a total of 14 personnel files reviewed (see findings in tag A1079).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Special Medical Record Requirements for Psychiatric Hospitals as evidenced by:

1) Failing to ensure each patient's assets listed in the psychiatric evaluation was stated in a descriptive, not interpretive, fashion. This was evidenced for 3 (#2, #3, #4) of 3 patients' records reviewed for psychiatric evaluations from a total of 5 sampled patients (see findings in tag B0117).

2) Failing to ensure each patient had an individual comprehensive treatment plan as evidenced by failure to include interventions and goals for all diagnoses for which the patient was being treated for 3 (#1, #2, #5) of 5 patient records reviewed for treatment plans from a total sample of 5 patients (see findings in tag B0118).

3) Failing to ensure a progress note was documented that addressed the decompensation of Patient #1 on 05/13/16 that resulted in seclusion and an inappropriate physical hold for 1 (#1) of 1 patient record reviewed for presence of progress notes related to an incident from a total of 5 sampled patients (see findings in tag B0128).

4) Failing to ensure the record of each patient who had been discharged had a discharge summary that included a recapitulation of the patient's hospitalization as evidenced by failure to have a completed discharge summary documented within 30 days of discharge for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for completion from a total of 5 sampled patients (see findings in tag B0133).

5) Failing to ensure the record of each patient who had been discharged had recommendations from appropriate services concerning follow-up or after care as evidenced by having a blank discharge summary in Patient #1's medical record and no documented evidence of plans for follow-up or after care for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for discharge planning from a total of 5 sampled patients (see findings in tag B0134).

6) Failing to ensure the record of each patient who had been discharged had a brief summary of the patient's condition on discharge as evidenced by having a blank discharge summary in Patient #1's medical record and no documented evidence of her condition on discharge for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for discharge planning from a total of 5 sampled patients (see findings in tag B0135).

Based on record reviews and interview, the hospital failed to ensure each patient's assets listed in the psychiatric evaluation was stated in a descriptive, not interpretive, fashion. This was evidenced for 3 (#2, #3, #4) of 3 patients' records reviewed for psychiatric evaluations from a total of 5 sampled patients.
Findings:

Patient #2
Review of Patient #2's Psychiatric Evaluation, dated 06/09/16, revealed S18NP documented and S9MD concurred the following on page 2 of 3 (top of page 2), under the section titled "PATIENT ASSETS": S18NP placed a check mark in a box next to the word "Family/Peer support".

Patient #3
Review of Patient #3's Psychiatric Evaluation, dated 06/09/16, revealed S18NP documented and S9MD concurred the following on page 2 of 3 (top of page 2), under the section titled "PATIENT ASSETS": S18NP placed a check mark in a box next to the word "NH staff".

Patient #4
Review of Patient #4's Psychiatric Evaluation, dated 06/02/16, revealed S18NP documented and S9MD concurred the following on page 2 of 3 (top of page 2), under the section titled "PATIENT ASSETS": S18NP placed a check mark in a box next to the word "Intelligent".

In an interview on 06/16/16 at 11:30 a.m., S2DON confirmed patient assets should have been more descriptive in nature and not interpretive.

Based on record reviews and interviews, the hospital failed to ensure each patient had an individual comprehensive treatment plan as evidenced by failure to include interventions and goals for all diagnoses for which the patient was being treated for 3 (#1, #2, #5) of 5 patient records reviewed for treatment plans from a total sample of 5 patients.
Findings:

Review of the outpatient policy titled "Treatment Planning", effective 07/02/12 and presented as a current policy by S8PD, revealed that the interdisciplinary treatment plan is a dynamic working document that directs the care of the patient throughout the continuum of care. It is individualized and based on the problems of the patient. The treatment plan is developed through an integrated process using the Psychiatric Evaluation, Psychosocial Assessment, and Nursing Assessment. The interdisciplinary treatment plan includes the following components: a list of problems including the date of their identification and designation of their status; goals which are specific, measurable, and patient-oriented expectations that are directly related to the identified problems and symptoms. Interventions are specific, staff-centered methods/modalities that are used to assist the patient in accomplishing the objectives. Interventions should include the specific staff responsible and frequency of the action. The treatment plan must be reviewed and updated/revised when appropriate.

