HospitalInspections.org

1. The Chief Executive Officer failed to establish clear lines of responsibility and accountability, develop effective communication mechanisms among departments, implement an effective mechanism for responding to complaints concerning patient care, and ensure appropriate training for staff related to the referral of organ and tissue donors. Refer to A0057

2. The Governing Body failed to ensure the facility had effective processes in place to determine the quality of care provided to patients by the medical staff.
Refer to A0049

Based on document review and staff interview, it was determined the Governing Body failed to ensure the facility had effective processes in place to determine the quality of care provided to patients by the medical staff.

Findings included:

The Executive Assistant to the CEO (Chief Executive Officer) was interviewed regarding the professional evaluation process for physicians and allied health professionals in an interview conducted on 11/8/19 at 9:45 am. The Executive Assistant stated there was no focused professional practice evaluation (FPPE) or ongoing professional practice evaluation (OPPE) process in place for the evaluation of the quality of care provided by the medical staff prior to June 2019 when "corporate" assigned the Executive Assistant to implement a program. The Executive Assistant stated she had no previous experience or training in developing and implementing a professional quality review program. She indicated she independently researched information on the process and reached out to a former colleague from a former behavioral health facility employer for guidance. The Executive Assistant indicated the FPPE and OPPE process is coordinated by herself and the Director of Medical Records, and the Medical Director conducts the reviews on all members of the medical staff. In response to questions, the Executive Assistant indicated there was no defined criteria for how the records were selected for review by the Medical Director. The Medical Assistant indicated Risk Management/Quality Improvement was not involved in the FPPE/OPPE process. The FPPE sample size was 5 records selected from admissions occurring during the first three months a newly privileged physician was on staff, and thereafter one record per month for each medical staff member regardless of the volume of patients seen. The records were selected at random by the Director of Medical Records, who delivered them to the Executive Assistant.

An interview with the Director of Health Information Management (HIM) was conducted on 11/8/19 at 12:25 PM. In response to questions, the Director indicated she generally selected the medical records for review by the Medical Director at random, trying to find as complete a chart as possible. She indicated she was required to select 5 records per physician for those on FPPE, and then she randomly selected 3 records per quarter for each physician for OPPE. The Director indicated she would include "red dot" charts in the sample if there were any during that quarter. She explained the Risk Manager would inform her if a patient was involved in a Level 1 or Level 2 event (The Joint Commission sentinel event classification). That patient's medical record would be marked with a red dot. In response to questions regarding who conducts reviews of the Medical Director's records, the Director of HIM responded that she "just gave them to another psychiatrist to review".

The review of the list of the active members of the Medical Staff revealed there were four psychiatrists and two family medicine physicians. The list of active members of the Allied Health Staff showed one general medicine nurse practitioner and three psychiatric nurse practitioners.

The Executive Assistant explained that all psychiatrists and psychiatric nurse practitioners on the active staff rosters are members of the same psychiatric medical group as the Medical Director, which was contracted to provide professional psychiatric services to the facility patients. The review of the Medical Director's credentialing file revealed the Medical Director is a Board Certified psychiatrist. The review of the evaluations of the Internal Medicine and Family Practice physicians on staff revealed the Medical Director conducted their OPPE reviews as well.

In an interview conducted with the Chief Executive Officer (CEO) and the Medical Director on 11/7/19 at 11:30 am, the CEO and the Medical Director confirmed there was no defined process in place for the review of the Medical Director's performance to ensure the quality of care he provided to patients. At the time of the interview, they indicated they would probably request review by another physician member of the Medical Director's practice.

Based on document review and staff interview it was determined the Governing Body failed to ensure the person appointed to be the Chief Executive Officer on 11/16/18 met the minimum qualifications of the position as defined in the job description, maintained the facility in compliance with regulatory requirements, and managed the facility in a manner that ensured clearly delineated lines of responsibility and accountability, effective communications between departments, staff were appropriately trained, and effective methods of evaluating the quality of care and services provided to patients.

Findings included:

1. The Chief Executive Officer Job Description dated 10/17/2018 included a list of Education/Experience/Skill Requirements. The list indicated the requirements for the position were:
-Bachelor of Arts degree in Business Administration, Healthcare Administration, Public Health, Marketing, or a clinical discipline; Masters degree in Business Administration or Healthcare Administration preferred
-Minimum of 3-5 years' experience in a senior leadership/CEO role in a behavioral health, acute care, and/or managed care environment
-Proven ability to lead successful licensure, accreditation, and compliance efforts in a behavioral health facility
-Demonstrates thorough knowledge of facility administration and clinical operations.

The facility failed to respond to a request to provide a copy of the CEO's application for the position. The executive assistant indicated the reason was the application was electronic, not paper.

A request to provide a copy of the Governing Body Meeting minutes documenting the Governing Body appointment of the Chief Executive Officer (CEO) resulted in receiving a document written on facility letterhead paper addressed, "To Whom It May Concern" and dated November 16, 2018. The document indicated the Governing Body unanimously approved the appointment of the (named) Chief Executive Officer at an Ad-hoc Governing Board Meeting on November 16, 2018. The document was signed by the appointed CEO and the Director of Clinical Services [of the parent corporation]). The document was notarized.

A request to provide the Governing Body Meeting minutes for the previous 12 months resulted in receiving a binder containing meeting minutes. The binder included minutes titled North Tampa Behavioral Health Board of Governors Meeting Minutes, Ad-Hoc Governing Board Meeting dated November 16, 2018. The minutes indicated the Chairman of the Board (Division President) was present by telephone,a Board Member (Director of Clinical Services[of the parent corporation]), and the person hired to fill the CEO position were in attendance. The minutes indicated the Board Member motioned to remove the previous CEO from the position of CEO and as a Governing Board Member. The Chairman seconded the motion. The Board Member motioned to appoint the applicant for the CEO position, who was in attendance, as the CEO and member of the Governing Board. The Chairman seconded the motion.

The untitled, undated document included in the file listed the CEO's name, address and email address at the top, and appeared to be a resume. The document indicated the CEO had a Bachelor of Science degree in Communications. The document listed the CEO's previous employment and experience as an Employee Benefits Consultant for an insurance company, a Vice President of Sales for a trucking company, and a quarterback for a professional football practice team. There was no evidence the Chief Executive Officer appointed by the Board of Governors on 11/16/19 met the education or experience requirements defined in the position description.

The Chief Executive Officer confirmed the finding he was appointed by the Governing Board despite not meeting the minimum requirements for the position as defined by the job description, in an interview conducted on 11/8/19 at 11:15 am.

2. The review of data maintained on the Florida Healthfinder website (https://www.floridahealthfinder.gov) for the 12 month period beginning November 1, 2018 through October 31, 2019 revealed the facility had incurred 31 violations of State regulations identified during 6 separate surveys conducted on 11/1/18, 12/18/18, 2/4/19, 3/20/19, 5/23/19, and 9/13/19.

Violations of state regulations related to maintenance of the facility (BB091) was cited in the survey ending on 12/18/18, on the survey ending 3/30/19, and was cited again on the current survey ending 11/8/19 (see photographic evidence). Violations of the state regulation related to an organized medical staff (H0229) was cited in the survey ending 3/20/19 and was cited again on the current survey ending 11/8/19. Violations of the state regulation related to appointing a patient representative was cited in the survey ending 11/1/18 and again in the current survey ending 11/8/19.

It was determined the volume and recurrent nature of regulatory non-compliance represented an on-going pattern of non-compliance with laws and regulations.

3. During a review of the facility's out patient services, identified as the Partial Hospitalization Program/Intensive Outpatient Program, (PHP/IOP), it was not clear who the Director of the program was. Review of the facility's Organizational Chart revealed the PHP/IOP reported directly to two Service Directors (Social Services and Clinical Services), neither of which were Physicians.

An interview was conducted on 11/06/2019 beginning at 2:35 PM with a Licensed Clinical Social Worker (LCSW) who had been identified as the Manager of the unit since June 2019. He reported that he felt he had the PHP up and running, and now with newly hired staff, he could concentrate on the IOP, which he identified as the step down unit.

He listed out patient staff of the PHP/IOP, which did not include a Physician or Psychiatrist as one of the regular staff who provided patient services or direction to the out patient clinic. When asked who he reported directly to, he named the Clinical Service Director and confirmed that he was not familiar with the Social Service Director that was listed on the Organizational Chart as one of his two direct supervisors.

In an interview with the Clinical Services Director on 11/08/2019 beginning at 1:05 PM, it was reported that the LCSW was the lead therapist. She confirmed the job description may not delineate that but "everyone knows that." A review of the Therapist II job description which the LCSW had signed on 11/08/2019, did not reveal that the Therapist II would take a lead role in directing the department. All essential functions of the job were direct patient related duties.

A review of the Policy entitled Outpatient Treatment Program Overview (Policy # OPO030), revealed staff that were a part of the out patient services as : "Under the direction of a psychiatrist, members of this team include: psychiatric/mental health nurses, social workers or other therapists, occupational therapists, and activity therapists"

In the interview with the Director of Clinical Services which was conducted on 11/08/2019 beginning at 1:05 PM, it was reported that the psychiatrists rotate through the out patient service as the Director, with a schedule of seven days on, seven days off. She provided the job description for the Doctors which she noted that all facility job descriptions cover both in patient and out patient services. A review of the job description did not refer to providing patient services or direction in the out patient clinic.

On 11/08/2019 at 3:40 p.m., the Registered Nurse who had taken a position at the PHP within the last month, reported when asked if she saw the facility's medical director provide out patient services at the PHP, "he sees patients on occasion."

On 11/08/2019 at 8:40 a.m., the Risk Manager was asked about the organization of the out patient services and who was directing or responsible for the out patient services. She reported that it would be the Director of Clinical Services but also the Director of Social Services could provide oversight.

