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Based on record review and interview, the facility failed to meet the Condition of Participation in Governing Body by failing to:

1. Ensure the medical staff actively address the COVID-19 crisis (COVID-19 is a highly contagious virus that affects the respiratory tract and is spread from person to person through coughing, sneezing, or talking. COVID-19 has spread worldwide) promptly, to provide adequate oversight and support for staff and patients. (Refer to A0049)

2. Ensure that the Quality Assurance and Program Improvement program reflects the complexity of the hospital's organization and services; involves all hospital departments and services and focuses on infection control related illness including but not limited to COVID-19. (Refer to A0263)

3. Ensure a safe and sanitary environment for 145 patients and all staff members who providing patient care. (Refer to A0747)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment to all 145 patients.

Based on interviews, and record review, the hospital Governing Body (GB) failed to ensure the medical staff provided adequate oversight of the hospital's response to the Coronavirus (COVID-19- a serious respiratory illness caused by virus and spread from person to person) pandemic (prevalent over the world), and actively participated in the mitigation (management) and prevention of COVID-19.

The deficient practice placed all 145 patients at the hospital and all staff members who provide patient care at risk to contact COVID 19 which can cause serious respiratory infection and possible death.

Finding:

On 7/28/20 at 8:40 a.m., a review of the GB Meeting Minutes, dated 7/13/20, with the assistance of the Chief Nursing Officer (CNO), Chief Operational Officer (COO), and Director of Risk Management (RM), revealed there was no mention of the COVID-19 virus, and confirmed by CNO, COO and RM.

A review of the following letters sent to all staff members from the Chief Executive Officer (CEO) included the following:

5/26/20: "Hospital staff practice appropriate hand hygiene and use of PPE, which include mask, gloves, and gowns ..." There was no indication of the type of mask the staff were required to wear that followed CDC and local health agency guidelines.

6/24/20: "Staff is required to wear masks on all patient care units, and when working in or walking through common areas ..." However, there was no specification regarding the type of mask to be worn. According to CDC guidelines, surgical face masks are to be worn by all direct care staff.

On 7/30/20 at 10:35 a.m., during an interview, the Medical Director, COO, and CNO stated staff should have implemented social distancing measures (placing chairs six feet apart during group meetings, marking the floors at six-foot intervals, adequate facial covering for direct care staff) sooner.

A review of the GB bylaws included the following stipulations under Section 11.8 Infection Control Function:
- Maintain surveillance of hospital infection control
- Develop and implement a preventive and corrective program designed to minimize infection hazards
-Supervise infection control in all phases of the hospital's activities

Based on record review and interview, the facility failed to meet the Condition for Coverage in Quality Assessment Performance Improvement (QAPI - an ongoing program the hospital develops, implements and maintains to improve patient outcomes and prevent medical errors) by failing to have an effective, program focusing on quality indicators, performance measures and/or problem prone areas in order to improve health outcomes during COVID-19 pandemic.

The facility failed to:

1. Ensure the QAPI program identified opportunities for improvement by setting priorities for performance improvement activities that focus on high-risk, high-volume or problem-prone areas. (Refer to A0283).

2. Ensure the QAPI program was ongoing with activities, that implemented preventive actions and mechanisms that included feedback and learning throughout the hospital, with the governing body and administrative officials, who are responsible and accountable for ensuring clear expectations for safety. (Refer to A0286).

3. Ensure the QAPI program reflected the facility's complex organization and services for their unique patients and involved all the departments and services. (Refer to A0308).

4. Ensure the governing body, medical staff, and administrative officials, who are responsible and accountable for the operations of the hospital, have a QAPI program to ensure patient safety. (Refer to A0309).

Based on record review and interview, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI - an ongoing program the hospital develops, implements and maintains to improve patient outcomes and prevent medical errors) program identified opportunities for improvement by setting goals and activities that focus on high-risk, high-volume and/or problem-prone areas.

This deficient practice had the potential for transmission of the corona virus disease among patients and staff members.

Findings:

On July 28, 2020 at 1:44 p.m., during record review of facility's 2020 QAPI program minutes, indicated no documentation of infection control projects for COVID-19.