Review of the hospital's policy titled "Admission Procedures", effective 07/02/12 and presented as a current policy by S8PD, revealed that that the nursing staff performs the nursing assessment to include evaluation of the following: physical health, identification of relevant medical conditions, infectious diseases, and allergies. The Nursing Care Plan/Preliminary Treatment Plan is completed within one day, and presenting problems are listed on the master problem list.

Patient #1
Review of Patient #1's "Nursing Home/Outpatient Psychiatric Evaluation" revealed his diagnoses included Depression, Anxiety, Diabetes, Congestive Heart Failure (CHF), Osteoporosis, Peripheral Vascular Disease (PVD), and Osteomyelitis.

Review of Patient #1's "Master Treatment Plan" revealed the identified problems were Mood Disturbance and Ineffective Coping for which a treatment plan was initiated. There was no documented evidence that the problems of Depression, Diabetes, CHF, Osteoporosis, PVD, and Osteomyelitis were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.

Patient #5
Review of Patient #5's "Admit Note/Psychiatric Evaluation" revealed her reason for admission included Depression, Insomnia, and Phantom Limb Pain (related to left above-the-knee amputation).

Review of Patient #5's "Master Treatment Plan" revealed the identified problems were Mood Disturbance and Ineffective Coping for which a treatment plan was initiated. There was no documented evidence that the problems of depression, Insomnia, and Phantom Limb Pain were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.

In an interview on 06/16/16 at 12:15 p.m., S8PD indicated "we don't handle medical diagnoses here, it's strictly a psychiatric facility." When informed that the policy she presented stated the Nursing Care Plan/Preliminary Treatment Plan is completed within one day, and presenting problems are listed on the master problem list, S8PD indicated "we've never done nursing medical care plans."

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/09/16 and was receiving medications to treat Diabetes. Further review revealed no documented evidence that a nursing care plan was developed and implemented for Diabetes.

In an interview on 06/16/16 at 11:30 a.m., S2DON indicated that the care plan did not include a plan for Diabetes.

Based on record reviews and interviews, the hospital failed to ensure a progress note was documented that addressed the decompensation of Patient #1 on 05/13/16 that resulted in seclusion and an inappropriate physical hold for 1 (#1) of 1 patient record reviewed for presence of progress notes related to an incident from a total of 5 sampled patients. Findings:

Review of the hospital policy titled "Patient Records", presented as a current policy by S8PD, revealed an interdisciplinary progress note will be written for individual sessions or special services delivered.

Review of the hospital policy titled "Incident Report", presented as a current policy by S8PD, revealed when an incident involves a patient, the charge nurse assesses the patient for injuries, then notifies the attending physician. A summary of the incident, the charge nurse's assessment, and the notification of physician are recorded in the nurse's notes.

Review of the "Hospital Abuse/Neglect Initial Report", presented by S8PD, revealed it was prepared on 05/13/16 by S8PD for an alleged physical abuse that occurred on 05/13/16 at 10:40 a.m. Further review revealed the description of the alleged incident included the following: patient became verbally aggressive during group therapy session and was escorted out by the therapist who attempted to calm her down and provide redirection; this was ineffective and patients' behavior became more aggressive and physical in nature; patient began trying to jump out her wheelchair and became more combative, swinging her arms and trying to hit staff; staff held patient in the chair, loaded her onto bus, and secured the wheelchair via safety belts; patient continued to fight against staff while she was being secured causing the seat belt to rub back and forth against her neck; patient was transported by 2 MHTs to the nursing home; upon arrival patient was noted to be calmer and controlled; patient reported to nursing home staff that she was choked by the staff at the PHP; bruises were noted to patient's neck, which appear to be from the seat belt, along with abrasions to bilateral arms. Further review of the report revealed the following interviews:

S6LPC reported going to a vacant room after hearing a patient yelling to find that S11PLPC had brought Patient #1 to an empty room in an attempt to calm her down; when this was ineffective, S11PLPC closed the door with the patient in the room to allow her to "gather herself"; client came out the room within 1 minute.