An interview was conducted with the Chief Executive Officer (CEO) on 11/8/19 at 10:30 am. The CEO was advised there appeared to be some confusion amongst the members of the Outpatient Services staff as to the identity of the Director of the department. The CEO indicated the hospital Medical Director was responsible as the Medical Director for Outpatient Services.

An interview was conducted with the RN Charge Nurse on C-Geriatric on 11/4/19 at 2:45 PM. Discussion centered on the posted schedule of daily activities showing six group therapy sessions daily and the variance presented by the review of the medical record documentation showing only three daily sessions actually being offered to Patient #25. The Charge Nurse indicated she was unfamiliar with the posted activity schedule. The Charge Nurse indicated she could not address the issue of the 1:15 PM group therapy session being canceled that day, or the frequency of patients being offered opportunities to attend group therapy due to group therapy being under a completely different department from nursing.

The Chief Executive Officer (CEO) and the Medical Director were interviewed on 11/8/19 at 11:30 am. Following their review of the physician's order in the medical record of Patient #1, the review of the patient's written grievance, and review of the information on the Grievance and Complaint Log, the CEO and the Medical Director confirmed the finding the Patient Advocate's determination the grievance as not substantiated was not accurate. They confirmed there was no process in place of which they were aware to monitor or confirm the accuracy of the Patient Advocate's findings and as a result, they confirmed the finding inaccurate data related to grievances failed to provide an effective means to identify, track, trend, and analyze valid issues affecting patients' quality of care.

The facility's policies for Organ/Tissue/Eye Donation (OTE 1002 and OTE 1003) were reviewed and noted to include nursing staff responsibilities and staff education related to organ, tissue or eye donations.
Facility policy OTE 1002 - Nursing Staff Responsibilities listed under Policy: point #9: "Nursing staff at all levels of licensure will receive education and training on the requirements of the designated organ procurement organization (OPO) serving this hospital. Due to the sensitive and potential life - saving impact of organ donation, nursing staff interacting with patients and their families must successfully complete in services about organ procurement and donation, ..."

Facility policy OTE 1003 - Staff Education listed under Policy, point #2: "In services regarding donation issues shall be conducted during orientation for new staff, annually thereafter, when there are policy and procedure changes and as needed."

In an interview with the Risk Manager on 11/06/2019 beginning at 8:45 a.m., it was reported that "per the Director of Nurses, there has been no training on Organ/tissue/eye donations."

In an interview with the Registered Nurse on the C unit, on 11/06/2019 beginning at 11:10 a.m., she confirmed she had been working at the facility for one year. She reported "not to my recollection" when asked if she had received training on organ donations at the facility.

A review of the new employee Orientation Agenda revealed there was no agenda item indicating training on organ, tissue or eye donations was provided.

Based on observation and interview it was determined the facility failed to post the State Agency Complaint numbers near patient phones for one unit (unit M) of four patient units toured.

Findings included:

On 11/04/2019 at 10:30, escorted by RN Supervisor, a tour of the patient care areas, Unit A, B, C, and M were initiated.
Observation of Unit M revealed the following:
- Phone Numbers to the following agencies were not posted as required:
- AHCA Complaint Line
- The Joint Commission
(see photographic evidence)

On 11/04/2019 during the tour and interview with the RN supervisor confirmed the finding and stated she would have the issue corrected.

Based on medical record review, document review and staff interview it was determined the facility failed to ensure the collection of accurate data in order to effectively identify, analyze, and develop effective plans of correction related to patient care and services.

Findings included:

The review of the Grievance and Complaint Log revealed a grievance submitted by Patient #1 was received on 9/17/19. The review of the written complaint dated 9/16/19 and signed by the patient, indicated the patient's concern was that the physician unfairly restricted her access to telephone communication. The review of the medical record revealed the physician documented telephone privileges were restricted due to the patient calling her family to complain about the facility. Although the written grievance signed by the patient indicated the patient's dissatisfaction was with the physician, the Log indicated the complaint category was designated as "Care". The Log included documentation of the Patient Advocate's interview with the physician (date and time not documented) indicating the patient's telephone privileges were restricted due to excessive telephone use. The log indicated the complaint was unsubstantiated. The log indicated the complaint was resolved to the patient's satisfaction although the patient was discharged on 9/17/19 prior to meeting with the Patient Advocate.

The review of the Grievance and Complaint Log for the previous 6 months revealed a total of 146 complaints and grievances were documented on the log. 104 of the 146, or approximately 72%, of all the documented complaints and grievances were classified as unsubstantiated. The Log included a column labeled "Type: Claims, Privacy, Care, Customer Service, Physician, Security". The detailed review of the narrative documentation on the log revealed 5 of the 146 complaints involved a reference to dissatisfaction with the physician. Only one was classified "physician", the other four were classified as customer service or care.

The review of the Governing Board meeting minutes for the previous four quarterly meetings revealed the minutes included the Board acknowledging the total number of patient complaints and grievances received during the quarter. None of the minutes reflected any discussion of the analysis of any data related to patient grievances, the review of any identified issues, or the review or approval of any plan of improvement related to patient grievances.

In an interview conducted on 9/6/19 at 10:30 am, the Risk Manager was unable to explain the manner in which data was collected from the complaint/grievance log for coding and categorization in order to analyze the data, other than to state the Patient Advocate was responsible for those tasks. The Risk Manager was unable to respond to a request to provide evidence to show what grievance category this particular grievance was assigned for data collection purposes. The Risk Manager indicated there was no process in place to review or audit the accuracy of findings or coding of grievance investigations by the Patient Advocate to ensure the process produced valid data for analysis.

The Chief Executive Officer (CEO) and the Medical Director, both members of the Governing Board, were interviewed on 11/8/19 at 11:30 am. Following their review of the physician's order in the medical record, the review of the patient's written grievance, and review of the information on the Grievance and Complaint Log, the CEO and the Medical Director confirmed the finding the physician's restriction of telephone privileges was not in compliance with regulatory requirements or facility policy. They confirmed the finding the Patient Advocate's determination the grievance as not substantiated was not accurate. They confirmed there was no process in place of which they were aware to monitor or confirm the accuracy of the Patient Advocate's findings and as a result, they confirmed the finding inaccurate data related to grievances failed to provide an effective means to identify, track, trend, and analyze valid issues affecting patients' quality of care.

Based on review of clinical records and staff interviews, it was determined the facility failed to ensure the procedure for submission of a written or verbal grievance was clearly explained in a language the patient could understand for one (#33) of thirty-four patients sampled.

Findings included:

A review of the clinical record for patient #33 revealed the patient was admitted on 10/04/2019. Review of the psychiatrist initial examination, dated 10/05/2019 at 10:30 am, revealed the patient reported he could only speak a little English and required a translator. A review of the admission documents provided to the patient, which included the grievance process, revealed all the documents were provided in English. There was no evidence the patient was provided information on the complaint process in a language the patient could understand.

An interview was conducted with the Director of Nursing (DON) and Nursing Supervisor on 11/08/2019 at 12:10 pm. The DON and Nursing Supervisor confirmed the above findings.

Based on review of clinical records, staff interviews, and review of policy and procedures, it was determined the facility failed to ensure the exercise of the patient's right to communicate openly and privately by phone was not restricted without written notice with justification for one (#1) of thirty-four patients sampled.

Findings included:

Review of the facility policy, "Visitation/Telephone," #PR1018, effective 9/23/2013, stated visitation and/or communication would not be restricted unless deemed clinically necessary for the therapeutic wellbeing of the patient. If visitation and/or communication are restricted, the patient and/or their family/representative would be notified of such clinical restrictions or limitations. The policy further stated, in the event a physician determines that a visitor and/or communication may be injurious to the patient, the physician may, for good cause, impose a denial of rights for the specific visitor and/or communication, and document justification and complete the Restriction of Communication and/or Visitor form.

A review of the medical record for patient #1 revealed the patient was admitted involuntarily under the Baker Act on 9/11/2019. At the time of admission, the patient provided the name of a representative. Review of the physician orders revealed on 9/15/2019 at 2:54 pm, a physician telephone order was received for "phone restriction." Review of the physician order form revealed no documentation to indicate the reason or rationale for the communication restriction. Review of the clinical record revealed no evidence the required form Restriction of Communication and/or Visitor was completed. A review of the clinical record revealed no evidence the patient or the patient's representative was provided written notice of the telephone restriction or the reasons for the restriction.

A review of the psychiatric progress note, dated 9/15/2019 at 11:30 am, revealed the covering psychiatrist for the patient's admitting psychiatrist met and examined the patient. The psychiatrist documented the patient had taken advantage of her phone privileges to call her husband and family and make complaints about the facility. The psychiatrist documented the patient exhibited manipulative behavior by having another patient call her husband to inform him that her phone privileges had been suspended.

On 11/07/2019 at 11:30 am the patient's admitting psychiatrist was interviewed. Following a review of the documentation in patient #1's clinical record, the psychiatrist confirmed there was no justification for restriction of the patient's right to communicate.

Based on record review and interviews with the Director of Risk Management the facility failed to incorporate all areas of the hospital in the QAPI (Quality Assurance) program for 2 out of 2 years (2018-2019) reviews.

Findings Included:

Review of Quality Assurance records for 2018-2019 revealed no mention of laboratory services.

During an interview on 11/08/19 at 2:00 PM the Director of Risk Management confirmed that the Laboratory Services that are provided on-site or sent out were not part of their QAPI program.

Based on medical record review, document review and staff interview it was determined the facility failed to ensure the collection of accurate data in order to effectively identify, analyze, and develop effective plans of improvement related to patient care and services.