On July 29, 2020 at 7:30 a.m., during interview with associate medical director, (MD) 2, MD 2 stated it is difficult to enforce social distancing and the use of face masks among their patient population.

On July 29, 2020 at 1:14 p.m., during concurrent interview with Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Director of Risk Management (DRM), and record review of facility's QAPI meeting minutes for 2020, DRM stated there was no documentation of infection control projects or activities for COVID-19.

A review of QAPI minutes - Performance Improvement (PI) Projects, dated January 21, 2020, February 25, 2020, March 31, 2020, May 26, 2020, and June 16, 2020, indicated: scissors clean, observation room clean, no corrugated boxes.

A review of QAPI minutes - Approval of Previous Minutes, dated May 26, 2020, indicated, no meeting was held in April 2020, due to COVID restrictions.

A review of Bylaws - Performance Improvement Committee, dated March 19, 2020, indicated the following, which included:
1. the Performance Improvement (PI) committee shall be a standing committee of the medical staff and shall consist of two members of the medical/allied health professional staff.
2. The PI committee shall meet not less than quarterly and special meetings can be called by the chairman, as required.
3. The committee shall recommend action for problem resolution to the Medical Executive Committee.
4. The committee is responsible for overseeing the continuous PI program.
5. Interventions to monitor and evaluate information regarding aspects of patient care and performance of important functions related to patient care, is subject to the approval by the governing board.
6. The PI committee determines the process or projects and provides resources/training for the projects.

Based on record review and interview, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program, with approval from the governing body, implemented preventive actions and had mechanisms in place for patient safety, to prevent the transmission of communicable diseases and infections, including the corona virus disease.

This deficient practice had the potential for the spread of the corona virus disease (COVID-19) among patients and staff members.

Findings:

On July 28, 2020 at 1:44 p.m., during record review of facility's 2020 QAPI program minutes, indicated no documentation of infection control projects to prevent the spread of COVID-19.

On July 29, 2020 at 1:14 p.m.,, during concurrent interview with Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Director of Risk Management (DRM), and record review of facility's QAPI meeting minutes for 2020, DRM stated there was no documentation of infection control projects or activities for COVID-19.

A review of QAPI minutes, dated January 21, 2020, February 25, 2020, March 31, 2020, May 26, 2020, and June 16, 2020, indicated the presentation of department Performance Improvement (PI) Projects, which included: scissors clean, observation room clean, no corrugated boxes.

A review of QAPI minutes, dated May 26, 2020, indicated under Approval of Previous Minutes, no meeting was held in April due to COVID-19 restrictions.

A review of Bylaws policy - Performance Improvement Committee, dated March 19, 2020, indicated the following, which included:
1. The Performance Improvement (PI) committee shall be a standing committee of the medical staff and shall consist of two members of the medical/allied health professional staff.
2. The PI committee shall meet not less than quarterly and special meetings can be called by the chairman, as required.
3. The committee shall recommend action for problem resolution to the Medical Executive Committee.
4. The committee is responsible for overseeing the continuous PI program.
5. Interventions to monitor and evaluate information regarding aspects of patient care and performance of important functions related to patient care, is subject to the approval by the governing board.
6. The PI committee determines the process or projects and provides resources/training for the projects.

Based on record review and interview, the facility's governing body (a body of officers having ultimate control) failed to ensure the QAPI program reflected the facility's complex organization and its services for their unique patients, which involved all the departments and services.

This deficient practice had the potential for the spread of corona virus disease (COVID-19) among patients and staff.

Findings:

On July 28, 2020 at 1:44 p.m., during record review of facility's 2020 Quality Assessment and Performance Improvement (QAPI - an ongoing program that the hospital develops, implements and maintains to improve patient outcomes and prevent medical errors) program's meeting minutes, indicated no documentation of infection control projects for COVID-19.

On July 29, 2020 at 7:30 a.m., during interview with associate medical director, (MD) 2, MD stated it is difficult to enforce social distancing and the appropriate use of face masks among their patient population.

