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At the time of the revisit on 01/11/2016, this Condition was not corrected.
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Based on review of hospital documents and interviews with staff, the hospital failed to have a comprehensive and effective quality assessment and performance improvement (QAPI) program, involving all hospital departments, with review, analysis and plans of action to improve health outcomes.

Findings:

1. Surveyors requested the hospital's current QAPI Plan and QAPI committee meeting minutes since the 11/04/2015 survey.

~ Only one meeting minutes was provided, 12/09/2015. Staff C, the current staff identified as responsible for the QAPI program, told the surveyors on the afternoon of 01/11/2016 that only one meeting had been held.

~ The QAPI plan had not been revised to show the different department projects; how often each department would submit data for review and analysis, or how that data would be monitored.

2. For the departments presented and data recorded, the QAPI meeting minutes did not contain evidence of analysis with plans of action and follow-up when indicated to ensure the corrective actions were effective and maintained. For example, but not limited to:
a. Pharmacy and Therapeutics - medication errors. The minutes recorded the pharmacist reported most medication errors occurred when a relief pharmacist was present, but no corrective actions were presented or a time-frame to follow-up to determine if the plan of action was effective.

b. Critical Incidents - incidents of aggressive behavior and falls. The minutes contained no analysis, plans of action or time frames for follow-up to try to decrease the occurrences.

c. Recreational Therapy - assessments with a target goal of 95% was not met. The minutes did not contain analysis as to why the target goal was not met, plans of actions or time frames for follow-up to determine if the plan of action was effective and target goal was reached.

4. The QAPI meeting minutes did not contain evidence Contracted services were reviewed.

At the time of the revisit on 01/11/2016, this Condition was not corrected.
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Based on review of hospital documents and staff interviews the hospital failed to:

a. provide an active on-going infection control program that monitored all areas of the hospital to ensure a safe and sanitary environment; and

b. designate an qualified infection control officer to ensure the infection control program was effective in preventing and controlling infections and was hospital-wide.

Findings:

Jim Taliaferro is a 14-bed inpatient psychiatric hospital. In addition to the psychiatric diagnoses, the hospital had a history of treating patients who also had newly diagnosed and medical history of Hepatitis C and Human Immunodeficiency Virus (HIV) and multi-drug organisms.


1. Although staff had been provided an inservice on proper cleaning of the hospital's OneTouch UltraMini blood glucose monitoring system (glucometer), on 01/11/2016 at 2:30 p.m., the staff identified as responsible for infection control, Staff B, stated no monitoring had been done to ensure disinfection and the policy was followed.


2. In regards to Infection Control of linens, on 01/11/2016 at 1:00 p.m., Staff D told the surveyors the hospital was still in the process of ensuring the linens were laundered according to the recommended standards.

~ The surveyors requested to review the revised policy. At the time of the exit conference on the afternoon of 01/11/2016, no revised policy had been provided.

~ Meeting minutes that contained infection control did not show review and analysis of laundry temperatures and plans of action had occurred.


3. Meeting minutes:
Only one Infection Control Committee Meeting minutes was provided to surveyors for review, 12/30/2015.

~ The meeting minutes only contained a listing of items, but did not demonstrate review, analysis and plans of actions with follow-up when indicated to ensure the corrective actions were effective and maintained. Examples include, but not limited to:
a. Twelve (12) tuberculin tests provided to staff and results were negative. The documentation did not how many tuberculin test were to be needed to done.

b. New employee physicals and orientation were being done on an individual bases. - The documentation did not list how many new employee physicals and orientation were to be done or how many had been done.

c. Client infections were listed for October, November and December, but that was not documentation if any were hospital acquired infection; if cultures were done; or if the antibiotic prescribed were effective.

~ The meeting minutes did not show a hospital and community-wide Risk Assessment had been conducted to identify the organisms present in the hospital and community. This was confirmed with Staff B on the afternoon of 01/11/2016.

~ Meeting minutes did not contain evidence the hospital's disinfectants had been review and approved.

~ There was no documentation of any surveillance/monitoring to ensure the infection control policies and procedures were followed. On 01/11/2016, Staff B stated she had not conducted any surveillance/monitoring for this, including hand hygiene compliance monitoring.


4. Only one meeting minutes, 12/09/2015, for the hospital's quality assessment and performance improvement (QAPI) was provided to the surveyors for review. Staff C, the staff responsible for the QAPI program, stated that only one meeting had occurred since the survey on 11/04/2015.

~ The meeting minutes did not contain evidence infection control data was reviewed, analyzed, with plans of actions and follow-up when indicated to ensure the corrective actions were effective and maintained.


5. On 01/11/2016 at 1:55 p.m., Staff B told the surveyors that she still did not have any infection control (IC) training, education or certification in infection control.