HospitalInspections.org

Based on policy reviews, document reviews, medical staff bylaws review, medical record reviews, observations, and interviews, the hospital failed to ensure there was an effective governing body that was legally responsible for the conduct of the hospital. This deficient practice had the potential to affect all staff and physicians providing services in the hospital and all patients receiving services in the hospital.

Findings include:

1. There were no governing body bylaws presented when a request was made by the surveyor to review the governing body bylaws.

During an interview on 09/20/23 at 2:49 PM, Interim Hospital Administrator (IHA) stated the Medical Staff Bylaws were the governing body bylaws. IHA confirmed the hospital did not have governing body bylaws.

2. The governing body failed to ensure patients were informed of their rights, patients participated in the development and implementation of the plan of care, the patient's representative were notified of admission including being informed of the patient's health status, being involved in care planning and treatment, and being able to request or refuse treatment, patients had the right to formulate advanced directives, and patients received care in a safe setting related to ligature risks, plastic garbage bags in patient care areas, and failed to ensure observation was maintained as ordered for one patient (Patient 3) ordered to be on 1:1 (one-on-one) line of sight (LOS) observation. (See findings in tag A0115)

3. The governing body failed to ensure an ongoing quality assessment process improvement (QAPI) program (1) was implemented and showed measurable improvement of indicators with quality outcomes; (2) set priorities for performance improvement activities that focused on high-risk, high-volume, or problem prone areas considering the incidence, prevalence, and severity of problem areas that affect health outcomes, patient safety, and quality of care; (3) included patient adverse incidents and events being tracked, trended and analyzed; (4) conducted annual performance improvement projects proportional to the scope and complexity of services and operations; (5) was accountable to the governing body (GB) for development, implementation, and maintenance of hospital-wide ongoing quality improvement and patient safety program that addressed setting priorities along with evaluations of improvement actions that showed measurable improvement with quality outcomes. (See findings in tag A0263)

4. The governing body failed to ensure there was an organized medical staff that operated under bylaws approved by the governing body, and which was responsible for the quality of medical care provided to patients by the hospital. (See findings in tag A0338)

5. The governing body failed to ensure the specific organ, tissue, and eye procurement requirements were met. (See findings in tag A0884)

6. The governing body failed to ensure the special medical record requirements for psychiatric hospitals were met for four (Patient (P) 1, P2, P3, and P4) of four patient records reviewed for special medical record requirements for psychiatric hospitals. (See findings in tag A1620)

7. The governing body failed to ensure the special staff requirements for psychiatric hospitals were met to ensure a qualified therapeutic activity therapist and Clinical Director were available to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures, and engage in discharge planning. (See findings in tag A1680)

Based on medical record review, policy review, observation, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure patients were informed of their rights, participated in the development and implementation of the plan of care, representatives were notified of admission and included being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment, right to formulate advanced directives, and received care in a safe setting related to ligature risks, plastic garbage bags in patient care areas, and observation of one patient on 1:1 line of sight (LOS) observation was maintained. The cumulative effects of these deficient practices place all inpatient psychiatric patients at risk of serious illness and/or death.

Findings include:

1. The facility failed to ensure one (Patient (P) 1) of four patient records reviewed was informed of their rights from a sample of 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital. (Refer to A0117)

2. The facility failed to ensure four patients P1, P2, P3, and P4 of four patient records reviewed participated in the development and implementation of the plan of care from a sample of 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital. (Refer to A0130)

3. The facility failed to ensure three patients P1 P2, and P3 of four patient records reviewed for the patient's representative was notified of admission and included being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment from a sample of 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital. (Refer to A0131)

4. The facility failed to ensure three patients P1, P2, and P3 of four patient records reviewed for the right to formulate advanced directives from a sample of 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital. (Refer to A0132)

5. The facility failed to ensure patients received care in a safe setting related to ligature risks, plastic garbage bags in patient care areas, and failed to observe one (Patient (P) 3) 1:1 line of sight (LOS) observation was maintained. These deficient practices had the potential to affect the safety and well-being of all inpatient psychiatric patients receiving services at the hospital. (Refer to A0144)

Based on medical record review, policy review, and interview, the facility failed to ensure one (Patient (P) 1) of four patient records reviewed were informed of patient rights from 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital.

Findings include:

Review of the facility's policy titled, "Patient Rights," revised 12/09/19, indicated, " ...Procedure ...2. Patients will have their rights explained to them upon admission and receive a Patient's Right Handbook. Patients are to sign and date the BH (behavioral health) - Patient's Rights Form ... 4.1. Undeniable rights: 4.1.1. Right to least restrictive treatment services
4.1.2. Right to dignity, privacy, and humane care 4.1.3. Right to be free from harm 4.1.4. Right to prompt medical treatment 4.1.5. Right to religious freedom 4.1.6. Right to education 4.1.7. Right to social interaction 4.l.8. Right to physical exercise and recreation 4.1.9. Right to be free from seclusion and restraint unless their behavior becomes dangerous to self or others 4.1.10. Right to see and receive the services of an advocate 4.1.11 . Right to have a family member or representative of their choice and their own physician notified promptly of their admission to SV [Sempervirens]"

Review of P1's "2029 - Patient Rights" form found in P1's paper medical record under the legal tab, indicated, "MY RIGHTS HAVE BEEN EXPLAINED TO ME and I have received a Patient's Handbook," was not signed or dated by P1. P1 was admitted to the facility on 09/12/23 and had not yet been signed by P1 on 09/18/23 when the P1's medical record was reviewed. Continued review of the document indicated, "While a patient on this unit, you have the right:

1. to wear your own clothes
2. to keep your personal possessions, including your toilet articles
3. to keep and be allowed to spend a reasonable sum of your money for small purchases
4. to have ready access to letter writing materials, including stamps
5. to use the telephone
6. to see visitors
7. to receive unopened mail
8. to private storage space"

The Patient Rights form the facility provides to patients failed to include all the patient rights listed in the Patient Rights policy that would allow patients to be informed of all their rights.

During an interview on 09/18/23 at 4:10 PM, the Director of Nursing (DON) confirmed P1 had not signed his/her patient rights form and staff should have attempted to obtain P1's signature. The DON confirmed the Patient Rights form failed to include all patient rights that were listed in the Patient Rights policy.

During an interview on 09/19/23 at 9:30 AM, P1 confirmed he/she had not received the Patient Rights' handbook or the Patients Right Form. P1 provided the surveyor with a folder of all paperwork that had been received since admission on 09/12/23 and there was no information related to patient rights present or a patient's right handbook present.

Based on medical record review, policy review, and interview, the facility failed to ensure four (Patient (P)1, P2, P3, and P4) of four patient records reviewed participated in the development and implementation of the plan of care from 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital.

Findings include:

1. Review of P1's Master Treatment Plan (MTP) titled, "Interdisciplinary Treatment Plan (ITP)," dated 09/12/23 and effective 09/13/23, failed to show the "ITP" included P1's signature as proof that the patient agreed with the plan or a note from the Social Worker indicating P1 refused to sign the "MTP/ITP."

During an interview on 09/19/23 at 9:30 AM, P1 stated he/she was never included in the development of the "MTP/ITP" or attended the multidisciplinary treatment planning meeting.

2. Review of P2's "Interdisciplinary Treatment Plan," located under the "Treatment Plan" tab, indicated P2's treatment plan was documented on 09/08/23 with a revised treatment plan documented on 09/09/23. There was no documentation indicating the hospital actively included P2 in the development, implementation, and revision of P2's plan of care.

During an interview on 09/19/23 at 9:55 AM, P2 stated he/she did not know what was included in his/her treatment plan.

During an interview on 09/21/23 at 4:30 PM, Interim Hospital Administrator (IHA) offered no explanation for patients not being included in the development, implementation, and revision of their treatment plans.

3. Review of P3's "Interdisciplinary Treatment Plan," located under the "Treatment Plan" tab, indicated P3's treatment plan was documented on 09/15/23. There was no documentation indicating the hospital actively included P3 in the development, implementation, and revision of P3's plan of care.

During an interview on 09/18/23 at 2:50 PM, Licensed Clinical Social Worker (LCSW) stated the patient did not usually attend the treatment plan meeting. LCSW stated he/she did not know if it is documented in the medical record that the social worker asked the patient to sign the treatment plan, be given a copy, discuss the reaction to the plan, and document when the patient refused to sign the treatment plan. LCSW stated it is being documented by time of discharge but not during the hospital stay as often.

4. Review P4's "MTP" titled, "ITP," dated 09/07/23 and effective 09/07/23, failed to show the "ITP" included P4's signature as proof that the patient agreed with the plan or a note from the Social Worker indicating P4 refused to sign the "MTP/ITP."

During an interview 09/19/23 at 4:10 PM, the Director of Nursing (DON) confirmed the above medical record findings in P1 and P4's medical record.

Review of the facility's policy titled, "Treatment Planning," revised 09/14/17, indicated, "Each patient must have an individualized, comprehensive Treatment Plan that must be based on an inventory of patient strengths and disabilities. A Problem outlining the reason for admission will be started within 24 hours of admission by the Social Worker, under the direction and supervision of the attending physician, with input from all disciplines. Thereafter, a Master Treatment Plan will be developed by all disciplines within 72 hours of admission ... 6. PATIENT PARTICIPATION IN TREATMENT PLANNING PROCESS: Patients will be included in the treatment planning process. Goals and treatment modalities will be developed by the treatment team with patient involvement. Patients will be included in the multidisciplinary treatment planning meeting based on individual tolerance level, level of alertness and ability to participate in assessment process. As soon as the MTP has been developed, the Social Worker will meet with the patient, give them a copy of the plan, and discuss their reaction to the plan. The patient will be asked to sign the MTP and will be given a copy. lf the patient refuses to sign the MTP, the Social Worker will make a note in the MTP of the refusal ... 8. The Treatment Plan will be signed by the RN, the Social Worker, the Activity Therapist, and the treating Psychiatric Prescriber. The client's signature will be collected by the Social Worker as proof that the client agrees with the plan.


25065

Based on medical record review, policy review, and interview, the facility failed to ensure three (Patient (P) 1 P2, P3) of four patient records reviewed for notification of the patient's representative of admission and included being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment from 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital.

Findings include:

1.Review of P1's "Notification of Admission," indicated, "The Hospital is required by 1aw to tell your next of kin or any other person you designate that you have been admitted to the hospital for inpatient psychiatric care. You can, however, instruct the hospital not to disclose this information. If you do not object to your next of kin being told that you have been admitted to the hospital, please provide the name of your next of kin and a phone number and address where he or she can be reached. You may choose to select another person to receive this information. The following person should be notified of my admission to the hospital:" " The document was left blank and failed to contain P1's signature.