S7LPN reported Patient #1 became agitated and began swinging at the staff and remembered a struggle to get Patient #1 onto the bus.

S14MHT reported Patient #1 was uncooperative with staff requiring multiple people to assist with loading her onto the bus. S14MHT indicated she and S15MHT secured the wheelchair into place on the bus while Patient #1 continued to yell and swing her arms as if she would hit S14MHT and S15MHT. S17MHT wrapped her arm around Patient #1's chest with one arm and held her hands down with the other hand. S17MHT rode with Patient #1 in this position during transport to the nursing home.

S15MHT reported as she was attempting to secure the front wheelchair restraints, Patient #1 began to swing at her. S17MHT grabbed Patient #1 with her left arm around Patient #1's upper chest and neck with her (S17MHT) right arm around patient #1's hands.

S11PLPC reported that at the end of her group session, Patient #1 became very upset and was yelling and screaming. As the wheelchair approached the exit door, Patient #1 swinging at S11PLPC. S17MHT came to assist and was observed to hold Patient #1's hands down to prevent her from harming herself or staff. She reported remembering seeing Patient #1 tussle with the seat belt while on the bus and getting caught up in it.

The summary of the investigation revealed that S11PLPC should not have attempted to calm client by placing client in empty room and improper EDGE techniques were used by S17MHT and S11PLPC with an "acting out" client."

Review of Patient #1's medical record revealed no documented evidence of the above observations in the progress notes, and there was no documented evidence of multidisciplinary notes in the record or a note by the charge nurse.

In an interview on 06/16/16 at 1:15 p.m., S8PD confirmed no progress note or multidisciplinary note was documented by S11PLPC of the above incident.

Based on record reviews and interviews, the hospital failed to ensure the record of each patient who had been discharged had a discharge summary that included a recapitulation of the patient's hospitalization as evidenced by failure to have a completed discharge summary documented within 30 days of discharge for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for completion from a total of 5 sampled patients.
Findings:

Review of the hospital policy titled "Discharge Summaries", presented as a current policy by S8PD, revealed that the attending physician will develop a discharge summary to be included in the patient's record within 30 days of discharge. The discharge summary shall give an account of the patient's inpatient treatment. All discharge summaries shall be authenticated by the responsible practitioner which will include signature, date, and time.

Review of the "PHP Admission / Discharge Log", presented by S8PD, revealed that Patient #1 was admitted on 05/02/16 and discharged on 05/16/16. Review of the "Discharge Summary" contained in Patient #1's medical record revealed the form was blank. There was no documented evidence that a discharge summary had been documented by S9MD as of 06/16/16 (31 days after discharge).

In an interview on 06/16/16 at 12:15 p.m., S8PD offered no comment when informed that the record review of Patient #1's medical record revealed no documented evidence of a discharge summary documented by S9MD.

Based on record reviews and interview, the hospital failed to ensure the record of each patient who had been discharged had recommendations from appropriate services concerning follow-up or after care as evidenced by having a blank discharge summary in Patient #1's medical record and no documented evidence of plans for follow-up or after care for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for discharge planning from a total of 5 sampled patients.
Findings:

Review of the hospital policy titled "Discharge Summaries", presented as a current policy by S8PD, revealed that the attending physician will develop a discharge summary to be included in the patient's record within 30 days of discharge. The discharge summary shall give an account of the patient's inpatient treatment and recommendations and arrangements for further treatment, including prescribed medications and after care. All discharge summaries shall be authenticated by the responsible practitioner which will include signature, date, and time.

Review of Patient #1's "Nursing Home/Outpatient Psychiatric Evaluation" documented by S9MD on 04/04/16 revealed no documented evidence of the time the evaluation was documented. Review of her "Physician Orders" revealed a telephone order was received from S9MD on 05/11/16 at 3:30 p.m. There was no documented evidence that the telephone order had been authenticated by S9MD as of the review of Patient #1's medical record on 06/15/16 (35 days since it was received and written).