Findings included:

The review of the Grievance and Complaint Log for the previous 6 months revealed a total of 146 complaints and grievances were documented on the log. 104 of the 146, or approximately 72%, of all the documented complaints and grievances were classified as unsubstantiated. The Log included a column labeled "Type: Claims, Privacy, Care, Customer Service, Physician, Security". The detailed review of the narrative documentation on the log revealed 5 of the 146 complaints involved a reference to dissatisfaction with the physician. Only one was classified "physician", the other four were classified as customer service or care.

The review of the Grievance and Complaint Log revealed a grievance dated 9/16/19 submitted by Patient #1 was received on 9/17/19. The review of the written complaint signed by the patient indicated the patient's concern was that the physician unfairly restricted her access to telephone communication. The review of the medical record revealed the physician documented telephone privileges were restricted due to the patient calling her family to complain about the facility. Although the written grievance signed by the patient indicated the patient's dissatisfaction was with the physician, the Log indicated the complaint category was designated as "Care". The Log included documentation of the Patient Advocate's interview with the physician (interview date not indicated) indicating the patient's telephone privileges were restricted due to excessive telephone use. The log indicated the complaint was unsubstantiated. The log indicated the complaint was resolved to the patient's satisfaction although the patient was discharged on 9/17/19 prior to meeting with the Patient Advocate.

The review of the Governing Board meeting minutes for the previous four quarterly meetings revealed the minutes included the Board acknowledging the total number of patient complaints and grievances received during the quarter. None of the minutes reflected any discussion of the analysis of any data related to patient grievances, the review of any identified issues, or the review or approval of any plan of improvement related to patient grievances.

In an interview conducted on 9/6/19 at 10:30 am, the Risk Manager was unable to explain the manner in which data was collected from the complaint/grievance log for coding and categorization in order to analyze the data, other than to state the Patient Advocate was responsible for those tasks. The Risk Manager was unable to respond to a request to provide evidence to show what grievance category this particular grievance was assigned for data collection purposes. The Risk Manager indicated there was no process in place to review or audit the accuracy of findings or coding of grievance investigations by the Patient Advocate to ensure the process produced valid data for analysis.

The Chief Executive Officer (CEO) and the Medical Director, both members of the Governing Board, were interviewed on 11/8/19 at 11:30 am. The CEO indicated the Grievance Committe members were the Patient Advocate/Baker Act Coordinator, the Risk Management Assistant, the Director of Utilization Management, and the CEO. He indicated the Committee had no regularly scheduled meetings and met only on an as-needed basis when something significant presented itself. The CEO and Medical Director both indicated they were unfamuiliar with the grievance submitted by Patient #1. Following their review of the physician's order in the medical record, the review of the patient's written grievance, and review of the information on the Grievance and Complaint Log, the CEO and the Medical Director confirmed the finding the physician's restriction of telephone privileges was not in compliance with regulatory requirements or facility policy. They confirmed the finding the Patient Advocate's determination the grievance as not substantiated was not accurate. They confirmed there was no process in place of which they were aware to monitor or confirm the accuracy of the Patient Advocate's findings and as a result, they confirmed the finding inaccurate data related to grievances failed to provide an effective means to identify, track, trend, and analyze valid issues affecting patients' quality of care.

Based on record review and interview it was determined the facility failed to administer medication appropriately per policy for one (#7) of thirty-four records reviewed.

Findings included:

A review of facility policy titled, Medication Administration and Records, page 5 of 9 item 4.2.5.1 states, "When a STAT initial medication dose is ordered, the dose will be administered within 15 minutes." Page 8 of 9, item 4.3.1.18, states "To indicate the administration of a scheduled medication, the nurse will cross out the time the medication was administered and initial directly to the right of the medication with time."

A review of Patient #7's medical record documents the patient was admitted to the facility on 03/13/2019 and discharged to home on 03/16/2019. A review of the Physician Orders revealed orders for treatment of the patient's alcohol withdrawal symptoms included:
-Obtain vital signs every 4 hours while awake at 0600, 1000, 1400, 1800, 2200 [MHT-mental health technician]
-Obtain vital signs PRN [as needed] in addition if patient is experiencing symptoms or awake at night. [MHT]
-Complete the CIWA [Clinical Institute Withdrawal Assessment] questions at the same time as the vital signs [RN - Registered Nurse or LPN - Licensed Practical Nurse]
-Thiamine 100 milligrams by mouth times 1 STAT and one by mouth every morning - Dietary Supplement
-Folic Acid 1 milligram by mouth times 1 STAT and one by mouth every morning - Dietary Supplement
-Multivitamin with minerals one by mouth x's 1 STAT and one by mouth every morning - Dietary Supplement
- Per Telephone order: Read Back & Verify Date and Time 03/13/2019 at 09:30

A review of Patient #7's MAR [medication administration record] documented the nurse initialed giving the Thiamine, Folic Acid and Multivitamin with minerals, however, the nurse did not document the time the medications were given in compliance with facility policy. Further review of the MAR revealed no documentation the medication was given on 03/14/2019 per physician order as confirmed by interview with the RN supervisor on 11/07/2019 at 3:34 pm. On 11/08/2019 at 7:45 am, an interview with the RN Supervisor stated she checked with the pharmacy and had the pharmacist pull a report to see if the nurse had removed the ordered medication from the AMDU [automatic medication dispensing unit]. The pharmacy record documented the nurse did remove the above medications ordered STAT (to be given immediately) at 10:42 pm on 03/13/2019 (Greater than 15 minute STAT timeline per policy) and the Nurse pulled the above medication on 03/14/2019 at 8:15 am for the routine daily dose. However, the nurse failed to document the administration of the medications to the patient on the patient's medication administration record per facility policy.

Based on record review and interview it was determined the facility failed to ensure complete and accurate medical records for five (#7, #8, #9, #13, #24) of thirty-four sampled records reviewed.

Findings included:

A review of Patient #7's medical record documents the patient was admitted to the facility on 03/13/2019 and discharged on 03/16/2019. A review of the physician discharge summary documents the date and time of Examination as March 19, 2019 Time 08:49 PM, However Patient #7 was discharged to home on 03/16/2019 after signing his discharge plan review at 09:37. An interview on 11/07/2019 with the RN Supervisor during record review confirmed the above findings.

A review of Patient #8's medical record documented the patient was admitted to the facility on 03/14/2019 and discharged on 03/16/2019. A review of the physician discharge summary for Course and Treatment documented, "Patient was offered and accepted a regimen of Vistaril and Trazodone as needed for anxiety and insomnia with good effects and all titrated to appropriate doses. Patient was noted to be compliant with medication and denied side effects. A review of the Medication Administration Record [MAR] and the pharmacy dispensing record showed Patient #8 was ordered the Vistaril and Trazodone PRN [as needed] however, there was no evidence the patient ever requested or was given the medication. An interview on 11/07/2019 with the RN Supervisor during record review confirmed the above findings.

A review of Patient #9's medical record documented the patient was admitted to the facility on 10/30/2019 and currently remained in-house. A detailed review of the medical record conducted with the RN supervisor on 11/7/19 failed to reveal a completed medical history and physical within Patient #9's medical record. An interview with the RN supervisor confirmed Patient #7's medical record was incomplete.

A review of Patient #13's medical record, specifically the interdisciplinary treatment plan documents the medical problem sheet, failed to list the patient's name, failed to document a completed follow up for discharge, and there was no evidence interdisciplinary treatment plan was updated every seven days. A review of Facility policy," Treatment Planning and Review" stated a comprehensive interdisciplinary treatment plan is initiated upon the Patient's admission, through the first twenty-four hours, and is fully developed/ reviewed/ revised by the multidisciplinary treatment team within seventy-two hours. This plan will be reviewed and updated every seven days or sooner. The finding was confirmed by the Risk Management Assistant and Nurse C at the time of the record review on 11/7/19.

A review of Patient #24's medical record documented the patient was admitted to the facility on 09/28/2019 and discharged on 10/07/2019. A review of the physician discharge summary indicated medications during the inpatient stay included, but were not limited to, Aristredo. A review of the Medication Administration Record (MAR) revealed no evidence the medication "Aristredo" was ever administered to Patient #24. A review of the physician orders failed to document an order for a drug listed as "Aristredo". An interview on 11/07/2019 at 15:27 with the Risk manager stated she confirmed with the pharmacy that they don't know what that drug is and it must be in error.

Based on review of clinical records, staff interview and review of policy and procedures it was determined the facility failed to ensure the discharge summary contained the disposition of the patient for four patients (#1, #2, #5, #33) and provisions for follow-up care for one (#33) of thirty-four patients sampled.

Findings included:

Review of the facility policy, "Discharge Summary," #MR8023, effective 6/2019, stated a discharge summary will be completed no later than thirty (30) days after patient discharge and shall include legal status, patient's disposition at discharge, and provisions for follow-up care.

1. Review of the clinical record for patient #1 revealed the patient was involuntarily admitted under the Baker Act law on 9/11/2019. The patient was determined to be competent to provide informed consent on 9/11/2019 and the patient signed consent for voluntary admission. On 9/16/2019 the patient was discharged from the facility. Review of the discharge summary, dated 9/16/2019, revealed no evidence of the patient's legal status or disposition at the time of discharge.

2. Review of the clinical record for patient #2 revealed the patient was involuntarily admitted under the Baker Act law on 10/05/2019. The patient was determined to be incompetent to provide informed consent on 10/06/2019 and the patient was assigned a healthcare proxy. On 10/15/2019, at the time of discharge, the patient had a hearing date set for 10/17/2019 for involuntary placement. Review of the discharge summary, dated 9/16/2019, revealed no evidence of the patient's legal status or disposition at the time of discharge.