2. Review of P2's "Notification of Patients Admission," located under the "Patient Data" tab, indicated "The Hospital is required by law to tell your next of kin or any other person you designate that you have been admitted to the hospital for inpatient psychiatric care. You can, however, instruct the hospital not to disclose this information. . ." Review of the form indicated ". . . I have not identified any person that the hospital may inform that I have been admitted to the hospital. I do not want this information disclosed to my next of kin or any other designated person." The statement had P2's initials on the signature with no date documented, and there was no signature and date of a witness.

3. Review of P3's "Notification of Patients Admission" indicated ". . . I have not identified any person that the hospital may inform that I have been admitted to the hospital. I do not want this information disclosed to my next of kin or any other designated person" was signed and dated by a staff member on the witness signature line. There was no documentation of a signature and date by P3.

During an interview on 09/21/23 at 4:30 PM, Interim Hospital Administrator (IHA) offered no explanation for the incomplete "Notification of Patients Admission" forms in P1, and P3's records.

Review of the facility's policy titled, "Patient Rights," revised 12/09/19, indicated, "4. There are two types of patients' rights; undeniable rights and rights that can be denied with "Good Cause": 4.1. Undeniable rights: 4.1.11. Right to have a family member or representative of their choice and their own physician notified promptly of their admission to SV [Sempervirens].


25065

Based on medical record review and interview, the facility failed to ensure three (Patient (P) 1, P2, and P3) of four patient records reviewed were provided the right to formulate advanced directives from 10 patient records sampled. This deficient practice had the potential to affect all inpatient psychiatric patients receiving services at the hospital.

Findings include:

1. Review of P1's "1163-Advnace Healthcare Directive Notification" dated 09/12/23, the date of admission, indicated, "You have the right to have an Advance Healthcare Directive (AHD). An AHD is a written instruction about your health care that is recognized under California law. It usually states how you would like health care provided, or states what decisions you would like to be made, if or when you are unable to speak for yourself. You may sometimes hear an AHD described as a living will or durable power of attorney. California law defines an AHD as either an oral or written individual health care instruction or a power of attorney (a written document giving someone permission to make decisions for you). Please give a copy to client." The document showed staff documented, "Patient unable to receive on intake due to sedation," Continued review of the document indicated, "1. AHD info given to client: Date 09/12/23 staff signature 2. Client has an AHD: Yes/NO" Both Yes and No were marked with the number zero failing to indicate if P1 had an AHD. Further review of the document indicated, "AHD located in: Client chart, other (specify), Unknown" was left blank.

During an interview on 09/19/23 at 9:30 AM, P1 was asked if he/she received Notification of Advanced Directives and stated, "Not sure what that is."

2. Review of P2's "1163- Advance Healthcare Directive Notification What Is An Advance Healthcare Directive (AED)?," located under the "Patient Data" tab, indicated "Staff: Please inform each adult client of the following information at the first visit in the outpatient services and subsequent to inpatient hospitalization. . . You have the right to have an Advance Healthcare Directive (AHD). . ." Review indicated there was a section on the form for staff to date and sign that the advance directive information was provided to the patient and to document whether the patient had an advance directive. Review of P2's advance directive form indicated the section for the staff's signature and date was blank (void of writing), and the question whether P2 had an advance directive had no check mark on the "Yes" or "No" lines.

3. Review of P3's "1163- Advance Healthcare Directive Notification What Is An Advance Healthcare Directive (AED)?," located under the "Patient Data" tab, indicated staff had signed on 09/15/23 that advance directive information had been provided to P3. Review indicated the question whether P3 had an advance directive had no check mark on the "Yes" or "No" lines.

During an interview on 09/21/23 at 4:30 PM, Interim Hospital Administrator (IHA) offered no explanation for advance directive information not being presented to patients and for the patient medical records not including documentation of the presence or absence of a patient's advance directive.


25065

Based on policy review, observations, and interviews, the hospital failed to ensure patients received care in a safe setting related to ligature risks as observed during the hospital tour on 09/18/23 from 9:50 AM through 12:00 PM and observation of one (Patient (P) 3) patient placed on one-to-one observation line of sight while awake on 09/19/23 at 9:00 AM. The cumulative effects of these deficient practices placed all inpatient psychiatric patients at risk of serious illness and/or death.

Findings include:

Observations on 09/18/23 at 9:50 AM, while on tour of the inpatient unit, accompanied by the Director of Nursing (DON), revealed the following ligature risks that were confirmed by the DON at the time of the observations:

1. The outside recreation patient patio was surrounded by chain link fence approximately 11 foot tall by 27 foot wide. The area was covered with approximately 27 feet by 27 feet of chain link fence.
2. The nursing station was observed to have monitors for the closed caption television (CCTV) of the outside recreation patient patio.
3. Seven of seven patient rooms had metal grates with one-inch openings covering the windows in the patient rooms. The windows were all open approximately two to three inches allowing access to the metal grates.
4. Room one had 12 Phillips head screws that were not tamper resistant in the door.
5. Room two had four screws that were not tamper resistant with Phillips head screws on a metal wall plate attached to the wall.
6. Room three had 12 Phillips head screws that were not tamper resistant in the door.
7. The utility room had 12 Phillips head screws that were not tamper resistant in the door.
8. Room four had 12 Phillips head screws that were not tamper resistant in the door.
9. Room five had 12 Phillips head screws that were not tamper resistant in the door.
10. The day room had 12 Phillips head screws that were not tamper resistant in the door and six Phillips head screws in a wall plate on the wall.
11. The hallway outside the day room had a fire extinguisher covered with a wood panel that contained 16 Phillips head screws that were not tamper resistant.
12. Room seven had 6 Phillips head screws that were not tamper resistant in the door and 10 Phillips head screws that were not tamper resistant in a wall plate on the wall.
13. The hallway outside of Room A had 12 Phillips head screws that were not tamper resistant in a wall plate on the wall.
14. Room A (restraint and seclusion room) had four Phillips head screws that were not tamper resistant in the door and four Phillips head screws in a wall plate on the wall.
15. Room B (restraint and seclusion room) contained a window with 14 standard head screws that were not tamper resistant.
16. Room C (restraint and seclusion room) contained a window with four Phillips head screws, a wall panel with three standard and two Phillips screws that were not tamper resistant,
17. The treatment room (patient intake) contained a large plastic bag in the garbage can.
18. The patient dining room had metal grates with one inch opening covering the windows that were approximately five feet tall by seven feet wide. The window was wide open with the opening measuring approximately five feet wide. There was a metal wall plate attached to the wall with two standard head screw that were not tamper resistant. There was a large garbage can that contained a plastic bag.

During an interview on 09/18/23 at 9:50 AM, the DON stated the outside recreation patient patio ligature risks were mitigated by always having staff present when patients were on the outside recreation patio. The DON also stated that the patio is continuously monitored via CCTV from the nurse's station.

During an interview on 09/18/23 at 9:50 AM while on tour of the inpatient unit, an individual sitting in front of the CCTV monitors in the nurse's station was asked if he/she was assigned to monitor the CCTV outside patient patio. He/she stated they were a student nursing instructor (SN)1 and not a staff member. SN1 further revealed he/she had not been assigned to watch the monitors.

Observation on 09/21/23 at 11:45 AM, while on tour of the inpatient unit, accompanied by the Interim Hospital Administrator (IHA), revealed two patients on the patio lying on a bench in the sun with no staff members present with them on the patio. Observation of the nursing station where the monitors for the CCTV's were located failed to show anyone in the nurse's station observing the CCTV monitors of the patio where the two patients were located.

2. Review of the hospital policy titled "Level of Observation," reviewed 07/17/23, indicated ". . . Line of Sight (1:1 LOS): patient must be within eyesight of the assigned staff. Assigned staff should be no further than approximately ten (10) feet from the patient with no physical
obstructions between the staff and patient. . . 1:1 While Awake (1:1 WA): while awake, including 1:1 LOS WA. . ."

Observation during the treatment team meeting conducted on 09/19/23 at 8:25 AM revealed Physician (Phys) 1 ordered P3 to be on one-to-one (1:1) observation line of sight while awake due to P3 exposing himself/herself on 09/18/23.

Review of P3's physician orders, located under the "Physician's Orders" tab indicated an order on 09/19/19 at 9:00 AM for "Initiate 1:1 line of sight while awake."

Observation on 09/19/23 at 10:10 AM outside P3's patient room revealed P3's room door was closed, and Security (Sec) 1 was seated in a chair to the right side of P3's door when facing the door. There was no means of Sec1 observing P3 with the room door closed.

During an interview on 09/19/23 at 10:10 AM, Sec1 stated he/she was doing 1:1 LOS "when [P3] out the room while awake and walking around." When asked how Sec1 knew P3 was asleep or awake with the room door closed, Sec1 stated he/she was to observe P3 when P3 was awake and "walking around."

During an interview on 09/19/23 at 10:20 AM, Phys1 stated P3 was ordered to be 1:1 LOS while awake. Phys1 stated Sec1 should be observing P3 with P3's room door open.

During an interview on 09/19/23 at 10:25 AM, Sec1 stated "they said when he/she was out and about. I was keeping an eye on him/her when [he/she] was out."

During an interview on 09/19/23 at 10:35 AM, Registered Nurse (RN) 3 stated the patient's door was supposed to be open when the patient was ordered to be observed 1:1 LOS while awake.

During an interview on 09/19/23 at 10:43 AM, RN4 stated "I said the patient's been placed on 1:1 LOS, so while awake and outside room, you're supposed to have LOS on [him/her]." RN4 stated he/she didn't recall talking with Sec1 about having the door remain open, but "I thought LOS would have implied that."


37588

Based on incident report review, Quality Improvement Tracking Process policy review, SV [Sempervirens] Quality Improvement Minutes review, governing body (GB) minutes review, document review, and interview, the facility failed to ensure an ongoing quality assessment process improvement (QAPI) program (1) was implemented and showed measurable improvement of indicators with quality outcomes (2) set priorities for performance improvement activities that focused on high-risk, high-volume, or problem prone areas considering the incidence, prevalence, and severity of problem areas the affect health outcomes, patient safety, and quality of care were developed, (3) included patient adverse incidents and events being tracked, trended and analyzed, (4) conduct an annual performance improvement project proportional to the scope and complexity of services and operations, (5) was accountable to the governing body (GB) for development, implementation, and maintenance of hospital-wide ongoing quality improvement and patient safety program that addressed set priorities along with evaluations of improvement actions that showed measurable improvement with quality outcomes. This deficient practice had the potential to affect the quality and safety of care provided to all patients receiving services in the hospital.

