HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations/conditions of participation by sharing hospital space, staff and services with another licensed facility.

Failure by the hospital to provide independent oversight can lead to dependence on another licensed entity for compliance with federal regulations and put patients at risk to receive poor quality care.

Findings included:

The hospital failed to meet applicable federal, state and local requirements by:

Sharing numerous support services.

Sharing of hospital staff.

Sharing of clinical care areas of the hospital.

Cross Reference Tag A 043
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Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations/conditions of participation by sharing hospital space, staff and services with another licensed entity.

Failure by the hospital to demonstrate individuality with space, staff, and services can lead to dependence on another licensed entity for compliance with federal regulations.

Findings included:

ITEM #1 - Shared Services

1. Review of the Governing Body documents and meeting minutes showed the following:

a. Review of the document titled, "Navos Second Amended and Restated Bylaws", showed that Navos is referred to as a single "corporation" which encompasses multiple different entities that is managed by a board of directors. The bylaws did not expressly mention the hospital or other facility types that are overseen by the governing body.

b. Review of the Governing Body meeting minutes for 2017 showed that Navos is largely operated as a single entity. The only direct reference to the hospital was found in the minutes dated 01/09/17. These minutes indicate that the "E & T" beds (evaluation and treatment, which is part of the residential treatment facility (RTF)) are located within the hospital, suggesting that these beds and the hospital beds are treated as part of the same facility.

2. Review of hospital policies showed that the policies did not distinguish if they applied to the hospital, other entities, or the organization as a whole. The director of inpatient nursing (Staff #201) was listed as the owner of the policies dealing with direct patient care.

3. Review of the Infection Control Program showed the following:

a. Review of the 2016-2017 infection control plan showed that the infection control committee was made up of "residential and hospital" nurses. Further review of the infection control plan indicates that areas with hospital and residential beds are treated as a single entity for surveillance, prevention and control, separately from outpatient settings.

b. Review of the infection control program evaluation for 2015-2016 and goals for 2016-2017 did not show any distinct review of the hospital patients or services. Data in the evaluation were separated by floor rather than facility type, indicating that surveillance of the hospital and RTF services is combined.

c. Review of the infection control program meeting minutes from 2017 showed that meetings were organization wide. Inpatient issues are not delineated by hospital patients or services, but rather as inpatient services.

4. Review of the Quality Assurance and Performance Improvement Program showed the following:

a. Review of the "Quality Improvement Program" showed that the quality program is divided into three distinct groups: outpatient programs; children's programs; inpatient programs. The inpatient program quality structure involves membership from various departments of the hospital, all of which are indicated as encompassing all inpatient services (hospital and RTF). The inpatient clinical program reports quality information to the overall quality improvement committee. The quality plan does not specifically address the hospital as a single entity.

b. At the time of this investigation, the hospital lacked a Quality Director. On 02/06/18 at 9:00 AM, Surveyor #2 interviewed the Hospital Administrator (Staff #201) regarding the hospitals services. The administrator stated that all functions of the hospital are incorporated with the RTF, and overseen by the organization as a single, inpatient entity.

5. Review of services provided under contract showed the following:

a. On 02/06/18 at 1:30 PM, Surveyor #2 interviewed the hospital administrator (Staff #201) regarding various names of the facility on contracts. The administrator stated that Navos Mental Health Solutions was the technical company name and any other naming conventions are placeholders for this name.

b. Review of the document "Service Agreement between Navos Mental Health Solutions and Farestart", signed 12/18/17, showed that Farestart provides 100 lunches and dinners to Navos Mental Health Solutions.

c. On 12/06/17 at 12:00 PM, Surveyor #2 observed a food service at the facility. The hospital and RTF patients were served at the same time, by the same staff, and in the same dining area.

d. Review of the document, "Janitorial Service Agreement," between ABM Onsite Services and Navos Mental Health Solutions, showed that janitorial services would be provided at the hospital location. The document does not specify specifically that it applies to the hospital, but rather the entire building.

e. On 12/07/17 at 8:50 AM, Surveyor #2 observed a housekeeper (Staff #203) perform room cleanings. Rooms for both the hospital and RTF patients were cleaned by the same staff during the same shifts

f. Review of the document titled, "Memorandum of Agreement between Qualis Health and Navos Inpatient Services," showed that Qualis Health served as the utilization and quality control review organization (QIO) for hospital patients and providers at Navos. The agreement specifically addresses the medicare provider number for the hospital portion of Navos Inpatient Services.

g. On 02/06/18 at 2:00 PM, Surveyor #2 asked the hospital administrator (Staff #201) if utilization review and quality data for only hospital patients or for both hospital and RTF patients was sent to the QIC. The administrator thought that data from both facility types was went to the QIC, but would need to confirm with the former quality director (Staff #202). The former quality director confirmed via phone call that the data from the hospital and RTF was sent to the QIC.

h. Additional external contracts for external staffing (Emerald City Medical Staffing), laboratory services (LabCorp), and dietician services were reviewed. All of the contracts were signed to provide services for Navos Inpatient Services or Navos Mental Health Solutions, which includes both the hospital and the RTF.