3. Review of the clinical record for patient #5 revealed the patient was involuntarily admitted under the Baker Act law on 9/02/2019. The patient was determined to be competent to provide informed consent on 9/02/2019 and the patient signed consent for voluntary admission. On 9/09/2019 the patient was discharged from the facility. Review of the discharge summary, dated 9/09/2019, revealed no evidence of the patient's legal status or disposition at the time of discharge.

4. Review of the clinical record for patient #33 revealed the patient was involuntarily admitted under the Baker Act law on 10/04/2019. The patient was determined to be competent to provide informed consent on 10/05/2019 and the patient signed consent for voluntary admission. On 10/14/2019 the patient was discharged from the facility. Review of the discharge summary, dated 10/14/2019, revealed no evidence of the patient's legal status or disposition at the time of discharge. Review of the record revealed a fax confirmation to a home health agency. An interview was conducted with the Director of Clinical Services on 11/08/2019 at 12:45 pm. The Director of Clinical Services confirmed the patient was discharged home with home health services.

An interview was conducted with the Director of HIM (Health Information Management) on 11/08/2019 at 2:30 pm. The Director of HIM reviewed the discharge summary for patient's #1, #2, #5, and #33 and confirmed the above findings.

Based on observations, record review, and interviews with the Laboratory Director, Director of Quality & Compliance, Director of Risk Management, Admissions Counselor, and the Admissions Specialist the facility failed to have laboratory services that meet the requirement of Part 493 by failing to follow Manufacturers' Instructions (MI) in 4 out of 4 (UScreen urine drug test cup, Medline Urine dipstick, Medline Urine Pregnancy, and Evencare G2 glucometer for glucose testing) waived testing performed for an undetermined amount of time (See A0582).

Based on observations, record review, and interviews with the Laboratory Director, Director of Quality & Compliance, Director of Risk Management, Admissions Counselor, and the Admissions Specialist the facility failed to have laboratory services that meet the requirements of part 493 by failing to follow Manufacturers' Instructions (MI) in 4 out of 4 (UScreen urine drug test cup, Medline Urine dipstick, Medline Urine Pregnancy, and Evencare G2 glucometer for glucose testing) waived testing performed for an undetermined amount of time.

Findings included:

A tour on 11/06/19 at 10:30 AM of the testing areas where waived testing was performed revealed 5 different areas. There were testing areas in admitting, and in each of the residential wings (Unit A, Unit B, Unit C, and Unit M).

In the admitting area, it was observed the following waived testing UScreen urine drug test cup, Medline Urine dipstick, Medline Urine Pregnancy, and Evencare G2 glucometer for glucose testing.
At 11:00 AM on 11/06/19 expired glucometer controls (expired 09/04/19) was observed in the drawer where the glucometer and test strips were stored. The controls were opened 08/16/11. There were no logs of quality control (QC), temperature, or humidity.

At 11:00 AM on 11/06/19 an Admission Councilor was observed running a Urine drug testing cup, a urine dipstick, and a urine pregnancy test. No timer was observed in use. When asked how long the test required to be ran, the Admission Councilor stated that the tests only took a few seconds to read the results.

The MI for the glucometer controls state "Control solution should be stored at 59-86 degrees Fahrenheit, Do not use if the expiration date has passed, Discard any unused control solution 90 days after first opening or after expiration date."

The MI for the glucose test strips revealed that high and low controls should be ran "If your test results do not agree with how you feel, At least once per week to make sure the meter and test strips are working properly, If your test strips were stored at temperature and humidity outside proper storage conditions, When you use your meter for the first time, Every time you open a new bottle of test strips, To practice your testing technique, If you drop your meter."

The MI for the Evencare G2 glucometer revealed that the meter has an operating temperature of 50-104 degrees Fahrenheit and less than 85% humidity.

The MI for the UScreen Urine Drug Test Cup revealed that they should be stored at 39-86 degrees Fahrenheit. It also states to "Wait 5 minutes to determine a positive result."

The MI for the Medline Urine dipstick states that it should be stored at 36-86 degrees Fahrenheit. It also states that "Based on the dry weight at the time of impregnation, the concentrations given may vary within manufacturing tolerances. The following table below indicates read times and performance characterizes for each parameter. The sensitivities are based on visual read studies." The following analytes are resulted in the urine dipstick, the read time for glucose is 30 seconds, Bilirubin is 30 seconds, Ketone is 40 seconds, specific gravity is 45 seconds, Blood is 60 seconds, pH is 60 seconds, Protein is 60 seconds, Urobilinogen is 60 seconds, Nitrite is 60 seconds, and Leukocytes is 120 seconds. The MI also states under QC "For best results, performance of reagent strips should be confirmed by testing known positive and negative specimens/controls in the following conditions." The conditions are when a new bottle is opened, if bottle open for more than 30 days, if quality is questioned, training new testing people, or when there is an issue with storage conditions.
The MI for the Medline Urine pregnancy testing revealed that it should be stored at 36-86 degrees Fahrenheit. The directions for use state to "immerse the test strip vertically in the urine specimen for at least 5 seconds." Then "Place the test strip on a non-absorbent, flat surface, start the timer and wait for the red line(s) to appear. Read the result at 3-4 minutes. Do not interpret the results after the appropriate read time. It is important that the background is clear before the result is read."

Interview on 11/06/19 at 11:30 AM with the Admissions Specialist confirmed that quality control, room temperature, or humidity logs were not being done or recorded.

During the tour conducted on 11/06/19 at 10:30 AM, the 4 residential units were observed to only perform glucose testing. There was no humidity documented where the glucometer was stored. This was confirmed by the Laboratory Director on 11/08/19 at 1:00 PM.

The MI for the glucose controls stated that "The purpose of the control solution is to validate the performance of the Evencare G2 Blood Glucose Monitoring System using a testing solution with a known range of glucose. A control test that falls with the acceptable range indicates the user's technique is appropriate and the test strip and meter are functioning properly." It also states, "If results continue to be out of range after all instructions have been followed, the system is not functioning properly. DO NOT use the system to test your blood glucose until you get a reading that is within the acceptable range."

Interview with the Director of Quality and Compliance on 11/07/19 at 11:00 AM revealed that the glucose QC should be ran daily and if not within acceptable limits there should be a corrective action and the QC ran again. She also stated that if not acceptable that glucometer should not be used to perform patient testing. She confirmed that there were no logs available for review prior to 06/01/19. This was confirmed during review of glucose QC logs by lack of documentation prior to 06/01/19.

Review of QC logs from Unit A from 06/01/19 to 11/04/19 revealed no QC performed on 11/03/19, 10/29/19, 10/28/19, 10/21/19, 09/23/19, 09/03/19, 09/02/19, 09/01/19, 08/31/19, 08/30/19, 08/29/19, 08/27/19, 08/19/19, 08/16/19, 08/12/19, 08/11/19, 08/07/19, 07/24/19, 07/15/19, 07/11/19, and 07/05/19.
The following days the QC was outside the acceptable range with no corrective action: (low acceptable range is 40-70) 10/24/19=21, 10/18/19=39, 10/17/19=39, 10/14/19=39, (low acceptable range is 39-69) 09/16/19=30, 09/15/19=30, 09/14/19=30, 09/13/19=29, 09/08/19=30, 09/07/19=32, 09/06/19=30, (low acceptable range is 41-71) 09/05/19=31, 08/26/19=37, (low acceptable range is 38-68) 07/25/19=36, 07/23/19=33, 07/22/19=36, (low acceptable range is 43-73) 07/13/19=34, 07/09/19=42, (high acceptable range is 162-219) 06/20/19=312, 06/19/19=301, and 06/07/19=236.

Review of QC logs from Unit B from 06/01/19 to 11/04/19 revealed no QC performed on 11/04/19, 10/22/19, 10/16/19, 10/11/19, 10/10/19, 10/08/19, 10/07/19, 10/06/19, 09/28/19, 09/19/19, 09/17/19, 09/08/19, 09/07/19, 09/03/19, 09/01/19, 08/27/19, 08/26/19, 08/25/19, 08/22/19, 08/12/19, 08/06/19, 08/03/19, 07/30/19, 07/28/19, 07/27/19, 07/25/19, 07/24/19, 07/19/19, 07/15/19, 07/11/19, 07/09/19, 07/08/19, 07/07/19, 07/06/19, 07/02/19, 06/28/19, 06/19/19, 06/15/19, 06/14/19, 06/10/19, 06/09/19, 06/08/19, 06/07/19, 06/06/19, 06/05/19, 06/04/19, 06/03/19, 06/02/19, and 06/01/19.
The following days the QC was outside the acceptable range with no corrective action: (low acceptable range 40-70) 10/26/19=94, (low acceptable range 41-71) 09/14/19=78, 09/06/19=37, 09/05/19=38, 09/04/19=40, 08/29/19=33, 08/28/19=38, 08/13/19=40, 08/10/19=40, 08/09/19=40, 08/07/19=39, 08/04/19=40, (low acceptable range 38-68) 07/20/19=34, (high acceptable range 162-219) 08/05/19=220, 07/05/19=306, 07/04/19=304, 07/01/19=245, and 06/30/19=302.