Findings include:

1. The facility QAPI program failed to measure, analyze, and track quality indicators that included measurable improvement of those indicators to improve health outcomes. (Refer to A0273)

2. The facility QAPI program failed to set priorities for performance improvement activities that focused on high-risk, high-volume, or problem prone areas considering the incidence, prevalence, and severity of problem areas that affect health outcomes, patient safety, and quality of care. The facility failed to take actions aimed at performance improvement, implement actions, measure success, and ensure improvements were sustained. (Refer to A0283)

3. The facility QAPI program failed to measure, analyze, and track patient adverse incidents and events. (Refer to A0286)

4. The facility failed to conduct an annual performance improvement project proportional to the scope and complexity of services and operations. (Refer to A0297)

5. The facility failed to ensure the QAPI program was accountable to the governing body (GB) for development, implementation, and maintenance of hospital-wide ongoing quality improvement and patient safety program that addressed set priorities along with evaluations of improvement actions that showed measurable improvement with quality outcomes. (Refer to A0309)

Based on Quality Improvement Tracking Process policy review, Quality Improvement Minutes review, Continuous Quality Improvement Work Plan Fiscal Year 2023-2024 review, review of the Joint Conference Committee minutes review, and interview, the facility quality assessment process improvement (QAPI) program failed to measure, analyze, and track quality indicators that included measurable improvement of those indicators to improve health outcomes. This deficient practice had the potential to affect the quality and safety of care provided to all patients receiving services in the hospital.

Findings include:

Review of the "Continuous Quality Improvement Minutes" for 2023 showed Quality Committee meeting minutes for 01/19/23, 02/16/23, 03/16/23, 04/20/23, 05/18/23, and 06/15/23 failed to show discussion related tracking, trending, and analysis of quality indicators and benchmarks. Review of the 01/19/23 minutes showed a quality report of "QI Tracking Forms" with currently 16 open tracking forms, all concerning Medication Reconciliation. May be further forms waiting to be written." Review of the 02/16/23 minutes showed "19 open tracking forms, mostly concerning Medication Reconciliation." Review of the 03/16/23 minutes showed, "21 open tracking forms, mostly concerning Medication Reconciliation."Review of the facility's annual governing body (GB) meeting minutes titled, "Joint Conference Committee," dated 06/29/22 indicated " ...H. Continuous Quality lmprovement (CQl) overview - work plans ... provided & reviewed the CQI lndicator Dashboard and Agenda item tracking reports."
During an interview on 09/21/23 at 4:00 PM with the Program Manager Quality Improvement (PMQI) and the Interim Hospital Administrator (IHA), the IHA revealed "since we don't have a Medical Director, we don't have that data." ...4. Documentation Monitoring - PMQI and IHA stated, "there is no data present," 5. Infection Control - community acquired (CA) and hospital acquired (HA) both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information ...7. Environment of Safety Monitoring - both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information, 8. Contracted Services Monitoring both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information 9. Morbidity and Mortality both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information, 10. Patient Rights Advocate Monitoring both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information 11.Incident Report trends both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis present. The PMQI and IHA were unable to provide any further evidence of quality benchmarks/indicators being tracked, trended, and analyzed by the facility.

During an interview on 09/21/23 at 1:15 PM, the PMQI was asked what the open tracking forms related to medication reconciliation meant. The PMQI stated, "When we have a discrepancy, we send out a QI tracking form to have the unit correct whatever the discrepancy is and in the case of open tracking forms it means the unit has not responded with a corrective action." The PMQI was asked what the problem was related to medication reconciliation and if it potentially involved narcotics discrepancies, the PMQI stated, "I don't know I wish the QI Coordinator was here." The PMQI was unable to provide any documentation related to tracking, trending, analysis, or process improvements associated with the identified problem related to medication reconciliation or evidence that a plan of correction had been completed according to the quality improvement tracking policy.

Review of the facility's policy titled, "Quality Improvement Tracking Process," revised on 03/28/22, indicated, "Procedure 1. When QI discover a situation or issue that warrants a response and/or corrective action a Quality lmprovement Tracking Form will be used to track the progress resolving thee concern ...l.3. Ql staff then emails the Ql Tracking Form to the Responsible Program Staff to complete the plan of action as written by Ql generally within 4 weeks of date of creation of Ql Tracking Form. 2. Program Staff will take actions to alleviate the issue identified in the Ql Tracking Form. 2.1. Program Staff will add applicable comments, attach applicable supporting evidence to show the required plan of action has been completed, sign and return completed Ql Tracking Form to Ql via email ...3. When the form is received back from Program Staff, the Ql Coordinator (QlC), or designee, will review the form and attached evidence to determine if the actions taken are acceptable ...3.1. lf the corrective actions are acceptable, the QlC will sign the Ql Tracking Form and forward to the Ql Analyst to log as completed ...3.2. lf the corrective actions are not acceptable or incomplete, the QlC, or designee, will return the form to the Responsible Program staff and indicate what additional or outstanding steps need to be taken. 4. lf the Ql Tracking Form is not returned by the due date, Ql staff will resend a reminder email to the responsible staff and CC the QIC. 4.1. lf the Ql Tracking Form is still not returned within ten business days of the reminder, Ql Analyst will email an additional reminder to the Program Staff and their immediate supervisor and will CC the QlC. 5. Ql will report on outstanding Ql Tracking Forms at CQI Meetings.

Based on the facility's "Continuous Quality Improvement Work Plan Fiscal Year 2023-2024 review, Joint Conference Committee for the facility's governing body minutes review, the facility's Continuous Quality Improvement Minutes review, the facility quality assessment process improvement (QAPI) program failed to set priorities for performance improvement activities that focused on high-risk, high-volume, or problem prone areas considering the incidence, prevalence, and severity of problem areas that affect health outcomes, patient safety, and quality of care. The facility failed to take actions aimed at performance improvement, implementation of actions, measurements of success to ensure improvements were sustained. This deficient practice had the potential to affect the quality and safety of care for all patients receiving services in the hospital.

Findings include:

During an interview on 09/21/23 at 4:00 PM with the Program Manager Quality Improvement (PMQI) and the Interim Hospital Administrator (IHA) regarding quality indicators, benchmarking, tracking, trending, and analysis of indicators, and review of a document titled, "Continuous Quality Improvement Work Plan Fiscal Year 2023-2024," and "Joint Conference Committee," dated 06/29/22 presented annually to the Governing Body (GB) was reviewed, along with the facility's Quality Committee minutes titled, "Continuous Quality Improvement Minutes" dated 1/19/23, 02/16/23, 03/16/23, 04/20/23, 05/18/23, and 06/15/23, the following indicators related to quality process improvement were presented to the GB and QAPI committee, "1. Peer Review - IHA stated "since we don't have a Medical Director, we don't have that data." ...4. Documentation Monitoring - PMQI and IHA stated, "there is no data present," 5. Infection Control - community acquired (CA) and hospital acquired (HA) both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information ...7. Environment of Safety Monitoring - both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information, 8. Contracted Services Monitoring both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information 9. Morbidity and Mortality both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information, 10. Patient Rights Advocate Monitoring both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information 11.Incident Report trends both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis present. The PMQI and IHA were unable to provide evidence of any other quality indicators that were being tracked, trended, and analyzed or that the QAPI program had set priorities for performance improvement activities that focused on high-risk, high-volume, or problem prone areas that affected health outcomes, patient safety, and quality of care and included measurements of success to ensure improvements were sustained.

Based on incident reports review, incident reporting policy review, and interview, the facility quality assessment process improvement (QAPI) program failed to measure, analyze, and track patient adverse incidents and events. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the facility's 2023 incident reports showed 16 reports that included categories such as left restraints on patient overnight, patient assaulted staff, patient reports pushed down by staff, patient AWOL (absent without official leave), MD (Medical Doctor) not responding to calls, and HIPPA (Health Insurance Portability and Accountability Act) violation. Review of the 2022 incident reports showed there had been 15 incident reports filed.

During an interview on 09/19/23 at 2:00 PM, the Interim Hospital Administrator (IHA) was asked if incident reports were being tracked, trended, and analyzed. The IHA stated, "we do not perform tracking, trending, and analysis of our incident reports on a regular basis." The IHA was asked if incidents were reported to the quality committee. The IHA stated, "let me think, no I do not have any evidence of tracking, trending and reporting to quality committee."

During an interview on 09/21/23 at 1:15 PM, the Program Manager Quality Improvement (PMQI) stated, "Currently we are not tracking, trending and analyzing incident reports by category." The PMQI was asked how he/she would know if you were having a problem or trend with any of the categories. The PMQI stated, "We are not trending that."

Review of the facility's policy titled, "Incident Reporting," no revision date, indicated, "Staff is required to report all incidents meeting specified criteria in accordance with procedures outlined below, insuring timely notification of incidents to all appropriate authority ...Definition(s) incident: an event or situation that occurs ...or which is concerning ...client or patient, that is unusual and meet the criteria specified below. The event may be a health and safety issue, a human rights issue, or a consumer emergency or any other issue that may invoke legal involvement ...For purposes of this policy, incidents are divided into two categories based on the nature and severity of the event. Examples of Level I and Level 2 are provided to assist staff in decision making concerning how and when to report an incident.

1. Level 1 Examples
1.1. Death of a client, patient, member of the public, or staff person on duty.
1.2. Serious or suspicious injury to client, patient, member of the public, or staff on duty.
1.3. Altercation between staff and client, patient, or member of the public, or between clients that
results in serious injury.
1.4. Tarasoff warning or other threat of a severe nature (e.g., death threat or bomb threat).
1.5. Environmental condition leading to temporary evacuation of a program facility.
1.6. Sexual assault or alleged sexual assault upon a client, patient, member of the public or staff
person on duty.
1.7. Medication error requiring immediate treatment or hospitalization.
2. Level 2 Examples
2.1. Vandalism, break-ins, damage to, or destruction of County property
2.2. Threats or other troubling communication to employees.
2.3. Theft of employee or client, patient, or member of the public.
2.4. Exposure to contagious disease or hazardous substance.
2. 5. Requests for assistance from law enforcement.
2. 6. Altercations resulting in minor or no injury.
2. 7. Minor medication errors or medication loss."

Based on the hospital's "Quality Improvement Minutes" review, the hospital's "Continuous Quality Improvement Work Plan Fiscal Year 2023-2024" review, and review of the "Joint Conference Committee" minutes review, document review, and interview, the facility quality assessment process improvement (QAPI) program failed to conduct and document an annual performance improvement project proportional to the scope and complexity of services and operations. This deficient practice had the potential to affect the quality and safety of all patients receiving services in the hospital.

Findings include:

During an interview on 09/21/23 at 4:00 PM with the Program Manager Quality Improvement (PMQI) and the Interim Hospital Administrator (IHA) regarding an annual performance improvement project proportional to the scope and complexity of services and operations the following documents were reviewed for the presence of an annual performance improvement project; "Continuous Quality Improvement Work Plan Fiscal Year 2023-2024," and "Joint Conference Committee," dated 06/29/22 presented annually to the Governing Body, along with the facility's Quality Committee minutes titled, "Continuous Quality Improvement Minutes" dated 1/19/23, 02/16/23, 03/16/23, 04/20/23, 05/18/23, and 06/15/23. During the interview the PMQI and IHA confirmed the documents reviewed did not contain evidence of an annual performance improvement project related to the scope and complexity of services and operations provided by the hospital. Both the PMQI and IHA confirmed the facility had not conducted an annual performance improvement project and was unable to provide documentation that one had been conducted.