On July 29, 2020 at 8:11 a.m., during interview with Infection Preventionist (IP), IP stated the governing body has not approved the policies and procedures for the infection control manual for 2020 because "COVID happened" and delayed the process.

On July 29, 2020 at 1:14 p.m.,, during concurrent interview with Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Director of Risk Management (DRM), and record review of facility's QAPI meeting minutes for 2020, DRM stated there was no documentation of infection control projects or activities for COVID-19.

A review of QAPI minutes, dated January 21, 2020, February 25, 2020, March 31, 2020, May 26, 2020, and June 16, 2020, indicated the presentation of department Performance Improvement (PI) Projects, which included: scissors clean, observation room clean, no corrugated boxes.

A review of QAPI minutes, dated May 26, 2020, indicated under Approval of Previous Minutes, no meeting was held in April due to COVID-19 restrictions.

A review of Bylaws - Performance Improvement Committee, dated March 19, 2020, indicated the following, which included:
1. The Performance Improvement (PI) committee shall be a standing committee of the medical staff and shall consist of two members of the medical/allied health professional staff.
2. The PI committee shall meet not less than quarterly and special meetings can be called by the chairman, as required.
3. The committee shall recommend action for problem resolution to the Medical Executive Committee.
4. The committee is responsible for overseeing the continuous PI program.
5. Interventions to monitor and evaluate information regarding aspects of patient care and performance of important functions related to patient care, is subject to the approval by the governing board.
6. The PI committee determines the process or projects and provides resources/training for the projects.

Based on record review and interview, the facility's governing body failed to ensure the QAPI program had interventions for patient safety, to prevent the spread of communicable diseases and infections.

This deficient practice had the potential for the transmission of corona virus disease (COVID-19) among patients and staff members.

Findings:

On July 28, 2020 at 1:44 p.m., during record review of facility's 2020 Quality Assessment and Performance Improvement (QAPI - an ongoing program the hospital develops, implements and maintains to improve patient outcomes and prevent medical errors) program's meeting minutes, indicated there was no documentation of infection control projects for COVID-19.

On July 29, 2020 at 7:30 a.m., during interview with associate medical director, (MD) 2, MD 2 stated it is difficult to enforce social distancing and the appropriate use of face masks among their patient population.

On July 29, 2020 at 8:11 a.m., during interview with Infection Preventionist (IP), IP stated the governing body has not approved the policies and procedures for the infection control manual for 2020 because "COVID happened" and delayed the process.

On July 29, 2020 at 1:14 p.m.,, during concurrent interview with Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Director of Risk Management (DRM), and record review of facility's QAPI meeting minutes for 2020, DRM stated there was no documentation of infection control projects or activities for COVID-19.

A review of QAPI minutes, dated January 21, 2020, February 25, 2020, March 31, 2020, May 26, 2020, and June 16, 2020, indicated the presentation of department Performance Improvement (PI) Projects, which included: scissors clean, observation room clean, no corrugated boxes.

A review of QAPI minutes, dated May 26, 2020, indicated under Approval of Previous Minutes, no meeting was held in April due to COVID restrictions.

A review of Bylaws - Performance Improvement Committee, dated March 19, 2020, indicated the following, which included:
1. The Performance Improvement (PI) committee shall be a standing committee of the medical staff and shall consist of two members of the medical/allied health professional staff.
2. The PI committee shall meet not less than quarterly and special meetings can be called by the chairman, as required.
3. The committee shall recommend action for problem resolution to the Medical Executive Committee.
4. The committee is responsible for overseeing the continuous PI program.
5. Interventions to monitor and evaluate information regarding aspects of patient care and performance of important functions related to patient care, is subject to the approval by the governing board.
6. The PI committee determines the process or projects and provides resources/training for the projects.

Based on interview and record review, the facility failed to ensure nursing staff developed the patient care plan/treatment plan for eight of nine sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, and 9) that identify patients at risk to contacting Coronavirus (COVID-19, serious respiratory illness caused by virus and spread from person to person), the goal, and the intervention to be provided to the patients to prevent the transmission of COVID- 19.