Review of QC logs from Unit C from 06/01/19 to 11/04/19 revealed no QC performed on 11/04/19, 11/03/19, 11/02/19, 11/01/19, 10/27/19, 10/24/19, 10/23/19, 10/22/19, 10/21/19, 10/20/19, 10/19/19, 10/18/19, 10/17/19, 10/16/19, 10/15/19, 10/14/19, 10/13/19, 10/12/19, 10/11/19, 10/09/19, 10/08/19, 10/07/19, 10/06/19, 10/05/19, 10/04/19, 10/03/19, 10/02/19, 10/01/19, 09/30/19, 09/29/19, 09/28/19, 09/27/19, 09/26/19, 09/25/19, 09/24/19, 09/23/19, 09/22/19, 09/21/19, 09/20/19, 09/19/19, 09/18/19, 09/17/19, 09/16/19, 09/15/19, 09/14/19, 09/13/19, 09/12/19, 09/11/19, 09/10/19, 09/08/19, 09/07/19, 09/06/19, 09/05/19, 09/04/19, 09/03/19, 09/02/19, 09/01/19, 08/31/19, 08/30/19, 08/29/19, 08/24/19, 08/23/29, 08/20/19, 08/17/19, 08/13/19, 08/07/19, 08/06/19, 08/05/19, 08/03/19, 07/30/19, 07/11/19, 07/09/19, 07/08/19, 06/28/19, 06/10/19, 06/09/19, 06/08/19, 06/07/19, 06/06/19, 06/05/19, 06/04/19, 06/03/19, 06/02/19, and 06/01/19.
The following days the QC was outside the acceptable range with no corrective action: (low acceptable range 41-71) 08/28/19=23, 08/27/19=14, 08/26/19=22, (low acceptable range 38-68) 08/22/19=21, 08/21/19=26, 08/19/19=32, 07/05/19=28, 07/04/19=30, (low acceptable range 43-73) 08/18/19=41, 08/16/19=24, 08/15/19=20, 08/14/19=29, 08/11/19=40, 08/10/19=42, 08/09/19=31, 08/08/19=26, 08/04/19=34, 08/02/19=35, and (high acceptable range 164-222) 08/27/19=271.

Review of QC logs from Unit M from 06/01/19 to 11/04/19 revealed no QC performed on 10/15/19, 08/22/19, 08/18/19, 06/10/19, 06/09/19, 06/08/19, 06/07/19, 06/06/19, 06/05/19, 06/04/19, 06/03/19, 06/02/19, and 06/01/19.
The following days the QC was outside the acceptable range with no corrective action: (low acceptable range 40-70) 11/03/19=35, 11/02/19=39, 11/01/19=39, 10/29/19=37, 10/24/19=39, 10/23/19=38, (low acceptable range 39-69) 09/29/19=22, 09/28/19=27, 09/24/19=21, 09/23/19=28, 09/19/19=22, 09/18/19=26, 09/16/19=22, 09/15/19=30, 09/14/19=30, 09/11/19=32, 09/10/19=29, 09/09/19=37, 09/08/19=38, (low acceptable range 41-71) 09/03/19=27, 09/02/19=27, 09/01/19=29, 08/31/19=24. 08/30/19=30, 08/29/19=30, 08/28/19=34, 08/27/19=33, 08/26/19=31, 08/25/19=33, 08/24/19=30, 08/23/19=32, 08/21/19=31, 08/20/19=32, 08/19/19=32, 08/17/19=33, 08/16/19=32, 08/15/19=38, 08/13/19=34, 08/12/19=34, 08/11/19=34, 08/10/19=33, 08/09/19=35, 08/08/19=37, 08/07/19=34, 08/06/19=30, 08/05/19=34, 08/04/19=34, 08/03/19=35, 08/02/19=37, 08/01/19=34, 07/31/19=39, 07/30/19=40, 07/29/19=37, 07/28/19=36, 07/27/19=39, (low acceptable range 42-72) 06/21/19=39, 06/19/19=41, (high acceptable range 164-222) 10/03/19=20, 09/26/19=241, 09/20/19=246, and 09/19/19=229.

Review of policies and procedures revealed that there was no policy for reviewing the glucose QC logs.
An interview on 11/07/19 at 4:01 PM with the Laboratory Director confirmed that the glucose logs were not being reviewed.

Review of the policy for waived testing revealed that there was no policy for urine dipstick testing and the policies for urine drug cup testing, urine pregnancy testing, and glucose did not follow Manufacturers' Instructions.

Interview on 11/06/19 at 4:16 PM the Director of Risk Management confirmed that the current policies for glucose testing were not reflective of what staff are currently doing and confirmed the policies for urine drug cup test, urine dipstick, and urine pregnancy did not describe procedures per MI requirements.

Review of the the 96 Testing Personnel employee files revealed that 25 staff members had no training, 67 testing personnel did not have adequate training (only glucose and urine drug cup quiz), and 4 testing personnel had training.

An interview on 11/08/19 at 5:00 PM the Director of Quality& Compliance confirmed that of the 96 employees on staff who perform waived lab testing 4 had training, 25 had no training, and 67 did not have adequate training. She also confirmed the Admission Councilor that was observed testing on 11/06/19 was one of the staff that did not have training.

The Laboratory Director confirmed on 11/08/19 at 12:30 PM that patients' insulin is adjusted based on the glucose values provided by the glucometers. This was confirmed by the review of 10 patient charts (L1-L10) for insulin orders and glucometer readings.

Based on review of the Facility's Organizational Chart, review of a dietary staff's employment experience, and interview with facility staff, the facility failed to employ a staff member qualified by experience or training as the Director of the Food and Dietetic service department.

Findings included:

On 11/04/2019 beginning at 10:00 a.m., the Director of Plant Operations provided a tour of the main kitchen. He reported the Manager wasn't in yet. The Organizational Chart listed the Dietary Department as reporting to the Director of Plant Operations. The staff member identified as the Manager was identified as the Lead Cook on the Organizational Chart of the Food and Nutrition Services Department.

On 11/05/2019 beginning at 12:18 p.m. an interview was conducted with the Lead Cook who had been identified as the Manager of the department. He confirmed he was the lead cook but had been filling in to cover the management duties for over a year. He reported he had manager experience through past jobs. The experience as a manager , per the interview, had not been in health care. He reported that he was not a Certified Dietary Manager but had the ServSafe Credential.

In an interview with the Consultant Registered Dietitian, on 11/05/2019 beginning at 1:20 p.m., it was confirmed that the facility had never appointed the staff member as the Manager of the department and she confirmed the Director of Plant Operations managed the department. The RD confirmed during that interview that she did not provide reports of her twice a week visits ( patients that she assessed, nutrition consultations that she responded to) to either the Director of Plant Operations or to the Director of Nursing. The Hospital Organizational Chart identified the RD reported to the DON.

In an interview with the Director of Nursing on 11/06/19 beginning at 9:37 a.m., she reported that the Registered Dietitian did not report to her, but reported to the Director of Plant Operations, who directed the Department of Food and Nutrition.

In an interview on 11/08/2019 beginning at 10:20 a.m. , the Director of Plant Operations was made aware that the staff member had not met the criteria of either training or education to be named the Manager of the department. Responsibilities as the Manager, such as providing continuing education with the staff , had not been fulfilled.

Based on interviews with the Consultant Registered Dietitian and the Director of Plant Operations, and review of the facility menus, and patient medical records, the facility failed to ensure that the nutritional needs of the patients were met, including those patients with physician ordered consults, physician ordered therapeutic diets, and patient identified food allergies, sensitivities and preferences.

Findings included:

In an interview with the Consultant Registered Dietitian (RD) on 11/05/2019, beginning at 10:20 a.m., it was confirmed that nurses upon receiving diet orders for patients both at admission and when the order changed during the patient's stay, would fax the order to the dietary department to ensure the patient would receive the correct diet. Also during the interview the procedure of notifying the RD of physician ordered consults or patients identified as being at nutrition risk by the nurses during their admission assessment, was through a log on each patient unit. The RD reported that she would review the log during her twice a week visits to the facility to determine which patients she needed to see that day.
The RD reported that due to short patient stays at the facility, some patients were not able to be assessed by the RD.

On 11/05/2019, the Director of Plant Operations (DPO) provided a stack of Admission orders and Nutrition Assessments from October and November 2019 to the surveyor as examples of the patient diet orders and nutrition consults. Of the 28 randomly chosen patient diet orders, orders for nutrition consults and patient -identified food preferences or allergies, 12 patients had physician ordered therapeutic diets, 2 had concerns of dehydration, 5 had either allergies or food prefences documented, 8 nutrition consults were ordered, with 5 not having been responded to, and one patient filed a nutrition related grievance of which the RD had not been made aware.


In an interview with the RD and DPO , conducted on 11/08/2019 beginning at 10:20 a.m., the RD confirmed that the Diet Manual for the facility had not been approved by the Medical Board and was not available to the Medical or Nursing staff. She also confirmed that since menus were planned on a weekly basis she was not able to run nutrient analysis on the menus nor develop extensions to guide the dietary staff in providing therapeutic diets to the patients. Both the Director of Plant Operations and the RD confirmed there had not been on-going training with the dietary staff, which included identifying foods to include for a therapeutic diet to ensure nutritional adequacy as well as variety to the patients.

Patient # 33 had a nutrition consult ordered (10/18/2019) because she had requested a vegan diet. It was not listed in the RD's log on the patient unit and it had not been responded to.

Patient #34 had a 'finger food' diet ordered (10/01/2019) , which was reported by a Registered Nurse on the C unit (11/04/2019 at 1:35 p.m) as part of the protocol for patients identified as being at high risk for suicide. The RD confirmed she was not aware that it was part of the protocol for patients at high risk of suicide. She surmised that the dietary staff would give foods that the patient could handle as the patient would not be allowed to use plastic ware when eating. She confirmed there was no planned 'finger food' diet and the dietary staff would have to provide it from what they had.