Based on the facility's Quality Improvement Minutes review, review of the hospital's Continuous Quality Improvement Work Plan Fiscal Year 2023-2024, and Joint Conference Committee minutes review, Medical Staff Bylaws review, and interview, the facility's governing body (GB) failed to ensure the quality assessment process improvement (QAPI) program was ongoing, defined, implemented, set priorities for improvements, evaluated improvements, showed measurable improvements, and determined the number of distinct improvement projects to be conducted annually for quality improvement and patient safety. This deficient practice had the potential to affect the quality and safety of care provided to all patients receiving services in the hospital.

Findings include:

During an interview on 09/19/23 at 8:15 AM, the Interim Hospital Administrator (IHA) stated the GB meets annually and is called the Medical Executive Committee (MEC). The IHA stated the facility did not currently have a Medical Director and the facility did not have GB Bylaws, only MEC Bylaws. The IHA stated The MEC is currently responsible for the hospital's operations and QAPI oversight.

During an interview on 09/21/23 at 4:00 PM with the Program Manager Quality Improvement (PMQI) and the IHA regarding quality indicators, benchmarking, tracking, trending, and analysis of indicators, incident reports, and annual process improvement projects, a document titled, "Continuous Quality Improvement Work Plan Fiscal Year 2023-2024," and "Joint Conference Committee" minutes," dated 06/29/22 presented annually to the GB was reviewed, along with the facility's Quality Committee minutes titled, "Continuous Quality Improvement Minutes" dated 01/19/23, 02/16/23, 03/16/23, 04/20/23, 05/18/23, and 06/15/23 were reviewed. The following indicators related to quality process improvement were presented to the GB and quality committee, "1. Peer Review - IHA stated "since we don't have a Medical Director, we don't have that data." ...4. Documentation Monitoring - PMQI and IHA stated, "there is no data present," 5. Infection Control - community acquired (CA) and hospital acquired (HA) both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information ...7. Environment of Safety Monitoring - both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information, 8. Contracted Services Monitoring both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information 9. Morbidity and Mortality both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information, 10. Patient Rights Advocate Monitoring both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis of the information 11. Incident Report trends both the PMQI and IHA confirmed there were no goals, tracking, trending, or analysis present. The PMQI and IHA were unable to provide any further evidence of quality benchmarks/indicators being tracked, trended, and analyzed by the facility. The PMQI and IHA were also unable to provide evidence that incidents were being tracked, trended, and analyzed or that the facility had conducted an annual process improvement project based on the scope and complexity of the services the hospital provided.

Review of the facility's "Humboldt County Behavioral Health Bylaws Of Medical Staff," revised 03/09/22, approved by the GB 03/09/22, indicated on page 3 " ...Preamble ...WHEREAS, [Humboldt County Department of Health and Human Services - Behavioral Health] operates the county psychiatric health facility known as [Sempervirens] ...WHEREAS, it is recognized that the quality of medical care for [Humboldt County Behavioral Health] is vested with the Medical Staff and, as such, must accept and discharge this responsibility, subject to the authority of the Governing Body, and that the cooperative efforts of the Medical Staff, the Medical Director, and the Governing Body are necessary to fulfill the department's obligations to its patients. THEREFORE, the physicians practicing in the inpatient and outpatient mental health services hereby organize themselves into a Medical Staff, in conformity with these bylaws which have been approved by the Governing Body.

Based on medical staff bylaws/rules and regulations review, the hospital failed to ensure there was an organized medical staff that operated under bylaws approved by the governing body, and which was responsible for the quality of medical care provided to patients by the hospital. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

1. The hospital failed to have the responsibility for the organization and conduct of the medical staff assigned to one physician. (See findings in tag A0347)

2. The hospital failed to ensure the medical staff conducted appraisal of its members for two (Physician 1, Physician 2) of two physician credentialing files reviewed for reappointment to the medical staff. (See findings in tag A0340)

3. The hospital failed to ensure the medical staff bylaws were enforced related to physician orders being signed within 24 hours for two (Patient (P) 2, P3) of four patient records reviewed for signed physician orders and 47 medical records being completed by the physician within 30 days of discharge. (See findings in tag A0353)

4. The hospital failed to ensure the patient's history and physical examination (H&P) was conducted within 24 hours of admission as required by hospital policy for one (Patient (P) 3) of four patient records reviewed for the H&P. (See findings in tag A0358)

Based on credentialing file reviews, review of the medical staff bylaws, and interviews, the hospital failed to ensure the medical staff conducted appraisal of its members for two (Physicians (Phys)1 and Phys2) of two physician credentialing files reviewed for reappointment to the medical staff. This deficient practice had the potential to affect all patients receiving psychiatric services in the hospital.

Findings include:

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . At least every two (2) years, each member of the Medical Staff shall be provided with a reappointment application. Within thirty (30) days of due date, the completed forms shall be returned to the Medical Director's Executive Secretary. . . The reappointment application shall be processed in substantially the same manner and subject to the same conditions as for new applications. . . Applications for reappointment will be subject to approval of the Governing Body. . ." Review of the appointment process indicated ". . . Upon receipt of the completed application for membership, the Credentials Committee shall make a determination of acceptance for appointment after examining all evidence of the character, professional competence, qualifications. and ethical standards of the practitioner. . . At its next regular meeting, after receipt of the application and the report and recommendation of the credentials committee . . . the Executive committee shall determine whether to recommend to the Governing Body that the practitioner be appointed to the Medical Staff, be rejected for Medical Staff membership, or that application be deferred for further consideration. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may be qualified by probationary conditions relating to such clinical privileges. . . When the recommendation of the Executive Committee is favorable to the practitioner, the Medical Director shall submit this opinion to the Joint Conference Committee for final approval by the Governing Body . . . When the Governing Body's decision is final, it shall send notice of such decision to the Medical Director's administrative secretary, Behavioral Health Director, and Medical Director. The Medical Director will notify the practitioner of the decision. Following favorable decisions by the Governing Body, applicants shall be notified of their staff appointments by the Medical Director . . ."

Review of Phys1's "MD [medical doctor] Staff Credentialing Verification" indicated Phys1's appointment date was 07/21/21 with the next appointment of 07/21/23. Review of Phys1's "Request For [sic] Medical Staff Privileges" indicated Phys1's privileges were approved by the governing body on 09/13/21, after the date of the Board's approval on 07/21/21. There was no documentation of an application for reappointment completed by Phys1 since the expiration of Phys1's appointment on 07/21/23.

Review of Phys2's "MD [medical doctor] Staff Credentialing Verification" indicated Phys2 was approved by the Board on 06/29/22 with the next appointment date of 06/29/24. Review of Phys2's "Request For [sic] Medical Staff Privileges" indicated the chairman of the credentials committee approved the request on 04/08/22, and the chairman of the Executive Committee approved the request on 05/27/22. Review of Phys2's "Request For [sic] Medical Staff Privileges" indicated the governing body signed the request on 07/06/22, after the date of the Board's approval on 06/29/22.

During an interview on 09/21/23 at 10:42 AM, Interim Hospital Administrator (IHA) stated Phys1's reappointment credentialing process had been completed except for the governing body approval. IHA stated the governing body meeting wasn't scheduled until November. IHA confirmed Phys2's governing body approval of Phys2's privileges was signed after Phys2's approval date of 06/29/22.

Based on medical staff bylaws review and interview, the hospital failed to have the responsibility for the organization and conduct of the medical staff assigned to one physician. This deficient practice had the potential to affect all physicians providing psychiatric services at the hospital and all patients receiving psychiatric services in the hospital.

Findings include:

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . The officer of the Medical Staff shall be the Medical Director. . . The Medical Director shall: 1. Act in coordination and cooperation with the Behavioral Health Director in all matters of mutual concern within the department. 2. Call, preside over, and be responsible for the agenda of all general meetings of the Medical Staff. 3. Serve as Co-Chair of the Executive Committee 4. Be responsible for the enforcement of Medical Staff bylaws, rules and regulations, for implementation of sanctions where these are indicated, and for the Medical Staff's compliance with procedural safeguards in all instances where corrective action has been requested against a practitioner. 5. Represent the views, policies, needs and grievances of the Medical Staff to the Governing Body and the Behavioral Health Director. . . 9. Appoint members of all Medical Staff Committees in consultation with the Behavioral Health Director. . ." Further review indicated ". . . Vacancy in the office of Medical Director shall be filled by contract agreement. The Behavioral Health Director must approve the appointment of the Medical Director. . ."

During an interview on 09/20/23 at 1:35 PM, Interim Hospital Administrator (IHA) confirmed the hospital did not currently have a Medical Director. IHA stated there was no one physician responsible for the medical staff.

Based on medical staff bylaws/rules and regulations review, document reviews, and interviews, the hospital failed to ensure the medical staff bylaws were enforced related to physician orders being signed within 24 hours for two (Patient (P) 2, P3) of four patient records reviewed for signed physician orders and 47 medical records being completed by the physician within 30 days of discharge. This deficient practice had the potential to affect all patients receiving services in the hospital and all physicians providing services in the hospital.

Findings include:

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations 1. All orders for treatment shall be in writing or in Order Entry in the electronic medical record. An order shall be considered to be in writing if dictated to a licensed staff member and signed within 24 hours by the physician ordering the treatment or the next physician assuming care of the patient. Orders dictated over the telephone shall be signed by the licensed staff to whom it was dictated and shall be counter-signed within 24 hours and dated by the physician ordering the treatment or the next physician assuming care of the patient. . . The Medical Staff acknowledges the importance of timely completion of medical records and discharge summaries in providing quality patient care. The discharge summaries have to be completed within thirty (30) days of discharge and will be out of compliance after this date. Charting completions for patients discharged from [name of hospital] will be out of compliance if not done within thirty (30) days of discharge."

Continued review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . A corrective action investigation may be initiated whenever reliable information indicates that a Medical Staff member may have engaged in, made, or exhibited statements, demeanor, or professional conduct that is reasonably likely to be . . . contrary to Medical Staff Bylaws, rules or regulations . . . Within thirty (30) days after the Credentials Committee's receipt of the request for corrective action, the Credentials Committee shall make a report of its investigation to the Executive Committee. . . Within thirty (30) days of the receipt of a report from the Credentials Committee, following its investigation of a request for corrective action involving reduction or suspension of clinical privileges, or a suspension or expulsion from the Medical Staff, the affected practitioner shall be permitted to make an appearance before the Executive Committee prior to it taking action on such request at the next scheduled meeting. . ."

1. Review of P2's physician electronic medication orders, located under the "Physician's Orders" tab, indicated there were 60 physician electronic orders that were documented and had not been signed by the physician within 24 hours of the order being dictated.