This deficient practice placed the patients at risk to COVID-19, which could cause serious respiratory illness and possible death.

Findings:

a. A review of Master Treatment Plan (a plan developed to provide care) fro Patient 1, 2, and 3 failed to address COVID-19 precautions.

On 7/30/20 at 9:340 a.m., during an interview, the Chief Operating Officer (COO) acknowledged there should be a plan of care that addressed COVID-19 for each patient.

A review of the facility policy, titled "Master Treatment Plan (MTP), " revised 12/19, included the following:
Provide a complete, individualized plan of care based on an assessment of the patient's specific needs.
Formulate a plan of care that meets the patient's objectives and needs.





38310

b. A review of Patient 5's record titled, "Master Treatment Plan" dated 5/6/20 to 7/6/20, failed to address COVID-19 precautions.

c. A review of Patient 6's record titled, "Master Treatment Plan" dated 7/14/20 and 7/15/20, failed to address COVID-19 precautions.

d. A review of Patient 7's record titled, "Master Treatment Plan" dated 7/22/20, failed to address COVID-19 precautions.

e. A review of Patient 8's record titled, "Master Treatment Plan" dated 7/25/20, failed to address COVID-19 precautions.

f. A review of Patient 9's record titled, "Master Treatment Plan" dated 7/1/20 to 7/12/20, failed to address COVID-19 precautions.

Based on observation, interview, and record review, the hospital failed to provide a sanitary dietary environment. This failure had the potential to result in food contamination.

Findings:

On 7/29/20 at 11:05 a.m., during a tour of the Dietary Department with the assistance of the Dietary Director and Plant Manager, there were areas of chipped enamel paint observed on the lower portion of the food preparation table and the cafeteria serving station. During a concurrent interview, the Dietary Director and Plant Manager stated the surfaces could potentially cause flaking paint particles to get into the food.

A review of the facility policy, titled, "Nutritional Services Department Safety," revised 10/1/19, indicated all chipped enamelware shall be discarded in favor of stainless steel or other non-chip pots and pans.

Based on record review and interview, the facility failed to meet the Condition of Participation in Infection Control Program to ensure a safe and sanitary environment for 145 patients and all staff members who providing patient care, by failing to:

1. Ensure staff members wore surgical facemask and patients wore face covering to prevent contacting of Coronavirus (COVID-19, serious respiratory illness caused by virus and spread from person to person). (Refer to A770)

2. Ensure staff and patients were practicing social distancing at all times, to prevent potential cross-contamination. (Refer to A770)

3. Update the policy, "COVID-19 Transmission Prevention," promptly. (Refer to A770)

4. Ensure the governing body monitored the implementation of infection control activities to prevent the transmission of infectious diseases, including the Coronavirus. (Refer to A 770)

5. Ensure the Infection Preventionist (experts on practical methods of preventing and controlling the spread of infectious diseases) communicated and collaborated with the QAPI program on infection prevention and control issues, related to the Coronavirus disease. (Refer to A 774)

The cumulative effect of these deficient practices resulted in the hospital's inability to provide quality care in a safe environment to all 145 patients.


38310

Based on observation, interview and record review, the hospital failed to meet the Condition of Participation in Infection Control by failing to:

1. Ensure that the governing body monitored the implementation of infection control activities to prevent the transmission of communicable diseases, including the corona virus disease. (Refer to A770)

2. Ensure the infection preventionist communicated and collaborated with the the QAPI program on infection prevention and control issues, related to the corona virus disease. (Refer to A774)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality health care in a safe and sanitary environment.

Based on record review and interview, the hospital failed to ensure the governing body monitored the implementation of infection control activities to prevent the transmission of communicable diseases, including the corona virus disease.

This deficient practice had the potential for the spread of the corona virus disease among patients and staff members.

Findings:

On July 28, 2020 at 11:02 a.m. to 11:56 a.m., during initial tour of the facility with Chief Operating Officer (COO) and Chief Nursing Officer (CNO), Registered Nurse (RN) 1 was observed wearing a cloth mask in the patient care area and patients were observed, in group meetings sitting, standing and walking less than six feet apart from each other and staff members, without face coverings.