Patient # 24 had filed a grievance on 07/25/2019 with the problem of "when swallowing , attempting to, everything goes up my nose and into my throat causing pain ...." . On 07/30/2019 the problem was resolved, per the Grievance Response form, based on a physician's ordered liquid diet. Review of the patient's admission diet order (07/19/19) revealed it was "liquid (Ensure)". There was no additional information about the quantity of the Ensure at each meal, or total amount to be consumed or provided. Per the History and Physical documented on 07/19/2019 the patient had prior medical history that included dysphasia (sic), and diabetes mellitus. The doctor included the patient's voiced concern as, "she does report that she has dysphasia (sic) and has trouble swallowing, she does report that she can swallow things however this would inlcude thick liquids and soft food. Will place patient on appropriate diet , have nutrition see patient. " (Dysphasia is difficulty with language, dysphagia is difficulty swallowing.)
There was no nutritional assessment noted in the chart for this patient during this hospital admission. Review of the intake at meals, documented by the Technicians revealed many meals were documented as '100%'. But there was no record of what volume or amount was being provided - one can, one liter, one cup? There was no assessment of the patient's estimated calorie, protein and fat requirements, how the diet order was meeting the patient's needs and whether it was a product that was compliant with a diagnosis of diabetes mellitus.
A care plan had been developed on 07/19/2019 that included a medical problem of Dysphagia, with the individualized focus of the intervention as ''to prevent choking.' The care plan form included under Interventions - 'what staff will do to assist the patient to achieve the goal', with a section identifying the practitioner's assessment and monitoring interventions . Both RD and Pharmacist were listed as part of the form, but the RD had not documented her intervention.
In an interview on 11/08/2019 beginning at 10:20 a.m. the RD confirmed she had not been made aware of the grievance with the resolution to provide a 'liquid (ensure)' diet. The RD reported that the facility does not supply ensure, so the order should have been clarified to identify the liquid diet as Boost, with the amount at each meal to provide and whether any other liquids would be available, including thickened liquids. The RD confirmed that staff marking 100% at meals was not helpful as there was no indication of what was provided. She confirmed that she is not usually included when care plans are developed.

Based on interview , it was determined that the facility failed to approve a current Diet Manual, failed to make it available to all staff for reference, and failed to use it as a reference when planning patient menus.

Findings included:

During an interview with the Consultant Registered Dietitian (RD) and the Director of Plant Operations, conducted on 11/08/2019 beginning at 10:20 a.m, it was reported that the Diet Manual that was located in the Dietary Department (the Academy of Nutrition and Dietetics Nutrition Care Manual) was a recent purchase that had yet to be approved by the Medical Staff. The RD confirmed that the Dietary Department had the only copy and it was not available to all staff, including the medical and nursing staff.

The RD reported that a staff member planned the menus on a frequent basis (almost weekly) and she was not able to run nutrient analysis on the menus due to the frequency with which they were planned. She confirmed that the staff member who planned the menus did not refer to the Diet Manual but used other ways to determine new menu choices or to use meals that had been widely accepted by patients in a rotating manner.

The RD also reported that since the menus changed frequently, she was not able to provide 'extensions' to the menus. If a therapeutic diet had been ordered, the cooks were responsible to read the labels on the processed foods or the ingredient labels to ensure an ingredient or food would fit the modified diet. She confirmed the cooks were not referring to the diet manual to ensure therapeutic diets were being served.
Reviewing Admission Orders for patients during September and October revealed that Therapeutic Diets were being ordered, such as Vegan, Gluten-free, Lowfat, Diabetic, and finger foods.

Based on facility record review and interview it was determined the facility failed to ensure at least two of the members of the Utilization Review committee were doctors of medicine or osteopathy.

Findings included:

A review of the facility's Utilization Management Plan, #UN 111.00 item V Regulatory Requirements states, "The Utilization Management Committee is composed of a variety of disciplines, including at least two physicians, one of whom is knowledgeable in the diagnosis and treatment of mental disorders.

A review of the Committee minutes and interview with the Director of Utilization Review confirmed only one physician is on the committee. The interview on 11/05/2019 at 10:00 with the Director of Utilization Review, stated a physician had left in late September or early October of 2019 and had not been replaced. She stated she had only been in the position since June and was learning the roles and responsibilities.

Based on observation and interview it was determined the facility failed to ensure the physical plant and the overall hospital environment was maintained to assure the safety and well-being of patients, staff and visitors.

Findings included:

On 11/04/2019 at 10:30, escorted by the RN Supervisor, a tour of the patient care areas, Unit A, B, C and M was initiated.

Observation of Unit A revealed the following:
- Patient Nutrition room observed microwave dirty with splattered substance on inside walls and ceiling, refrigerator with dried spilled liquid substance and an open container of a sports drink not labeled with a patient name or date opened, sink faucet dripping with buildup of greenish yellow brown substance on spout, sink bowl dirty, flooring under sink discolored with black/brown biogrowth.
- AED [automated external defibrillator] last electrical safety inspection completed 03/2019 label states inspection due 09/2019 - one month overdue.
- Phone jack at open nursing station pulled out of the wall with exposed wires.

Observation of Unit B revealed the following:
- Patient Nutrition room observed sink faucet dripping with buildup of greenish yellow brown substance on spout, sink bowl dirty, flooring under sink discolored with black/brown biogrowth.
- Laundry room sink faucet corroded, flooring under sink discolored with black/brown biogrowth.
- AED [automated external defibrillator] last electrical safety inspection completed 03/2019 label states inspection due 09/2019 - one month overdue.

Observation on Unit C revealed the following:
- Patient Nutrition room observed sink faucet dripping with buildup of greenish yellow brown substance on spout, sink bowl dirty, flooring under sink with standing water, floor tile buckling and discolored with black/brown biogrowth.
- AED [automated external defibrillator] last electrical safety inspection completed 03/2019 label states inspection due 09/2019 - one month overdue.

Observation of Unit M revealed the following:
- AED [automated external defibrillator] last electrical safety inspection completed 03/2019 label states inspection due 09/2019 - one month overdue.
- Phone Numbers to the following agencies were not posted:
- AHCA Complaint Line
- The Joint Commission
(see photographic evidence)

On 11/04/2019 interview with RN supervisor confirmed the above findings.
On 11/05/2019 interview with Director of Plant Operations and RN Educator/Infection Preventionist, stated corrective actions and repairs to the above areas have been initiated.

Based on observation and interview it was determined the facility failed to ensure proper disposal of trash on the premises.

Findings included:

On 11/05/2019 at approximately 10:00, escorted by the Director of Plant Operations and the Maintenance Assistant, a tour of the facility premises loading dock, employee smoking area and trash storage area revealed three metal trash bins. One bin was open with bags of trash showing, the bin had a rusted hole in the front right side measuring approximately 6 inches by 9 inches with loose trash exposed and on the ground. The area had used pallets stacked behind the bin with more scattered loose trash as well as trash and debris buildup in and around grounds of waste management holding receptacles. (see photographic evidence).

An interview with Maintenance Assistance stated trash pick up was due and agreed the trash should not be on the ground.

Based on observation and interview it was determined the facility failed to ensure a sanitary environment.

Findings include:

On 11/04/2019 beginning at 10:30 a.m., a tour of the nutrition pantries on the four patient units was initiated. Unit A was observed to have a dirty refrigerator with dried spilled liquid substance (see photographic evidence), open containerof sports drink with no patient name or date opened. Nutrition Rooms on Units A, B, & C had actively dripping water from sinks onto the floor, sink faucets (see photographic evidence) leaking, faucets with thick green/yellow/brown build-up on spouts. (see photographic evidence). Flooring under sinks in nutrition rooms on Unit A, Unit B, Unit C buckling, discolored blackish brown with musty odor (see photographic evidence) . An interview with the Director of Plant operations stated the sinks have been an ongoing issue.
On 11/04/2019 at approximately 10:30 a.m. during an observation of the dining room, a large spill of a brown liquid was noted to the right of the coffee dispenser on a side counter. The spill was approximately the size of a dinner plate.
This same spill was also observed during observation of the lunch meal, on 11/04/19 at approximately 11:35 a.m.
This same spill was also observed during observation of the breakfast meal on 11/05/19 at approximately 8:30 a.m. At this time the Director of Plant Operations was made aware of the spill. He reported he had not seen the spill and wondered where the liquid had come from. He pulled the drain pan off of the front of the coffee urn and surmised that the cause might be a clogged drain.
On 11/04/19 at 11:40 a.m. , the air filter on the side of the ice machine was noted to be coated in a gray fuzzy residue, which also coated the outside surface of the filter housing. The Director of Plant Operations reached up to the filter housing and was able to drag his finger through the fuzzy residue, leaving a clear line on the housing strut. He reported that he has a contracted company that changes out the filters and he would have to contact them for service.
On 11/04/19 beginning at 11:45 a.m. , a tour was made of the nourishment room on the C unit. There were several dried out corn kernels observed inside of the micro wave oven. The rotating plate located inside of the micro wave oven was noted to be soiled with a brownish colored residue.
On 11/05/2019, beginning at 8:45 a.m., a tour was made of the nourishment pantries on two of the four patient units. Housed in each pantry was a micro wave oven. The insides of both micro wave ovens , on Unit A and Unit B, were noted to have bits of dried dark residue, with splatters on the floor of the microwave, side walls and ceilings. The surfaces were greasy to the touch. The Director of Plant Operations had accompanied the surveyor into the pantries and reported that the Technicians on the units are to wipe out the insides of the microwaves when there is a spill. He reported that he would have to assign the task of cleaning the micro wave ovens to a housekeeper.

On 11/07/2019 at approximately 11:00 am an interview with the RN educator/Infection Preventionist confirmed the above findings and stated she has been working diligently since her hire in May 2019.

Based on review of clinical records, staff interview and review of policy and procedure it was determined the facility failed to ensure the patient's discharge plan was reassessed after continuing care needs were identified for one (#33) of thirty-four patients sampled.

Findings included:

Review of the facility policy, "Discharge Planning," #CS1008, effective 6/24/2017, stated discharge planning begins at the point of admission by the physician and continues throughout treatment as an interdisciplinary effort.