Review of P3's physician electronic medication orders indicated there were 24 physician electronic orders that were documented and had not been signed by the physician within 24 hours of the order being dictated.

During an interview on 09/20/23 at 1:50 PM, Medical Records Manager (MRM) confirmed P2's and P3's computer-generated physician orders were not signed by the physician as of the date of review on 09/20/23 (P2's orders were documented as of admit on 09/08/23, and P3's orders were documented as of admit on 09/15/23). MRM stated the new computer system did not document times of staff/physician signatures.

During an interview on 09/20/23 at 3:20 PM with Physician (Phys) 1 and MRM present, Phys1 stated since introduction of the hospital's new computer system, there's been less than a smooth roll-out. MRM stated the person entering the physician order had to send the order to the physician to sign it. Phys1 stated he/she was aware the computer order had to be signed, but he/she wasn't getting the order to sign from the person entering it.

2. Review of the "Ward Clerk Correction Log All outstanding corrections 20230921," presented by MRM, indicated there were 47 medical records that had not been completed within 30 days of discharge, with the longest date being 10/26/21.

During an interview on 09/20/23 at 1:35 PM, MRM confirmed the 47 medical records were incomplete past the 30 days after discharge.

During an interview on 09/21/23 at 12:00 PM, Interim Hospital Administrator (IHA) stated they send emails to the contracted agency providing physicians to notify of outstanding medical records for each physician. IHA stated the hospital had not suspended any physician's privileges due to delinquent medical records.

Based on medical staff bylaws/rules and regulations review, medical record review, and interview, the hospital failed to ensure the patient's history and physical examination (H&P) was conducted within 24 hours of admission as required by hospital policy for one (Patient (P) 3) of four patient records reviewed for the H&P. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . Each patient admitted to [name of hospital] will have a medical history and physical examination completed and documented no more than thirty (30) days before or twenty-four (24) hours after admission. The medical history and physical examination must be completed and documented by a licensed physician or other qualified licensed nurse practitioner or physician assistant in accordance with State law and hospital policy. When the history and physical examination is conducted within thirty (30) days before admission, an update must be completed within twenty-four (24) hours of admission by a licensed practitioner who is credentialed and privileged by the hospital's Medical Staff
to perform history and physical examination. . ."

Review of P3's "1012-Client Information Form" located in the front of P3's medical record and not under a tab divider indicated P3 was admitted on 09/15/23. Review of P3's "203 l- Physical Examination," located under the "Consults" tab, indicated the H&P was conducted on 09/17/23, 48 hours after P3 was admitted.

During an interview on 09/20/23 at 1:35 PM, Medical Records Manager (MRM) confirmed P3's H&P was not performed within 24 hours of admission.

Based on medical record review, policy review, and interviews, the hospital failed to ensure medical record entries were dated, timed, and authenticated for four (Patient (P) 1, P2, P3, and P4) of four patient records reviewed for medical record entry authentication. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Nursing Documentation," revised 08/24/23, indicated ". . . Progress notes are to include: Date Time period covered (0730-1930; 1930-0000; 0001-0730) [7:30 AM - 7:30 PM; 7:30 PM - 12:00 AM; 12:01 AM - 7:30 AM]. . ." The policy did not address authentication and specific timing of each entry.

Review of the hospital policy titled "Electronic Signatures," reviewed 11/21/22, indicated authorized staff ". . . use electronic signatures to sign electronic records. At [name of hospital], the term "electronic signature" means the signing of a document done through pressing the "Submit" key to submit a document in the EHR [electronic health record]. . ." The policy did not address dating and timing of electronic signatures.

1.Review of P1's "2015 - Patient Rehabilitative Therapy Progress Note" (copied by Medical Records Manager [MRM]) dated 09/12/23, 09/13/23, 09/14/23, 09/15/23, 09/16/23, 09/17/23, and 09/18/23 indicated Licensed Clinical Social Worker (LCSW) did not date and time when he/she co-signed the notes.

Review of P1's "Notification of Patients Admission" located in the front of the medical record (no tab divider in place) indicated the staff did not time when signing the form on 09/12/23.

Review of P1's progress notes copied by MRM and documented by the psychiatrist, the nursing staff, the social worker, and the activity therapist indicated no progress note was timed when documented.

Review of P1's "Safety Agreement" located in the front of the medical record (no tab divider in place) indicated the staff did not time when signing the agreement on 09/12/23.

2. Review of P2's "2015 - Patient Rehabilitative Therapy Progress Note" (copied by Medical Records Manager [MRM]) dated 09/10/23, 09/11/23, 09/13/23, 09/14/23, 09/16/23 - 09/19/23 indicated Licensed Clinical Social Worker (LCSW) didn't date and time when he/she co-signed the notes.

Review of P2's progress notes copied by MRM and documented by the psychiatrist, the nursing staff, the social worker, and the activity therapist indicated no progress note was timed when documented.

3. Review of P3's "2015 - Patient Rehabilitative Therapy Progress Note" copied by MRM and dated 09/16/23 indicated LCSW didn't date and time when he/she co-signed the note.

Review of P3's "Safety Agreement" located in the front of the medical record (no tab divider in place) indicated the staff did not time when signing the agreement on 09/15/23.

Review of P3's "Notification of Patients Admission" located in the front of the medical record (no tab divider in place) indicated the staff did not time when signing the form on 09/15/23.

Review of P3's progress notes copied by MRM and documented by the psychiatrist, the nursing staff, the social worker, and the activity therapist indicated no progress note was timed when documented.

4. Review of P4's "2015 - Patient Rehabilitative Therapy Progress Note" (copied by Medical Records Manager [MRM]) dated 09/07/23 indicated Licensed Clinical Social Worker (LCSW) did not date and time when he/she co-signed the notes.

Review of P4's progress notes copied by MRM and documented by the psychiatrist, the nursing staff, the social worker, and the activity therapist indicated no progress note was timed when documented.

Review of P4's "Safety Agreement" located in front of the medical record (no tab divider in place) indicated the staff did not time, date, or sign agreement.

During an interview on 09/20/23 at 1:50 PM, MRM stated the new computer system doesn't print the time when signatures are electronically entered on medical record entries.

During an interview on 09/21/23 at 4:30 PM, Interim Hospital Administrator (IHA) offered no explanation for medical record entries not being dated and timed when staff sign medical record entries.


37588

Based on medical staff bylaws review, medical record reviews, and interviews, the hospital failed to ensure all physician orders were dated, timed, and authenticated in accordance with the federal regulations and within 24 hours in accordance with hospital policy for four (Patient (P) 1, P2, P3, and P4) patient records reviewed for authentication of physician orders. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations 1. All orders for treatment shall be in writing or in Order Entry in the electronic medical record. An order shall be considered to be in writing if dictated to a licensed staff member and signed within 24 hours by the physician ordering the treatment or the next physician assuming care of the patient. Orders dictated over the telephone shall be signed by the licensed staff to whom it was dictated and shall be counter-signed within 24 hours and dated by the physician ordering the treatment or the next physician assuming care of the patient. . ."

1. Review of P1's physician orders (copied by Medical Records Manager (MRM) dated 09/12/23, 09/15/23, and 9/16/23 indicated the physician did not time when he/she co-signed the orders.

2. Review of P2's computer-generated physician orders, located under the "Physician's Orders" tab, indicated there were 54 physician orders entered with no documentation of the date, time, and signature of the physician as of the review of the medical record on 09/18/23. P2 was admitted on 09/08/23.

3. Review of P3's computer-generated physician orders, located under the "Physician's Orders" tab, indicated there were 23 physician orders entered with no documentation of the date, time, and signature of the physician as of the review of the medical record on 09/18/23. P3 was admitted on 09/15/23.

4. Review of P4's physician orders (copied by Medical Records Manager [MRM]) dated 09/06/23, 09/07/23, 09/08/23, 09/09/23, and 09/13/23 indicated the physician did not time when he/she co-signed the orders.

During an interview on 09/20/23 at 1:50 PM, Medical Records Manager (MRM) confirmed P2's and P3's computer-generated physician orders were not signed by the physician as of the date of review on 09/20/23. MRM stated the new computer system did not document times of staff/physician signatures.

During an interview on 09/20/23 at 3:20 PM with Physician (Phys) 1 and MRM present, Phys1 stated since introduction of the hospital's new computer system, there has been less than a smooth roll-out. MRM stated the person entering the physician order had to send the order to the physician to sign it. Phys1 stated he/she was aware the computer order had to be signed, but he/she was not getting the order to sign from the person entering it.

Based on observation, "ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] Standard 170-2017 Ventilation of Health Care Facilities" review, policy review, and interview, the facility failed to ensure the medication storage area maintained a relative humidity (RH) of less than 60 percent (%). This deficient practice had the potential to affect all inpatient psychiatric patients receiving medications at the hospital.

Findings include:

During an observation and interview on 09/18/23 at 11:20 AM, while in the hospital's inpatient unit medication room, the Licensed Vocational Nurse (LVN) stated, "the humidity gets so high that when we try to open the Ativan (antianxiety medication) it just dissolves." The medication room was observed to have a portable air conditioning unit without humidity controls. The medication room was observed to have no exhaust or intake air vents that would supply air from a centrally controlled heating, ventilation, and air conditioning (HVAC) system for temperature and humidity regulation in the space. The LVN confirmed the temperature log for the medication room did not include monitoring of humidity.

During a telephone interview on 09/21/23 at 9:30 AM, the pharmacy consultant (PC) was asked if there were any humidity requirements for medication storage areas and stated, "Not off the top of my head but I have not studied any guideline requirements for medication storage." The PC was asked if he/she participated in the policy development for medication storage and stated, "They come up with the policies and I may look at them, but it's been awhile since I looked at the medication storage policy."

During a telephone interview on 09/21/23 at 11:30 AM, the Facilities Maintenance Manager (FMM) confirmed the facility did not have centralized air conditioning system with the ability to control humidity levels in the facility. The FMM stated, "whatever the outside humidity level is would be what the inside humidity level is. If it's raining, the inside humidity level would be 100%."

Review of the facility's policy titled, "Labeling and Storage of Drugs," revised 06/01/23, failed to indicate any relative humidity requirements for medication storage.

Review of "ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] Standard 170-2017 Ventilation of Health Care Facilities" table 7.1 located on page 5 indicated, "Medication Room ...Relative Humidity ...Less than 60%."

Based on policy review and interview, the hospital failed to ensure the specific organ, tissue, and eye procurement requirements were met. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

The hospital failed to have a written agreement with an Organ Procurement Organization (OPO). (See findings in tag A0886)

Based on policy review and interview, the hospital failed to have a written agreement with an Organ Procurement Organization (OPO). This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Organ and Tissue Donation," reviewed 08/01/23, indicated the hospital ". . . does not provide for nor assume responsibility for organ and tissue donation of patients. Patients who elect to participate in organ and tissue donation must do so fully independently of the hospital. . ."