Concurrently, during the tour, the CNO and Registered Nurse (RN) 1 were observed wearing cloth face coverings in patient care areas.

Concurrently, COO stated it was difficult for the staff to keep the patients six feet apart from each other in the facility because of their psychological problems, including anxiety.

On July 29, 2020 at 7:30 a.m., during interview with associate medical director, (MD) 2, MD stated it is difficult to enforce social distancing and the appropriate use of face masks among their patient population.

On July 29, 2020 at 7:40 a.m., during tour of the facility with the COO, two staff members, Registered Nurse (RN) 2 and Psychiatric Technician (PT), were observed standing less than six feet apart from each other during the passing of medications for 8:00 a.m.

Concurrently, the COO stated that RN 2 and PT should have been spaced further apart from each other during the passing of medications.

On July 29, 2020 at 8:11 a.m., during interview with Infection Preventionist (IP), IP stated the governing body has not approved the policies and procedures for the infection control manual for 2020 because "COVID happened and delayed the process."

A review of Emergency Management for Corona Virus policy, dated July 2020, indicated the following, which included:
1. Closed access to all visitors, unless medical or psychiatric emergency arises with the patient.
2. All employees and medical staff will be screened for COVID-19 prior to the start of their shift.
3. All staff members will be given a surgical mask to wear upon entry to the facility.
4. All patients on the units will be instructed in social distancing.
5. All staff will wear a surgical or N-95 mask on the clinical units.
6. Patients without symptoms of COVID-19, will continue treatment by attending group meetings with patients at least 6 feet apart from each other.
7. Group meetings will have 10 people maximum, including therapist or counselor, with patients sitting with chairs in between and at least 6 feet apart.
8. Employees are encouraged to practice social distancing by maintaining distance of 6 feet apart from others.

Based on record review and interview, the facility failed to ensure the infection preventionist communicated and collaborated with the the QAPI program on infection prevention and control issues, related to the corona virus disease (COVID-19).

This deficient practice had the potential for spread of COVID-19 among patients and staff members.

Findings:

On July 28, 2020 at 1:44 p.m., during record review of facility's 2020 Quality Assessment and Performance Improvement (QAPI - an ongoing program the hospital develops, implements and maintains to improve patient outcomes and prevent medical errors) program, there was no documentation of infection control projects for COVID-19.

On July 29, 2020 at 7:30 a.m., during interview with associate medical director, (MD) 2, MD stated it is difficult to enforce social distancing and the appropriate use of face masks among their patient population.

On July 29, 2020 at 8:11 a.m., during interview with Infection Preventionist (IP), IP stated the governing body has not approved the policies and procedures for the infection control manual for 2020 until July, because "COVID happened and delayed the process."

On July 29, 2020 at 1:14 p.m.,, during concurrent interview with Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Director of Risk Management (DRM), and record review of facility's QAPI meeting minutes for 2020, DRM stated there was no documentation of infection control projects or activities for COVID-19.

A review of QAPI minutes, dated January 21, 2020, February 25, 2020, March 31, 2020, May 26, 2020, and June 16, 2020, indicated the presentation of department Performance Improvement (PI) Projects, which included: scissors clean, observation room clean, no corrugated boxes.

A review of QAPI minutes, dated May 26, 2020, indicated under Approval of Previous Minutes, no meeting was held in April due to COVID restrictions.

A review of Bylaws - Performance Improvement Committee, dated March 19, 2020, indicated the following, which included:
1. The Performance Improvement (PI) committee shall be a standing committee of the medical staff and shall consist of two members of the medical/allied health professional staff.
2. The PI committee shall meet not less than quarterly and special meetings can be called by the chairman, as required.
3. The committee shall recommend action for problem resolution to the Medical Executive Committee.
4. The committee is responsible for overseeing the continuous PI program.
5. Interventions to monitor and evaluate information regarding aspects of patient care and performance of important functions related to patient care, is subject to the approval by the governing board.
6. The PI committee determines the process or projects and provides resources/training for the projects.