6. Review of hospital policy titled "Provision of Nursing Care, Treatment, and Services" Policy #3023513 Approved 04/16; regarding the structure of the staffing states; "There are two patient care units, each with 35 beds. Both units have licensed and designated Evaluation and Treatment beds and licensed and designated Hospital beds. Services are identical on both units. Nursing care, as part of the hospital's acute inpatient psychiatric services, is available to all patients 24 hours a day, 7 days a week ..."

a. 12/6/17 at 10:30 AM, Surveyor #8 reviewed the staffing plan with the Charge Nurse Staff #801. The Charge Nurse stated that the staff are trained the same and can work with all the patients.

b. Interview with Med Nurse, Staff #806, confirmed that the staff work with hospital and RTF patients and treat them the same.

c. Chief Nursing Officer, Staff #802 confirmed the above findings.

7. Hospital policy titled "Pre-Admission Screening and Patient Placement," Policy #3023511, Reviewed 10/16 states, "If a patient is admitted to an "E" [Residential Treatment Facility] (RTF) bed is found during admission process to have Medicare or a private insurance, ... the patient will be transferred to an "H" [Hospital] bed. ...If a patient admitted to an "E" (RTF) bed is found to have Medicare or Private Insurance. ... after the admission process has started ...the patient will be transferred to an "H" bed (Hospital) bed when one is available. Policy titled "Patient Access- Inpatient Bed placement" Approved 11/1/17 stated "if funding is unknown, the patient will be placed into an E bed while funding is investigated ...once coverage is identified, a bed transfer would be submitted if a patient is in an incorrect bed according to their funding source."

a. On 2/6/18 at 11:15 AM, Surveyor #8 interviewed the Charge Nurse, Staff #801, about the process of patient transfers from the Hospital (H) service to the RTF (E) service. The Charge Nurse explained that each day he receives a notice of the patients that need to be transfered. The Charge Nurse Staff #801, shared the notice with this Surveyor. The document titled "UR Patient Admit / Discharge Request" dated 10/14/17 identified Patient #801 with instruction to discharge from H bed status and Admit to E bed status. the "Funding Source" was noted as "Medicare" and under comments was "Decertified from Medicare" and "Must Move ASAP"

b. On 02/06/18 at 10:00 AM, Surveyor #8 reviewed the transfer process with the Director of Revenue Cycle (Staff #805). The Director related that hospital and RTF transfers are driven solely by the patient's funding source.

8. On 02/06/18 at 9:30 AM, Surveyor #8 reviewed the bed transfer for Patient #801.

a. The discharged medical record showed an order (dated 11/21/17) for the Hospital bed transfer to a "RTF" bed. Further assessment of the record revealed the following:

i. No documentation in the medical record to indicate need or purpose to move the patient from a Hospital bed to Residential Treatment bed.

ii. There were no discharge notes or discharge instructions indicating that the patient had been discharged from one facility and admitted to the other facility.

iii. There was no physician discharge summary for the patient's hospital stay.

iv. There was no physician admit note or history and phsyical, and there was no nursing admission assessment for the RTF admission/transfer.

v. There was no informed consent obtained for treatment in the RTF facility.

vi. There was no evidence the patient was informed of their rights upon admission to the RTF program.

b. At the time of review, Chrage Nurse (Staff #801) confirmed the findings and that no new consents are signed for care and treatment in the transferred facility.

9. Review of the medical record for Patients #802, #803, #804, and #806 revealed the following:

a. No evidence or supporting documentation indicating the need to discharge from hospital bed status (Patients #802 and #806) and admit to RTF patient status. No evidence or supporting documentation indicating the need to discharge from the RTF and admit to hospital bed status (Patients #803 and #804).

b. There was no consent for treatment signed on admit to RTF facility for Patients #802 and #806. There was no consent signed on admit to the hospital services for Patients #803 and #804.

c. The medication administration record was not separate from the other licensed facility.

d. At the time of interview, the Nurse Manager (Staff #801) confirmed these findings and that no new consents are signed for care and treatment in the transferred facility.

10. Review of the medical record for Patients #801, #802, #803, #804, and #806 revealed the following:

a. Three of the 5 charts were Hospital Patients that transferred to the RTF facility. There were no discharge summaries present in the chart following the hospital discharge.

b. The Nurse Manager (Staff #801) confirmed discharge summaries are done after the hospital patient has been discharged from the RTF facility.

11. The facility's "Patient Rights and Responsibilities" dated 04/28/16 stated the patient may make informed decisions regarding their care ... request or refuse care, have a right to a psychosocial and medical evaluation within 24 hours of admission to determine whether continued detention in the facility is necessary, have all information complied, obtained or maintained in the course of receiving treatment kept confidential ..."

12. On 02/06/18 at 10:30 AM, Surveyor #8 reviewed the transfer process for Patient #801 in the medical record with the RN Nurse Manager Staff #801. The Manager shared that the managers receive notification of insurance/funding changes and they begin the process of transferring a patient from a hospital bed to an RTF bed, or from an RTF to a hospital bed. They start with getting a doctor's order and then seeing if there is an open bed, make the changes in the electronic medical record and then move the patient. RN #801 confirmed that there is no conversation to inform the patient, there is no "discharge" paperwork tor the patient and or their family. RN #801 reported that the patient is only aware of room change.