The hospital did not have a written agreement with an OPO that addressed the criteria for referral, including the referral of all individuals whose death is imminent or who have died in the hospital, included the definition of "imminent death," included the a definition of "timely notification," addressed the OPO's responsibility to determine medical suitability for organ donation, specified how the tissue and/or eye bank will be notified about potential donors using notification protocols developed by the OPO in consultation with the hospital-designated tissue and eye bank, provided for notification of each individual death in a timely manner to the OPO (or designated third party) in accordance with the terms of the agreement, ensured that the designated requestor training program offered by the OPO had been developed in cooperation with the tissue bank and eye bank designated by the hospital, permitted the OPO, tissue bank, and eye bank access to the hospital's death record information according to a designated schedule, included that the hospital is not required to perform credentialing reviews for, or grant privileges to, members of organ recovery teams as long as the OPO sends only "qualified, trained individuals" to perform organ recovery, and the interventions the hospital will utilize to maintain potential organ donor patients so that the patient organs remain viable.

During an interview on 09/21/23 at 12:00 PM, Interim Hospital Administrator (IHA) stated the hospital did not arrange for eye, tissue, and organ donation.

Based on policy reviews, medical staff bylaws reviews, document reviews, medical record reviews, observations, and interviews, the hospital failed to meet the Conditions of Participation specified in§§482.1 through 482.23 and §§482.25 through 482.57. These deficient practices had the potential to affect all physicians and staff providing services in the hospital and all patients receiving services in the hospital.

Findings include:

1. The hospital failed to ensure there was an effective governing body that was legally responsible for the conduct of the hospital. (See findings in tag A0043)

2. The hospital failed to ensure patients were informed of their rights, patients participated in the development and implementation of the plan of care, the patient's representative were notified of admission including being informed of the patient's health status, being involved in care planning and treatment, and being able to request or refuse treatment, patients had the right to formulate advanced directives, and patients received care in a safe setting related to ligature risks, plastic garbage bags in patient care areas, and failed to ensure observation was maintained as ordered for one patient (Patient 3) ordered to be on 1:1 (one-on-one) line of sight (LOS) observation. (See findings in tag A0115)

3. The hospital failed to ensure an ongoing quality assessment process improvement (QAPI) program (1) was implemented and showed measurable improvement of indicators with quality outcomes; (2) set priorities for performance improvement activities that focused on high-risk, high-volume, or problem prone areas considering the incidence, prevalence, and severity of problem areas that affect health outcomes, patient safety, and quality of care; (3) included patient adverse incidents and events being tracked, trended and analyzed; (4) conducted annual performance improvement projects proportional to the scope and complexity of services and operations; (5) was accountable to the governing body (GB) for development, implementation, and maintenance of hospital-wide ongoing quality improvement and patient safety program that addressed setting priorities along with evaluations of improvement actions that showed measurable improvement with quality outcomes. (See findings in tag A0263)

4. The hospital failed to ensure there was an organized medical staff that operated under bylaws approved by the governing body, and which was responsible for the quality of medical care provided to patients by the hospital. (See findings in tag A0338)

5. The hospital failed to ensure the specific organ, tissue, and eye procurement requirements were met. (See findings in tag A0884)

Based on policy reviews, medical staff bylaws review, observations, document reviews, and interviews, the hospital failed to ensure the special medical record requirements for psychiatric hospitals were met for four (Patient (P) 1, P2, P3, and P4) of four patient records reviewed for special medical record requirements for psychiatric hospitals. These deficient practices had the potential to affect all patients receiving services in the hospital.

Findings include:

1. The hospital failed to ensure the psychiatric evaluation included the patient's medical history for two patients (P2 and P3) of four patient records reviewed for documentation of a medical history. (See findings in tag A1632)

2. The hospital failed to ensure the psychiatric evaluation included a record of the patient's mental status for three patients (P1, P2, and P4) of four patient records reviewed for documentation of mental status. (See findings in tag A1633)

3. The hospital failed to ensure the psychiatric evaluation included how intellectual function, memory function, and orientation were determined for two patients (P 2 and P3) of four patient records reviewed for documentation of memory function, intellectual function, and orientation. (See findings in tag A1636)

4. The hospital failed to ensure the psychiatric evaluation included an inventory of the patient's assets in descriptive terms for four patients (P1, P2, P3, and P4) of four patient records reviewed for documentation of patient assets. (See findings in tag A1637)

5. The hospital failed to ensure the patient had an individualized, comprehensive treatment plan based on an inventory of the patient's strengths and disabilities for four patients (P1, P2, P3, and P4) of four patient records reviewed for documentation of patient assets. (See findings in tag A1640)

6. The hospital failed to ensure the patient's treatment plan included short-term and long-range goals written as observable, measurable patient behaviors to be achieved for four patients (P1, P2, P3, and P4) of four patient records reviewed for documentation of goals in the patient's treatment plan. (See findings in tag A1642)

7. The hospital failed to ensure documentation of the therapeutic treatment received was appropriate to the needs and interests of patients and was directed toward restoring and maintaining optimal levels of physical and psychosocial functioning for four patients (P1, P2, P3, and P4) of four patient records reviewed for therapeutic activities. (See findings in tag A1650)

Based on policy review, medical staff bylaws review, medical record reviews, and interviews, the hospital failed to ensure the psychiatric evaluation included the patient's medical history for two (Patients (P) 2 and P3) of four patient records reviewed for documentation of a medical history. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Psychiatric Evaluations," reviewed 04/07/21, indicated ". . . The Medical staff serving [name of hospital] is responsible for the completion of the psychiatric
evaluations on all [name of hospital] patients. Psychiatric evaluations will be completed within sixty (60) hours of the patient's admission to [name of hospital] and will contain all of the elements on the ["name of hospital 1096 Assessment form. That form contains all the psychiatric
evaluation data required. . ." The policy did not address the specific topics to be included in the evaluation.

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . Psychiatric Evaluation shall be completed within twenty-four (24) hours of admission, utilizing the approved Psychiatric Evaluation format . . ." The bylaws did not address the specific topics to be included in the evaluation.

1.Review of P1's psychiatric evaluation titled, "IP Psychiatric Note" dated 09/13/23, found in P1's electronic medical record indicated, "Patient reports an extensive medical history but is unable to give me any details." There was no further medical history documented in P1's psychiatric note.

2. Review of P2's "IP [Inpatient] Psychiatric Note" documented by Physician (Phys) 2 on 09/09/23 and copied by Medical Records Manager (MRM) for review indicated Phys2 documented past medical history of "multiple previous hospitalizations." There was no documentation of P2's diagnoses of eating disorder, asthma, and diabetes as documented in the psychosocial assessment conducted on 09/10/23.

3. Review of P3's "IP Psychiatric Note" documented by Phys1 on 09/16/23 and copied by MRM for review indicated Phys1 documented past medical history as recent hospitalization at this hospital from 04/17/23 - 06/02/23. There was no diagnoses of P3's attention deficit hyperactive disorder, cannabis abuse, history of eye trauma, and inhalant abuse as documented in the psychosocial assessment conducted on 09/17/23.

During an interview on 09/20/23 at 3:20 PM, Phys1 confirmed the psychiatric eval did require the medical history of the patient to be documented in the evaluation.

4. Review of P4's psychiatric evaluation titled, "IP Psychiatric Note" dated 09/07/23, found in P4's electronic medical record revealed there was no documented medical history.

During an interview on 09/21/23 at 4:30 PM, the Interim Hospital Administrator (IHA) confirmed the above medical record findings.


37588

Based on policy review, medical record reviews, and interviews, the hospital failed to ensure the psychiatric evaluation included a record of the patient's mental status for one (Patient (P)2) of four patient records reviewed for documentation of mental status. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Psychiatric Evaluations," reviewed 04/07/21, indicated ". . . The Medical staff serving [name of hospital] is responsible for the completion of the psychiatric
evaluations on all [name of hospital] patients. Psychiatric evaluations will be completed within sixty (60) hours of the patient's admission to [name of hospital] and will contain all of the elements on the ["name of hospital 1096 Assessment form. That form contains all the psychiatric evaluation data required. . ." The policy did not address the specific topics to be included in the evaluation.

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . Psychiatric Evaluation shall be completed within twenty-four (24) hours of admission, utilizing the approved Psychiatric Evaluation format . . ." The bylaws did not address the specific topics to be included in the evaluation.

Review of P2's "IP [Inpatient] Psychiatric Note" documented by Physician (Phys) 2 on 09/09/23 and copied by Medical Records Manager (MRM) for review indicated Phys2 documented memory as "Not Assessed."

An interview was requested with Phys2, and the Interim Hospital Administrator (IHA) stated Phys2 was not working during the survey and was not available to be interviewed.

During an interview on 09/20/23 at 3:20 PM, Phys1 stated he/she records mental status related to how the patient looks when he/she walks in, the patient's appearance, and makes a subjective note of the patient's appearance upon arrival. Phys1 stated he/she could not comment on Phys2's psychiatric evaluation of P2.

Based on policy review, medical staff bylaws review, medical record reviews, and interviews, the hospital failed to ensure the psychiatric evaluation included how intellectual function, memory function, and orientation were determined for two (Patient (P) 2 and P3) of four patient records reviewed for documentation of memory function, intellectual function, and orientation. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Psychiatric Evaluations," reviewed 04/07/21, indicated ". . . The Medical staff serving [name of hospital] is responsible for the completion of the psychiatric
evaluations on all [name of hospital] patients. Psychiatric evaluations will be completed within sixty (60) hours of the patient's admission to [name of hospital] and will contain all of the elements on the ["name of hospital 1096 Assessment form. That form contains all the psychiatric
evaluation data required. . ." The policy did not address the specific topics to be included in the evaluation.

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . Psychiatric Evaluation shall be completed within twenty-four (24) hours of admission, utilizing the approved Psychiatric Evaluation format . . ." The bylaws did not address the specific topics to be included in the evaluation.

1. Review of P2's "IP [Inpatient] Psychiatric Note" documented by Physician (Phys) 2 on 09/09/23 and copied by Medical Records Manager (MRM) for review indicated Phys2 documented P2 was oriented to person, place, time, and situation; fund of knowledge was within normal limits for developmental level; insight and judgement were limited; and memory was not assessed. There was no documentation of the means used by Phys2 to determine the documented assessment of orientation, knowledge, insight, judgement, and memory.

2. Review of P3's "IP Psychiatric Note" documented by Phys1 on 09/16/23 and copied by MRM for review indicated Phys1 documented P3's attention span as poor concentration; oriented but disoriented to time; fund of knowledge within normal limits for developmental level; insight and judgement were poor; memory within normal limits with immediate, recent, and remote memory intact. There was no documentation of the means used by Phys1 to determine the documented assessment of orientation, knowledge, insight, judgement, and memory.