Review of the clinical record for patient #33 revealed the patient was admitted on 10/04/2019 and discharged on 10/14/2019.

Review of the initial psychiatric evaluation, dated 10/05/2019 at 10:30 am, revealed the patient reported speaking only a little English and required a translator for communication. Documentation of the patient's history of present illness revealed the patient had chronic back pain which made walking difficult, had problems with his colon and needed a wheelchair. The patient reported he cannot live alone because he cannot take care of himself. The psychiatrist documented per the intake report the patient reported trying to find placement in an ALF (Assisted Living Facility) but reported he would rather be dead. The patient's living condition stated he lived alone. Documentation stated the estimated length of stay was 7-8 days and initial discharge plan was residential placement.

Review of the clinical record revealed collateral information was obtained from the patient's daughter on 10/07/2019 at 4:24 pm. The daughter reported her father had been at an assisted living facility but he complained about the food, expressed feelings of depression, potentially due to loss of independence, had been aggressive at times, and had been previously hospitalized for suicidal and homicidal ideations. The daughter expressed concerns related to the patient's cognitive decline, being non-compliant with medications, his inability to manage his medications, and stated the patient should not be driving anymore due to having two unreported car accidents.

Review of the patient's individualized Interdisciplinary Treatment Plan, dated 10/07/2019, revealed the initial discharge plan was to return to his previous living arrangement and attend outpatient therapy with a psychiatrist or therapist. The patient's strengths were listed as support system, spirituality or religious affiliation, and capable of independent living. The patient's weaknesses were listed as employment/job concerns and physical/medical problems. Review of the plan revealed the anticipated discharge date was 10/14/2019 and the initial discharge criteria was improved stabilization in mood, thinking, and/or behavior. Review of the treatment plan listed one active psychiatric problem which was depressed mood without psychosis. The plan listed one active medical problem which was chronic pain. Review of the plan revealed the RN (Registered Nurse), Social Worker, and Activity Therapist signed the interdisciplinary plan. There was no signature by the physician. There was no evidence the patient was provided the opportunity to participate in the treatment and discharge planning in a language he could understand.

Review of the Psychiatric Progress notes for the last three days prior to discharge revealed the following. On 10/12/2019 the psychiatrist documented the patient was a planned discharge for today but on evaluation the patient reported his mood was "not good." The patient reported depression level was 5 out of 10 with anxiety. The patient reported he did not feel he was safe for discharge and requested a change to his medications. The patient further reported he had little to no support system, no primary care physician and no psychiatrist. He reported he had no family to assist him in locating the physicians he needed or to drive him. The progress note stated sleep is "much better than last night," his appetite was poor, patient reported adherence to medications, and denied any suicidal or homicidal ideations, plans or intent. The psychiatrist stated the patient had not been attending groups due to a language barrier. The progress note stated the patient's response to treatment: has achieved some treatment goals but still in process.

On 10/13/2019 at 10:45 am the Psychiatric Mental Health Nurse Practitioner evaluated the patient. The progress note stated the patient's chief complaint was "I don't feel good, I have constant pain in the stomach and I don't eat food." The patient reported difficulty sleeping and racing thoughts. Review of the plan was to order a nutrition counseling consult and increase his medication for depression and insomnia. The progress note stated the patient's response to treatment: has achieved some treatment goals but still in process and the estimated date of discharge was 3-5 days.

Review of the psychiatric discharge summary, signed by the psychiatrist, no date or time documented, revealed the patient was admitted for suicidal ideation, anxiety and depression on 10/04/2019. The psychiatrist documented 10/14/2019 "I'm okay." The summary stated the patient participated in groups and activities. The physical/mental condition documented was in a wheelchair and the functional condition was stable. The recommendations for follow-up and aftercare were to continue current medications and follow-up with outpatient mental health care on 10/21/2019 at 8:00 am. Review of the discharge plan provided to the patient at the time of discharge revealed a section for scheduled aftercare providers. The plan provided the name, address, phone number, appointment day and time for a mental health follow-up appointment and one other community resource directory. The discharge location was to patient's home. The plan stated medical equipment was n/a (not applicable), self-care activities of daily living stated no help was needed, and shopping, appointments, picking up prescriptions, and managing bills stated no help was needed. The plan was signed by the patient on 10/14/2019 and the form indicated the patient was provided a copy. There was no indication the plan was reviewed with the patient in a language he could understand.

An interview with the Director of Clinical Services was conducted on 11/08/2019 at 12:45 pm at which time she confirmed the above findings. The Director of Clinical Services confirmed the patient was discharged with home health services, not indicated on the discharge plan, and a confirmation fax was located in the clinical record.

Based on review of clinical records and staff interview it was determined the facility failed to ensure a list of home health agencies (HHAs) was presented to patients and failed to inform the patient of their freedom to choose for one (#33) of thirty-four patients sampled.

Findings included:

Review of the clinical record for patient #33 revealed the patient was admitted on 10/04/2019 and discharged on 10/14/2019.

Review of the clinical record revealed collateral information was obtained from the patient's daughter on 10/07/2019 at 4:24 pm. The daughter reported her father had been at an assisted living facility but he complained about the food, expressed feelings of depression, potentially due to loss of independence, had been aggressive at times, and had been previously hospitalized for suicidal and homicidal ideations. The daughter expressed concerns related to the patient's cognitive decline, being non-compliant with medications, his inability to manage his medications, and stated the patient should not be driving anymore due to having two unreported car accidents.

Review of the Interdisciplinary Treatment Plan, dated 10/07/2019, revealed the initial discharge plan was to return to his previous living arrangement and attend outpatient therapy. Review of the plan revealed the anticipated discharge date was 10/14/2019 and the initial discharge criteria was improved stabilization in mood, thinking, and/or behavior. Review of the interdisciplinary treatment plan revealed no evidence the patient was provided the opportunity to participate in treatment and discharge planning in a language he could understand.

Review of the psychiatric discharge summary, signed by the psychiatrist, no date or time documented, revealed the patient was admitted for suicidal ideation, anxiety and depression on 10/04/2019. The psychiatrist documented 10/14/2019 "I'm okay." The physical/mental condition documented was in wheelchair, functional condition was stable. The recommendations for follow-up and aftercare stated to continue current medications, follow-up with outpatient care on 10/21/2019 at 8:00 am. Review of the discharge plan provided to the patient at the time of discharge revealed a section for scheduled aftercare providers. The plan provided the name, address, phone number, appointment day and time for a mental health follow-up appointment and one other community resource directory.

An interview with the Director of Clinical Services was conducted on 11/08/2019 at 12:45 pm regarding the discharge plan and services for aftercare for patient #33. The Director of Clinical Services confirmed the patient was discharged with home health services and provided a confirmation fax. During the interview the Director of Clinical Services confirmed a list of home health agencies (HHAs) was not presented to patients and the patient was not informed of his freedom to choose. She confirmed there was no documentation of home health services on the discharge plan provided to the patient and confirmed the discharge plan was not provided in a language the patient could understand.

Based on interviews with facility staff, review of the facility's Policies for Organ/Tissue/Eye Donation, and review of the agenda for Orientation for new Employees, the facility failed to ensure staff were educated on the facility's procedures for organ, tissue and eye donations.

Findings included:

The facility's policies for Organ/Tissue/Eye Donation (OTE 1002 and OTE 1003) were reviewed and noted to include nursing staff responsibilities and staff education related to organ, tissue or eye donations.
Facility policy OTE 1002 - Nursing Staff Responsibilities listed under Policy: point #9: "Nursing staff at all levels of licensure will receive education and training on the requirements of the designated organ procurement organization (OPO) serving this hospital. Due to the sensitive and potential life - saving impact of organ donation, nursing staff interacting with patients and their families must successfully complete in services about organ procurement and donation."

Facility policy OTE 1003 - Staff Education listed under Policy, point #2: "In services regarding donation issues shall be conducted during orientation for new staff, annually thereafter, when there are policy and procedure changes and as needed."

In an interview with the Risk Manager on 11/06/2019 beginning at 8:45 a.m., it was reported that "per the Director of Nurses, there has been no training on Organ/tissue/eye donations."

In an interview with the Registered Nurse on the C unit, on 11/06/2019 beginning at 11:10 a.m., she confirmed she had been working at the facility for one year. She reported "not to my recollection" when asked if she had received training on organ donations at the facility.

A review of the new employee Orientation Agenda revealed there was no agenda item indicating training on organ, tissue or eye donations was provided.

Based on staff interview and review of job descriptions and the Organizational Chart, the facility failed to develop criteria for the position of Director of the Outpatient services.

Findings included:

During a review of the facility's outpatient services, identified as the Partial Hospitalization Program/Intensive Outpatient Program, (PHP/IOP), it was not clear who the Director of the program was.
Review of the facility's Organizational Chart revealed the PHP/IOP reported directly to two Service Directors (Social Services and Clinical Services), neither of which were Physicians.

An interview was conducted on 11/06/2019 beginning at 2:35 p.m. with a Licensed Clinical Social Worker (LCSW) who had been identified as the Manager of the unit since June 2019. He reported that he felt he had the "PHP up and running, and now with newly hired staff, he could concentrate on the IOP," which he identified as the step down unit .

He described the daily schedule of the PHP consisting of group therapy sessions, which he confirmed he was actively involved in providing to patients admitted to the out patient program. The daily agenda also included nursing education and recreational therapy. He listed out patient staff of the PHP/IOP, which included two Social Workers, one of which was Licensed, a Registered Nurse, an Administrative Assistant and a Transporter. He did not include a Physician or Psychiatrist as one of the regular staff who provided patient services or direction to the out patient clinic. When asked who he reported directly to, he named the Clinical Service Director and confirmed that he was not familiar with the Social Service Director that was listed on the Organizational Chart.