13. Review of the medical records for patients #802, #803, #804, and #806, did not show evidence that the document titled "An Important Message From Medicare About Your Right" was present for both admission and/or discharge.


ITEM #2 - Shared Staff

1. On 02/06/18 at 9:00 AM, Surveyor #2 interviewed the Hospital Administrator (Staff #201) regarding the organization of the hospital. The administrator stated that both facility types (The hospital and RTF) operate under a single "umbrella", with all functions and staffing carried out by Navos as a single entity. This includes facilities and administrative staff.

2. Review of the Medical Staff showed the following:

a. Review of the document titled, "Organized Medical Staff Bylaws," revised 05/12, showed that the organized medical staff were appointed to the inpatient or outpatient services departments of Navos.

b. Review of the document titled, "Navos Organized Medical Staff Privileging Application," showed that providers were privileged for the inpatient or outpatient setting. Neither the minimal criteria nor the core privileges distinguish between the hospital and RTF inpatient settings, but treat both facilities as a single entity.

c. On 02/06/18 at 1:30 PM, surveyor #2 interviewed the Hospital Administrator (Staff #201) regarding credentialing of medical staff at the hospital. The administrator stated that medical staff are credentialed as either inpatient or outpatient staff, rather than credentialed for the hospital or RTF.

3. Review of the pharmaceutical services organizational chart showed that Navos operates a single pharmaceutical services staff that reports to the Clinical Chief Officer (Staff #205).

4. Review of various job descriptions showed the following:

a. Review of the position description for the hospital administrator showed that the administrator was responsible for the operation of Inpatient Services, which includes both the hospital and RTF facilities.

b. Review of the position description for the inpatient quality manager showed that the manager oversaw the quality program for all inpatient services. Per the position description this program encompasses regulations that apply to both the hospital and RTF licensures.

c. Review of the position description for the director of care management and court services showed that the director reports to the inpatient hospital administrator, which would oversee both the hospital and RTF.

d. Review of the position description for the director of pharmacy showed that the director reports to the chief of inpatient services, who would oversee both the hospital and the RTF.

5. On 12/06/17 Surveyor #8 observed the 8:00 AM medication pass on the 3rd floor. Interview with the Medication Nurse (Staff #806) showed that she does not know which patient is a Hospital patient and which patient is an RTF patient, and they are treated the same.

6. Review of hospital policy titled "Provision of Nursing Care, Treatment, and Services" Policy #3023513 Approved 04/16; regarding the structure of the staffing, states, "There are two patient care units, each with 35 beds. Both units have licensed and designated Evaluation and Treatment beds [RTF beds] and licensed and designated Hospital beds. Services are identical on both units."

7. On 02/06/18 at 9:30 AM, Surveyor #8 interviewed the Nurse Manager (Staff #801) regarding nurse staffing for the hospital patients. The Nurse Manager stated that they have one staff oriented to work with all the patients. Staff are not oriented to a hospital program and a separate RTF program; it is one in the same.

ITEM #3 - Shared Space

1. Review of the following documents showed how the hospital and residential treatment facility (RTF) began to share facility space:

a. In a letter sent to the Washington State Department of Health (DOH), dated 04/21/06, Navos requested to integrate beds from their hospital license and RTF license onto the same floor. Prior to the request, both facility types were housed on separate floors with separate staff.

b. Centers for Medicare and Medicaid Services (CMS) approved the proposal on 04/12/06. The Washington State Department of Health (DOH) approved the proposal on 05/01/07.

c. In a subsequent letter, dated 04/23/07, Navos requested an additional reorganization of the hospital and RTF beds. Under the new proposal, hospital and RTF rooms would be interspersed throughout each floor.

d. No approval letter was on file from CMS or DOH.

e. In a final letter, dated 12/29/10, Navos stated it was increasing the number of hospital beds to the maximum allowed under the state license and rearranging hospital and RTF rooms again.

f. No approval letter was on file from CMS or DOH.

2. Review of the floor plans for the "Inpatient Hospital Building" showed that both the Navos hospital and RTF shared much of the same space on the second and third floors of the buildings. Shared space included food service and dining areas, pharmaceutical services and medicine administration areas, patient exam and treatments rooms, bathing facilities, and recreational areas. Patient rooms were also interspersed throughout each floor and not divided into units. The rooms were not laid out per the requests outlined above.

3. On 12/06/17 from 10:00 AM to 1:00 PM, Surveyor #2 toured the second and third floors of the hospital and confirmed that the hospital and RTF licenses shared the same spaces for bathing, food service, recreation, patient care, and pharmaceutical services and had rooms interspersed throughout both floors.

4. On 02/06/18 at 9:00 AM, Surveyor #2 interviewed the hospital administrator (Staff #201) regarding the floor plan requests sent to DOH. The administrator stated that the facility was unable to locate documentation approving the changes to the floor plans from CMS or DOH.