During an interview on 09/20/23 at 3:20 PM, Phys1 offered no explanation for not having documentation of the means he/she used to determine the documented assessment of orientation, knowledge, insight, judgement, and memory.

Based on policy review, medical staff bylaws review, medical record reviews, and interviews, the hospital failed to ensure the psychiatric evaluation included an inventory of the patient's assets in descriptive terms for four (Patient (P) 1, P2, P3, and P4) of four patient records reviewed for documentation of patient assets. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Psychiatric Evaluations," reviewed 04/07/21, indicated ". . . The Medical staff serving [name of hospital] is responsible for the completion of the psychiatric
evaluations on all [name of hospital] patients. Psychiatric evaluations will be completed within sixty (60) hours of the patient's admission to [name of hospital] and will contain all of the elements on the ["name of hospital 1096 Assessment form. That form contains all the psychiatric
evaluation data required. . ." The policy did not address the specific topics to be included in the evaluation.

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . Psychiatric Evaluation shall be completed within twenty-four (24) hours of admission, utilizing the approved Psychiatric Evaluation format . . ." The bylaws did not address the specific topics to be included in the evaluation.

1. Review of P1's psychiatric evaluation titled, "IP Psychiatric Note" dated 09/13/23, found in P1's electronic medical record (EMR) failed to show documentation of an inventory of P1's assets in descriptive terms.

2. Review of P2's "IP [Inpatient] Psychiatric Note" documented by Physician (Phys) 2 on 09/09/23 and copied by Medical Records Manager (MRM) for review indicated Phys2 did not document assets/strengths and disabilities on P2's psychiatric evaluation. There was no documentation of P2's assets/strengths and disabilities in descriptive terms.

3. Review of P3's "IP Psychiatric Note" documented by Phys1 on 09/16/23 and copied by MRM for review indicated Phys1 documented P3's asset/strength as "resiliency" and did not document disabilities/barriers. There was no documentation of P3's assets/strengths and disabilities in descriptive terms.

4. Review of P4's psychiatric evaluation titled, "IP Psychiatric Note" dated 09/07/23, found in P4's EMR failed to show documentation of an inventory of P4's assets in descriptive terms.

During an interview on 09/20/23 at 3:20 PM, Phys1 confirmed the psychiatric evaluation has to include an inventory of the patient's assets written in descriptive terms.


37588

Based on policy review, medical staff bylaws review, medical record reviews, and interviews, the hospital failed to ensure the patient had an individualized, comprehensive treatment plan based on an inventory of the patient's strengths and disabilities for four (Patient (P) 1, P2, P3, and P4) of four patient records reviewed for documentation of patient assets. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Treatment Planning," reviewed 07/15/20, indicated "Policy: Each patient must have an individualized, comprehensive Treatment Plan that must be based on an inventory of patient strengths and disabilities. . ."

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . The Master Interdisciplinary Treatment Plan shall be prepared within seventy-two (72) hours of admission to [name of hospital] and shall be signed and dated by the appropriate disciplines and shall be signed and dated by the patient and appropriate disciplines as outlined in policy . . ." The bylaws did not address the components of the treatment plan.

1. Review of P1's "Interdisciplinary Treatment Plan" dated 09/13/23, found in P1's electronic medical record (EMR) failed to show documentation that an inventory of P1's strengths and disabilities were assessed and used in the development of an individualized treatment plan for P1.

2. Review of P2's "Interdisciplinary Treatment Plan" documented on 09/08/23 and copied by Medical Records Manager (MRM) for review indicated there was no documentation of P2's assets/strengths and disabilities to be used in the development of an individualized treatment plan.

3. Review of P3's "Interdisciplinary Treatment Plan" documented on 09/18/23 and copied by MRM for review indicated P3's asset/strength was documented as "resiliency," and there was no documentation of disabilities. Review of P3's treatment plan indicated there was no documentation of P3's assets/strengths and disabilities to be used in the development of an individualized treatment plan.

4. Review of P4's "Interdisciplinary Treatment Plan" dated 09/07/23, found in P4's EMR failed to show documentation that an inventory of P4's strengths and disabilities were assessed and used in the development of an individualized treatment plan for P4.

During an interview on 09/18/23 at 2:50 PM, Licensed Clinical Social Worker (LCSW) stated the social worker should be documenting the patient's assets/strengths and weaknesses/disabilities on the treatment plan.

During an interview on 09/21/23 at 4:30 PM, the Interim Hospital Administrator (IHA) confirmed the above medical record findings.

.


37588

Based on policy review, medical staff bylaws review, medical record reviews, and interviews, the hospital failed to ensure the patient's treatment plan included short-term and long-range goals written as observable, measurable patient behaviors to be achieved for four (Patient (P) 1, P2, P3, and P4) of four patient records reviewed for documentation of goals in the patient's treatment plan. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Treatment Planning," reviewed 07/15/20, indicated ". . . Establishing Goals: Goals are statements that describe in behavioral terms what the patient will be able to do as a result of their hospitalization and treatment. Because they serve as outcome criteria, they must be measurable. Formulating measurable goals requires the use of objective, action verbs such as: attends, demonstrates, states, identifies, verbalizes [sic] and participates. 3.2.1 Short Term Goals: These are the expected outcomes that will be demonstrated or achieved by the patient in the earlier phase of care. Goals should reflect what a change in the actual behavioral problem which will assist the client to reduce or be free of the problem listed on the treatment plan, and are small steps to achieving the long-term goals. Target dates for short term [sic] goals must be indicated. If a short-term goal is not achieved within a reasonable time frame from the initial Target Date (48 hours), the Treatment Team needs to reassess the interventions being utilized to obtain such short term [sic] goals, and change or update the Treatment Plan accordingly. 3.2.2 Long Term Goals: refers to behaviors that should be achieved by the time of discharge and that constitute the criteria for discharge from the hospital. In formulating long-term goals, the Treatment Team needs to think in terms of what the patient will be saying, doing, or looking like at the time of discharge. . ."

Review of the "Bylaws of Medical Staff," approved by the governing body on 06/09/22, indicated ". . . Inpatient Medical Staff Rules and Regulations. . . The Master Interdisciplinary Treatment Plan shall be prepared within seventy-two (72) hours of admission to [name of hospital] and shall be signed and dated by the appropriate disciplines and shall be signed and dated by the patient and appropriate disciplines as outlined in policy . . ." The bylaws did not address the components of the treatment plan.

1. Review of P1's "Interdisciplinary Treatment Plan (ITP)" dated 09/13/23, found in P1's electronic medical record (EMR) revealed Problem #1: Delusional thinking regarding his/her housing and his/her current staff providers, while being unable to formulate a viable plan of care for [his/her] basic needs indicated, a long-term goal (LTG): Client will deny homicidal or suicidal intent; exhibit/endorse at least 50% increase in their ability to develop healthy cognitive patterns and beliefs about self and others, including [his/her] staff; and have a safe plan of care w/in [within] 24hrs of DC [discharge]. STG [Short Term Goal]: Client will not harm self or others; exhibit/endorse at least 25% increase in [his/her] ability to assess personal risk traits and resiliency traits, explore and resolve residual stress from this recent inpatient hospitalization and loss of [his/her] [son/daughter] (3/23), and learn to use medication and relaxation techniques; and have adequate sleep, nutrition, and hygiene w/in 48hrs of admit. Problem #2: Fall Risk due to patient's age over 60 years old. LTG: Fall Risk - Within 24 hours prior to discharge patient will not experience any falls or fall related injuries. STG: Fall Risk - Within 24 hours of problem start date, patient will verbalize at least one fall prevention precaution. Problem#3: Medical - GERD (Gastroesophageal reflux disease)." P1's Problem #1 LTG and STGs were unrelated to the problem listed and were not written as observable or measurable patient behaviors to be achieved. P1's Problem #2 LTG and STG were not written as observable or measurable behaviors. Problem#3 Medical - GERD (Gastroesophageal reflux disease)." P1's ITP failed to show a LTG or a STG for Problem #3.

2. Review of P2's "ITP" documented on 09/08/23 and copied by Medical Records Manager (MRM) for review indicated a goal was written as "Client will deny homicidal or suicidal intent; exhibit/endorse at least 50% [percent] increase in their ability to: address and create a viable plan of care, identify resources to utilize, and verbalize their wants and needs as ct [client] has presenting disorganized thought content; and have a safe plan of care w/in [within] 24hrs [hours] of DC [discharge]." A second goal documented indicated "Will cooperate with medication treatment within 48 hours of admission." The goals were not developed and written as observable, measurable patient behaviors to be achieved.

3. Review of P3's "ITP" documented on 09/18/23 and copied by MRM for review indicated goals were written as "Pt [patient] will exhibit at least 50% reduction in psychosis and have a safe and sensible plan of care for food, clothing and shelter w/in 24 hrs [hours] of discharge" and patient "will exhibit at least 25% reduction in psychosis, and have adequate sleep nutrition and hygiene w/in 72 hours of admit." A third goal documented indicated "Will cooperate with medication treatment within 48 hours of admission." The goals were not developed and written as observable, measurable patient behaviors to be achieved.

During an interview on 09/18/23 at 2:50 PM, Licensed Clinical Social Worker (LCSW) confirmed the goals documented in P2's and P3's treatment plans were not written as observable, measurable patient behaviors to be achieved.

4. Review of P4's "ITP" dated 09/07/23, found in P4's EMR indicated, Problem #1: Client began decompensating, failing to engage appropriately with [his/her] personal hygiene and activities of daily living creating unsafe and poor living conditions while endorsing religiously based delusions. LTG# 1: Client will deny homicidal or suicidal intent; exhibit/endorse at least 50% reduction of major symptoms of grave disability by participating in her activities of daily living (ADLS), affect identification and expression, including cognitive restructuring, and communication training denying perceptual disturbances and have a safe plan of care w/in 24hrs of DC (discharge). STG #1: Client will not harm self or others: exhibit/endorse at least 25% increase in [his/her] ability to identify potential side effects of [his/her] medication noncompliance and risk of nontreatment combined with recent polysubstance use, create a safety plan, distress tolerance, including overall mental health (denying delusions beliefs and involuntary perceptions); and have adequate sleep, nutrition, and hygiene w/in 48hrs of admit. P4's LTG and STG were not related to Problem #1 and were not written as observable or measurable behaviors.

During an interview on 09/21/23 at 4:30 PM, the Interim Hospital Administrator (IHA) confirmed the above medical record findings for P1 and P4.