In an interview with the Clinical Services Director, on 11/08/2019 beginning at 1:05 p.m., it was reported that the LCSW was the lead therapist. She confirmed the job description may not delineate that but 'everyone knows that'. A review of the Therapist II job description which the LCSW had signed on 11/08/2019, did not reveal that the Therapist II would take a lead role in directing the department. All essential functions of the job were direct patient related duties.

A review of the Policy entitled 'Outpatient Treatment Program Overview' (Policy # OPO030), revealed staff that were a part of the out patient services as : "Under the direction of a psychiatrist , members of this team include: psychiatric / mental health nurses, social workers or other therapists, occupational therapists, and activity therapists"

In the interview with the Director of Clinical Services which was conducted on 11/08/2019 beginning at 1:05 p.m., it was reported that the Psychiatrists rotate through the out patient service as the Director, with a schedule of seven days on, seven days off. She provided the job description for the Doctors which she noted that all facility job descriptions cover both in patient and out patient services. A review of the job description did not refer to providing patient services or direction in the out patient clinic.

On 11/08/2019 at 3:40 p.m., the Registered Nurse who had taken the position at the PHP within the last month, reported when asked if she saw the facility's medical director provide out patient services at the PHP, 'he sees patients on occasion.'

On 11/08/2019 at 8:40 a.m., the Risk Manager was asked about the organization of the outpatient services and who was directing or responsible for the out patient services. She reported that it would be the Director of Clinical Services but the Director of Social Services also could provide oversight.

An interview was conducted with the Chief Executive Officer (CEO) on 11/8/19 at 10:30 am. The CEO was advised there appeared to be some confusion amongst the members of the Outpatient Services staff as to the identity of the Director of the department. The CEO indicated the hospital Medical Director was responsible as the Medical Director for Outpatient Services.

Based on a review of Quality Improvement monthly reports and interview with facility staff, the facility failed to ensure quality monitoring was occurring for the Out Patient Program.

Findings included:

During an interview with a Social Worker on the Out Patient unit, on 11/06/19 beginning at 2:35 p.m., when asked about quality improvement monitoring, he responded that he reviews his charts and the other providers on the unit for completeness. He reported that he doesn't share that information formally with the Director of Clinical Services and he wasn't sure what monitoring of the unit that she did or if she reported any data at the Quality Improvement meetings.

On 11/07/2019 beginning at 12:40 p.m., the Director of Clinical Services reported that she had taken over the out patient services program in August and she was not familiar with the prior Quality Monitoring of the program.
She reported on 11/07/2019 at 1:40 p.m. that the Risk Manager had confirmed that there was no quality monitoring of the outpatient services program reported at the Quality Improvement (QI) meetings. She reported that the Risk Manager had told her that as long as she had been with the facility (hired in February), there had been no reports from the outpatient program at the QI meetings.

During a review of the printed reports of the monthly QI meetings, reports from the meetings held on 03/28/2019, and 08/31/2019 included the note 'not reviewed' for the monitoring by the Outpatient:PHP/IOP. The meeting report for 05/30/2019 indicated, "tabled to June meeting" for the QI report for the outpatient service.

Based on review of clinical records and staff interview it was determined the facility failed to ensure progress notes, recorded by the doctor responsible for the care of the patient, documented the patient's progress or lack of progress towards attaining short and long-range goals outlined in the patient's individual treatment plan for one (#33) of thirty-four patients sampled.

Findings included:

Review of the clinical record for patient #33 revealed the patient was admitted involuntarily under the Baker Act law on 10/04/2019 for suicidal ideations. Review of the discharge summary revealed the patient was discharged on 10/14/2019.

Review of the initial psychiatric evaluation, dated 10/05/2019 at 10:30 am, revealed the patient reported speaking only a little English and required a translator for communication. Review of the nurse/MHT (Mental Health Technician) group progress notes for the length of the patient's admission revealed the patient did not participate in group therapy due to a language barrier.

Review of the clinical record revealed on 10/07/2019 the Interdisciplinary Treatment Plan was signed by the patient. Review of the plan listed one active psychiatric problem which was depressed mood without psychosis. The plan listed one active medical problem which was chronic pain. Review of the plan revealed the RN (Registered Nurse), Social Worker, and Activity Therapist signed the interdisciplinary plan. There was no signature by the physician.

Review of the plan revealed the patient's individualized long-range goal was to improve his overall mood. The plan stated the short-term goal was to attend and participate in at least one group daily.

Review of the Psychiatric Progress notes for the last three days prior to discharge revealed the following. On 10/12/2019 the psychiatrist documented the patient was a planned discharge for today but on evaluation the patient reported his mood was "not good." The patient reported depression level was 5 out of 10 with anxiety. The patient reported he did not feel he was safe for discharge and requested a change to his medications. The patient further reported he had little to no support system, no primary care physician and no psychiatrist. He reported he had no family to assist him in locating the physicians he needed or to drive him. The progress note stated sleep is "much better than last night," his appetite was poor, patient reported adherence to medications, and denied any suicidal or homicidal ideations, plans or intent. The psychiatrist stated the patient had not been attending groups due to a language barrier. The progress note stated the patient's response to treatment: has achieved some treatment goals but still in process.

On 10/13/2019 at 10:45 am the Psychiatric Mental Health Nurse Practitioner evaluated the patient. The progress note stated the patient's chief complaint was "I don't feel good, I have constant pain in the stomach and I don't eat food." The patient reported difficulty sleeping and racing thoughts. Review of the plan was to order a nutrition counseling consult and increase his medication for depression and insomnia. The progress note stated the patient's response to treatment: has achieved some treatment goals but still in process.

Review of the Interdisciplinary Treatment Plan revealed the initial discharge plan, dated 10/07/2019, was to return to his previous living arrangement and attend outpatient therapy with a psychiatrist or therapist. The patient's strengths were listed as support system, spirituality or religious affiliation, and capable of independent living. The patient's weaknesses were listed as employment/job concerns and physical/medical problems. Review of the plan revealed the anticipated discharge date was 10/14/2019 and the initial discharge criteria was improved stabilization in mood, thinking, and/or behavior. Review of the interdisciplinary plan revealed the patient's short and long-range goals were resolved on 10/14/2019. Review of the discharge plan revealed no documented changes to the plan.

Review of the psychiatric discharge summary, signed by the psychiatrist, no date or time documented, revealed the patient was admitted for suicidal ideation, anxiety and depression on 10/04/2019. The psychiatrist documented 10/14/2019 "I'm okay." The summary stated the patient participated in groups and activities. The physical/mental condition documented was in wheelchair, functional condition was stable. The recommendations for follow-up and aftercare stated to continue current medications, follow-up with outpatient care on 10/21/2019 at 8:00 am.

An interview with the Director of Clinical Services was conducted on 11/08/2019 at 12:45 pm and the Risk Manager on 11/08/2019 at 3:15 pm. Following review of the clinical record the Director of Clinical Services and the Risk Manager confirmed the above findings.

Based on review of clinical records and staff interview it was determined the facility failed to ensure the record of each discharged patient had recommendations from appropriate services concerning aftercare for one (#33) of thirty-four patients sampled.

Findings included:

Review of the clinical record for patient #33 revealed the patient was admitted involuntarily under the Baker Act law on 10/04/2019 for suicidal ideations. The patient was discharged from the facility on 10/14/2019.

Review of the initial psychiatric evaluation, dated 10/05/2019 at 10:30 am, revealed the patient reported speaking only a little English and required a translator for communication. Review of the nurse/MHT (Mental Health Technician) group progress notes for the length of the patient's admission revealed the patient did not participate in group therapy due to a language barrier.

Review of the Interdisciplinary Treatment Plan, dated 10/07/2019, revealed the initial discharge plan was to return to his previous living arrangement and attend outpatient therapy with a psychiatrist or therapist. The patient's strengths were listed as support system, spirituality or religious affiliation, and capable of independent living. The patient's weaknesses were listed as employment/job concerns and physical/medical problems. Review of the plan revealed the anticipated discharge date was 10/14/2019 and the initial discharge criteria was improved stabilization in mood, thinking, and/or behavior. Review of the interdisciplinary treatment plan revealed no evidence the patient was provided the opportunity to participate in treatment and discharge planning in a language he could understand.

Review of the clinical record revealed collateral information was obtained from the patient's daughter on 10/07/2019 at 4:24 pm. The daughter reported her father had been at an assisted living facility but he complained about the food, expressed feelings of depression, potentially due to loss of independence, had been aggressive at times, and had been previously hospitalized for suicidal and homicidal ideations. The daughter expressed concerns related to the patient's cognitive decline, being non-compliant with medications, his inability to manage his medications, and stated the patient should not be driving anymore due to having two unreported car accidents.

Review of the psychiatric discharge summary, signed by the psychiatrist, no date or time documented, revealed the patient was admitted for suicidal ideation, anxiety and depression on 10/04/2019. The psychiatrist documented 10/14/2019 "I'm okay." The summary stated the patient participated in groups and activities. The physical/mental condition documented was in wheelchair, functional condition was stable. The recommendations for follow-up and aftercare stated to continue current medications, follow-up with outpatient care on 10/21/2019 at 8:00 am. Review of the discharge plan provided to the patient at the time of discharge revealed a section for scheduled aftercare providers. The plan provided the name, address, phone number, appointment day and time for a mental health follow-up appointment and one other community resource directory.

An interview with the Director of Clinical Services was conducted on 11/08/2019 at 12:45 pm regarding the discharge plan and services for aftercare for patient #33. The Director of Clinical Services confirmed the patient was discharged with home health services and provided a confirmation fax. She confirmed there was no documentation of home health services on the discharge plan provided to the patient and confirmed the discharge plan was not provided in a language the patient could understand.