Review of the "PHP Admission / Discharge Log", presented by S8PD, revealed that Patient #1 was admitted on 05/02/16 and discharged on 05/16/16. Review of her "Physician Orders" on 06/15/16 revealed no documented evidence that a discharge order was written by S9MD. Review of the "Discharge Summary" contained in Patient #1's medical record revealed the form was blank. There was no documented evidence that a discharge summary had been documented by S9MD as of 06/16/16 (31 days after discharge).

In an interview on 06/16/16 at 12:15 p.m., S8PD offered no comment when informed that the record review of Patient #1's medical record revealed no documented evidence of a discharge summary documented that included recommendations and arrangements for further treatment, including prescribed medications and after care.

Based on record reviews and interview, the hospital failed to ensure the record of each patient who had been discharged had a brief summary of the patient's condition on discharge as evidenced by having a blank discharge summary in Patient #1's medical record and no documented evidence of her condition on discharge for 1 (#1) of 2 (#1, #5) outpatient PHP patient records reviewed for discharge planning from a total of 5 sampled patients.
Findings:

Review of the hospital policy titled "Discharge Summaries", presented as a current policy by S8PD, revealed that the attending physician will develop a discharge summary to be included in the patient's record within 30 days of discharge. The discharge summary shall give an account of the patient's inpatient treatment and the patient's condition on discharge (measurable comparison with condition on admission). All discharge summaries shall be authenticated by the responsible practitioner which will include signature, date, and time.

Review of the "PHP Admission / Discharge Log", presented by S8PD, revealed that Patient #1 was admitted on 05/02/16 and discharged on 05/16/16. Review of the "Discharge Summary" contained in Patient #1's medical record revealed the form was blank. There was no documented evidence that a discharge summary had been documented by S9MD as of 06/16/16 (31 days after discharge) that included a brief summary of her condition on discharge.

In an interview on 06/16/16 at 12:15 p.m., S8PD offered no comment when informed that the record review of Patient #1's medical record revealed no documented evidence of a discharge summary documented that included a brief summary of her condition on discharge.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Special Staff Requirements for Psychiatric Hospitals as evidenced by:

1) Failing to ensure personnel in the outpatient PHP were qualified as evidenced by failure to have current license verification, current certifications in CPR and/or EDGE, and competency evaluations performed by appropriately qualified personnel for 1 (S8) of 1 RN personnel file reviewed, 2 (S14, S17) of 2 MHT personnel files reviewed, and 2 (S6, S11) of 2 LPC/PLPC personnel files reviewed for competency from a total of 5 outpatient services personnel files reviewed (see findings in tag B0137).

2) Failing to ensure its outpatient services PHP had a director of social services who monitored and evaluated the quality and appropriateness of social services furnished as evidenced by having the PHP under the direction of a RN who was responsible for the services provided by LPCs, PLPCs, and the LMSW (see findings in tag B0152).

Based on record reviews and interviews, the hospital failed to ensure personnel in the outpatient PHP were qualified as evidenced by failure to have current license verification, current certifications in CPR and/or EDGE, and competency evaluations performed by appropriately qualified personnel for 1 (S8) of 1 RN personnel file reviewed, 2 (S14, S17) of 2 MHT personnel files reviewed, and 2 (S6, S11) of 2 LPC/PLPC personnel files reviewed for competency from a total of 5 outpatient services personnel files reviewed.
Findings:

Review of the hospital's "2016 Staff Development Plan", presented as the current plan by S8PD, revealed that elements of the competence assessment process begins upon hire and continues throughout the employee's tenure. An evaluation of each employee's competence is conducted during the orientation process, ninety days post employment, and annually thereafter. The evaluation includes an objective assessment of the individual's job performance which is made through daily observations, performance evaluations, job-specific competency skills check lists, direct observation, during treatment planning, and periodic age-specific testing/other testing. Within 30 days of hire, all staff will be oriented to the unit/department to which they have been assigned as evidenced by completion of the Unit-Specific Orientation Checklist. Within 60 days of hire, employees with direct patient care responsibilities will obtain and maintain current certification in EDGE and in Cardiopulmonary Resuscitation (CPR).