25065

Based on medical record review, policy review, observations, and interviews, the hospital failed to ensure documentation of the therapeutic treatment received was appropriate to the needs and interests of patients and was directed toward restoring and maintaining optimal levels of physical and psychosocial functioning for two (Patient (P)2 and P3) of four patient records reviewed for therapeutic activities. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital policy titled "Rehabilitative Therapy," revised 07/27/23, indicated the program was designed ". . . to meet the needs and interests of patients on a short term, acute psychiatric unit and promotes the restoration and maintenance of optimal levels of each patient's physical and psychosocial functioning. Individual and specific treatment interventions to meet objectives of interdisciplinary treatment plans are developed on an ongoing basis by the multidisciplinary treatment team and implemented by multidisciplinary facility staff. . . Group participation is not mandatory and is highly encouraged, in order to encourage participation, the following procedures will be followed: . . . The Day room television will be turned off during scheduled group times. . . Patients who are unwilling, or unable, to join scheduled groups will be given safe activities to complete in their assigned rooms or common areas. . . This should be documented in the 2015-Patient Rehabilitative Therapy Progress Note. . ."

Review of the "2015 - Patient Rehabilitative Therapy Progress Note" indicated nine columns with the following titles above each column: time, name of group, staff signature, attendance, involvement, appearance, mood/affect/attitude, cognition/communication, co-occurring addressed.

1. Review of P2's "Interdisciplinary Treatment Plan," dated 09/08/23 and copied by Medical Records Manager (MRM), indicated P2's rehabilitative therapy interventions included "Due to the client's challenges with self-injurious thoughts and behaviors; they will be encouraged to attend the following groups including: coping skills: Meditation & [and] Mindfulness, Awareness of Triggers and Warning Signs, Social Skills Building, Communication, Self Esteem, Art, Exercise, Stretching, and Yoga. . ."

Review of P2's "2015 - Patient Rehabilitative Therapy Progress Note," copied by MRM for review, for 09/19/23 indicated P2 was in P2's room reading during the group scheduled from 3:00 PM to 4:00 PM and from 6:00 PM to 6:15 PM. There was no documentation that Activity Therapist (AT) 1 provided P2 with safe activities to complete in P2's room at these times.

Review of P2's "2015 - Patient Rehabilitative Therapy Progress Note" dated 09/18/23 indicated from 2:30 PM to 3:00 PM during the "Social Games" group, P2 was coloring, and from 6:00 PM to 6:15 PM during the "Meditation" group, P2 was in his/her room coloring.

Review of P2's "2015 - Patient Rehabilitative Therapy Progress Note" dated 09/13/23 indicated from 2:30 PM to 3:00 PM for the "Social Games" group, from 3:00 PM to 4:00 PM for the "Art & [and] Music group, and from 7:30 PM to 8:00 PM for the "Wrap Up group," P2 was asleep.

There was no documentation in P2's medical record that P2 was provided rehabilitative therapy interventions of coping skills that included meditation and mindfulness, awareness of triggers and warning signs, social skills building, and communication as stated in P2's "Interdisciplinary Treatment Plan."

There was no documentation in P2's medical record that nursing and social work groups had been provided.

2. Review of P3's "Interdisciplinary Treatment Plan," dated 09/15/23 and copied by MRM, indicated P3's rehabilitative therapy interventions included ". . . Due to the patient's challenges with psychosis; they will be encouraged to attend the following groups including: coping skills: Meditation & [and] Mindfulness, Awareness of Triggers and Warning Signs, Social Skills Building, Communication, Self Esteem, Art, Exercise, Stretching, and Yoga. . ."

Review of P3's "2015 - Patient Rehabilitative Therapy Progress Note" dated 09/16/23 indicated P3 did not participate in groups scheduled at 10:30 AM to 12:10 PM "Activities Group" (in room), from 2:30 PM to 3:00 PM "Social games" (in hall), and from 3:00 PM to 4:00 PM "Art & Music" (in room).

There was no documentation in P3's medical record that P3 was provided rehabilitative therapy interventions of coping skills that included meditation and mindfulness, awareness of triggers and warning signs, social skills building, communication, self esteem, art, and exercise as stated in P3's "Interdisciplinary Treatment Plan."

There was no documentation in P3's medical record that nursing and social work groups had been provided.

Observation on 09/19/23 on the patio of the inpatient psychiatric unit at 10:05 AM revealed Activity Therapist (AT) 1 seated with no patients present. AT1 was asked by the surveyor about the exercise group that was scheduled for 10:00 AM. AT1 stated two patients had come and left stating they were tired.

Observation in the day room of the inpatient psychiatric unit on 09/19/23 at 11:00 AM for the "coping skills" group revealed a patient was seated at a computer playing a computer game. Observation revealed a female patient was seated in front of the television watching a program. There was no observation of AT1 going to patient rooms to attempt to get patients to attend the coping skills group.

During an interview on 09/19/23 at 11:07 AM, AT1, when asked about the coping skills group that was to be conducted at 11:00 AM, AT1 stated "doing is coping." AT1 stated he/she tries to allow patients to do what they want to do in order to cope.

During an interview on 09/21/23 at 2:55 PM, Licensed Clinical Social Worker (LCSW) stated he/she was the direct supervisor of the activity therapists. LCSW stated there was typically a nursing group. When LCSW reviewed the schedule of groups in patient records, LCSW confirmed there were no scheduled nursing and social work groups. LCSW stated they had removed the social work groups while the LCSW was out, and when the interns were out, they had stopped doing social work groups. LCSW stated the activity therapist was supposed to go to each patient's room to wake them to attend the group. LCSW stated watching a television program and playing computer games would not be how he/she would structure a group on coping skills. LCSW stated AT1 allowed patients to be more fluid and allowed patients to do other activities.

Based on job description review and interview, the hospital failed to ensure a qualified therapeutic activity therapist and Clinical Director were available to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures, and engage in discharge planning. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

1. The hospital failed to ensure the hospital's clinical director met the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry. This deficient practice had the potential to affect all patients receiving services in the hospital. (See findings in tag A1692)

2. The hospital failed to have a clinical director who monitored and evaluated the quality and appropriateness of services and treatment provided by the medical staff. This deficient practice had the potential to affect all patients receiving services in the hospital. (See findings in tag A1693)

3. The hospital failed to ensure the therapeutic activity therapist was qualified in accordance with the hospital's job description for activity therapist for one (Activity Therapist 1) of one activity therapist job description reviewed. (See findings in tag A1726)

Based on job description review, document review, and interview, the hospital failed to ensure the hospital's clinical director met the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of documentation sent by Interim Hospital Administrator (IHA) on 09/25/23 indicated "[name of hospital] operates in accordance to our licensing body, California Department of Health Care Services as an Acute Psychiatric Hospital and a Psychiatric Health Facility which gives us the distinct title of "S-PHF." These statues are further defined in California Code of Regulations title 22 section, division 5, chapters 2 & 9. Under chapter 9 article 3, section 77061 it is permissible for the Hospital Administrator (Sr. Program Manager job classification) to also serve as the "Clinical Director". When [name of hospital] has a Medical Director that person is appointed by the Governing Body as the department's Medical Director and as the Clinical Director of [name of hospital]. Our department continues to actively recruit for a Medical
Director.

Review of the hospital's job description titled "Senior Program Manager - Mental Health (M&C)," opening date 02/01/23, indicated ". . . Some assignments may require an appropriate license to practice as a Licensed Clinical Social Worker, Marriage and Family Therapist, Licensed Clinical Psychologist, or Psychiatrist in the State of California. In addition, some assignments may require two years post licensure experience providing direct services in a mental health and/or drug and alcohol program. Desirable education and Experience: A typical way to obtain the knowledge and skills outlined above: Equivalent to possession of a Master's degree with major coursework in social services, counseling, psychology or other appropriate field and five years of experience, including supervisory and/or administrative experience in a mental health or human services program.

During an interview on 09/20/23 at 1:35 PM, IHA stated he/she was the Clinical Director of the hospital as well as the Administrator. IHA confirmed he/she was not a physician and did not have the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry.

Based on job description review, document review, and interview, the hospital failed to have a clinical director who met the qualifications as written in the federal regulations who monitored and evaluated the quality and appropriateness of services and treatment provided by the medical staff. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of documentation sent by Interim Hospital Administrator (IHA) on 09/25/23 indicated "[name of hospital] operates in accordance to our licensing body, California Department of Health Care Services as an Acute Psychiatric Hospital and a Psychiatric Health Facility which gives us the distinct title of "S-PHF". These statues are further defined in California Code of Regulations title 22 section, division 5, chapters 2 & 9. Under chapter 9 article 3, section 77061 it is permissible for the Hospital Administrator (Sr. Program Manager job classification) to also serve as the "Clinical Director". When [name of hospital] has a Medical Director that person is appointed by the Governing Body as the department's Medical Director and as the Clinical Director of [name of hospital]. Our department continues to actively recruit for a Medical
Director.

Review of the hospital's job description titled "Senior Program Manager - Mental Health (M&C)," opening date 02/01/23, indicated ". . . Some assignments may require an appropriate license to practice as a Licensed Clinical Social Worker, Marriage and Family Therapist, Licensed Clinical Psychologist, or Psychiatrist in the State of California. In addition, some assignments may require two years post licensure experience providing direct services in a mental health and/or drug and alcohol program. Desirable education and Experience: A typical way to obtain the knowledge and skills outlined above: Equivalent to possession of a Master's degree with major coursework in social services, counseling, psychology or other appropriate field and five years of experience, including supervisory and/or administrative experience in a mental health or human services program.

During an interview on 09/20/23 at 1:35 PM, IHA stated he/she was the Clinical Director of the hospital as well as the Administrator. IHA confirmed he/she was not a physician and did not have the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry. IHA confirmed there was no physician at the hospital with the responsibility of Clinical Director who monitored and evaluated the quality and appropriateness of services and treatment provided by the medical staff.

Based on review of job description, personnel file, and interview, the hospital failed to ensure the therapeutic activity therapist was qualified in accordance with the hospital's job description for activity therapist for one Activity Therapist (AT) 1 of one activity therapist job description reviewed. This deficient practice had the potential to affect all patients receiving services in the hospital.

Findings include:

Review of the hospital's job description titled "Activity Therapist," dated October 1995, indicated ". . . Desirable Education and Experience: . . . Equivalent to graduation from a four-year college or university with major coursework in activity therapy, leisure activities, recreation, psychology, sociology or related field and one year of experience providing activity therapy to patients in a mental health setting. Possession of a valid National Council of Therapeutic Recreation Certification and/or registration with California Parks and Recreation Certification Board."

Review of AT1s "Employment Application" indicated AT1 had a bachelor's degree in psychology. Review indicated AT1 had no prior experience as an activity therapist and did not have a valid National Council of Therapeutic Recreation Certification and/or registration with California Parks and Recreation Certification Board.

During an interview on 09/21/23 at 2:55 PM, Licensed Clinical Social Worker (LCSW) stated he/she was responsible for supervising the activity therapists. LCSW stated AT1 is not the senior activity therapist. LCSW stated that currently they do not have a certified or registered activity therapist. LCSW confirmed AT1 did not meet the qualifications of a qualified activity therapist as stated in the job description.