Nurses and MHTs
S8PD
Review of S8PD's personnel file revealed she was hired on 02/13/15 as the RN Program Director of the outpatient PHP. Further review revealed her EDGE certification had expired on 03/31/16. Her competency evaluation was completed by S1ADM who was not a RN and had no medical experience.

S14MHT
Review of S14MHT's personnel file revealed she was hired on 04/07/16. Further review revealed no documented evidence of EDGE and CPR certification as required by hospital policy within 60 days of employment.

S17MHT
Review of S17MHT's personnel file revealed she was hired on 08/25/10 and terminated on 05/19/16. Further review revealed her CPR certification had expired on 04/30/14, and she was not currently certified at the time of her termination.

LPC/PLPC/LCSW:
S6LPC
Review of S6LPC's personnel file revealed she was hired on 10/24/14. Further review revealed no documented evidence that her LPC license was verified since 10/23/14 to determine that she had a current, unencumbered license to practice. S6LPC's EDGE certification had expired on 05/31/16. Further review revealed her competency was evaluated by S8PD, a RN and not an appropriately qualified LPC.

S11PLPC
Review of S11PLPC's personnel file revealed she was hired on 07/10/15. Further review revealed her skills competency was evaluated on 08/14/15 by S8PD, a RN and not an appropriately qualified LPC. Further review revealed an "Employee Conference Report" dated 05/19/16 that included a remediation plan for S11PLPC to receive a refresher course on EDGE. There was no documented evidence that S11PLPC had received a refresher course on EDGE as of the date of this review on 06/16/16.

In an interview on 06/16/16 at 3:55 p.m., S1ADM indicated personnel have to have EDGE training within 60 days of hire. He further indicated after the event of 05/05/13/16 (related to Patient #1), they decided to wait to do EDGE training for everyone who was due when they did the refresher course for S11PLPC. He confirmed the expired EDGE training and CPR for the above-listed staff and that S14MHT had not been certified in EDGE and CPR within 60 days as required by hospital policy. S1ADM confirmed he did not have medical experience, and S8PD's competency evaluation should have been conducted by a qualified RN. He further indicated S6LPC and S11PLPC should have been evaluated for competency by a qualified LPC and not a RN.

Based on record reviews and interviews, the hospital failed to ensure its outpatient services PHP had a director of social services who monitored and evaluated the quality and appropriateness of social services furnished as evidenced by having the PHP under the direction of a RN who was responsible for the services provided by LPCs, PLPCs, and the LMSW.
Findings:

Review of the "Employee List", presented as the list of current employees of the outpatient PHP by S8PD, revealed the director of the program was S8PD who was a RN. Further review revealed there a LMSW listed as a PRN employee, 3 LPCs, one of whom was licensed as LPC Supervisor, and 2 PLPCs. There was no documented evidence that the PHP had a director of social services who was responsible for the services provided by LPCs, PLPCs, and the LMSW.

Review of the hospital policy titled "Psychosocial Assessment", presented as a current policy by S8PD, revealed that a detailed psychosocial assessment will be conducted on each patient by a social worker within 24 hours of admission.

Review of Patient #1's and Patient #2's medical records revealed each of their psychosocial assessments were conducted by S20PLPC. There was no documented evidence that a master's level social worker was involved to oversee the quality and appropriateness of the service provided by S20PLPC.

In an interview on 06/16/16 at 9:10 a.m., S6LPC indicated she supervises the PLPCs for licensure, but she is not their supervisor at the outpatient PHP. She further indicated the PLPCs are under the direction of S8PD who is a RN. She further indicated it was her understanding that the PLPC "can do most anything without signing off by the LPC." She indicated she constantly reviews their work and "can say it's adequate, but I'm not satisfied with it."