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The facility was not in compliance with the CMS (Center for Medicare/Medicaid Services) Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 176, 12/29/17). Specifically, the facility was not in compliance with 482.12 governing Board. Significant corrections evidencing compliance will be required.

Complaint (PIT18C046P) was substantiated. Deficient practices, both related to the complaint and unrelated to the complaint were identified and cited with the details noted further in this report.
The CONDITION is not met as evidenced by:
Based on the nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a significant nature of non-compliance with regards to patient's rights as follows:

(482.12(b) Tag A-057)
The information reviewed during the survey provided evidence the Chief Executive Officer failed to maintain all State and Federal Regulatory Requirements failed to maintain all State and Federal regulatory requirements by not conducting an immediate investigation into an allegation of sexual abuse for one patient (MR1).

Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined the facility failed to maintain all State and Federal regulatory requirements by not conducting an immediate investigation into an allegation of sexual abuse for one patient (MR1).

Finding include:

Review of the facility's Amemded amd Restrated Governing Board Bylaws approved and dated July 2016 revealed "...9.3 Authority and Responsiblity of Administrator...Maintaining all state and federal regualtory requirements..."

1) Review of facility documentation provided to the Department on October 22, 2018 at approximately 11:00 AM revealed "...August 7, 2018,... CEO notified HR (Human Resources) that ...Detective...contacted her regarding an allegation against an employee by a former patient (MR1). HR and legal were notified...CEO advised to have detective contact HR and legal. Detective...conveyed to the ...CEO that he did not want us conducting an internal investigation..."

During interview on October 22, 2018 at approximately 12:00 PM EMP2 confirmed the above findings and revealed no the CEO informed staff of the above finding and that no investigation should be conducted per the police department's request.

The facility was not in compliance with the CMS (Center for Medicare/Medicaid Services) Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 176, 12/29/17). Specifically, the facility was not in compliance with 482.13 Patient Rights. Significant corrections evidencing compliance will be required.

Complaint (PIT18C046P) was substantiated. Deficient practices, both related to the complaint and unrelated to the complaint were identified and cited with the details noted further in this report.
The CONDITION is not met as evidenced by:
Based on the nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a significant nature of non-compliance with regards to patient's rights as follows:

(482.13 Tag A-0144)
The information reviewed during the survey provided evidence the facility did not provide a safe environement for their patients by permitting an employee to continue working while being investigated for an alleged sexual assault.

(482.13 Tag A-0145)
The information reviewed during the survey provided evidence that one of 10 patients sampled for a review of abuse allegations (MR1) the facility failed to conduct an investigation into the allegations of abuse at the time the facility recieved notification of said allegations.

Based on a review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility did not provide a safe environment for their patients by reinstating an employee to return to work while a pending allegation of sexual abuse was being investigated.

Findings include:

Review of facility policy "Patient Rights" effective December 2015, revealed "...q. Patients have the right to recieve care in a safe setting..."

Review of facility policy "Progressive Discipline" last revision March 2018 revealed "...An employeee will not be returned to work from a suspension until it is verifeid that no pending charges related to investigation remain..."

Review of facility documentation revealed on August 7, 2018, the facility was notified that a former patient (MR1) filed a complaint of a n alleged sexual abuse with the local police by a current employee during her admission to the facility between April 2018 and July 2018.

Review of facility documentation revealed EMP1 was suspended pending an investigation for inappropriate touching that occurred on August 14, 2018 involving MR2.

Review of facility documentation revealed that on August 15, 2018, a Detective from the local police department appeared on site at the facility requesting information on EMP1. At that time, the Detective informed the facility he had been informed by a facility employee that EMP1 had been implicated in an alleged inappropriate touching allegation by MR2.

Review of facility docuemntation revealed the facility reinstated EMP1 on September 10, 2018 absolving EMP1 of any wrongdoing regarding the August 14, 2018, inapproriate touching allegation despite EMP1 remaining a suspect in the alleged sexual abuse allegation made by MR1.

Review of facility documentation revealed that EMP1 was arrested by the local police department at the facility on October 16, 2018 on a warrant for alleged sexual abuse of MR1.

During an interview on October 22, 2018, at approximately 6:00 PM, EMP4 confirmed the above findings and that the facility reinstated an employee while a suspect in a pending police investigation for alleged sexual abuse of a former patient.

Based on a review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility failed to ensure the safety and security of their patient population by not immediately investigating allegations of abuse for two of 10 medical records reviewed (MR1 and MR6).
Findings include:
Review of facility policy "Abuse, Neglect, Assault, Alleged or Suspected" last revised April 2016 revealed "...Purpose: To provide for the safety of patients with an organized method of inquiry and reporting of suspected abuse including, but not limited to physical assault, rape, or other sexual molestation, and domestic abuse or neglect. Policy: Employees will report any suspected abuse or neglect of a patient. All accusations of physical, emotional, or psychological abuse of any patient necessitate immediate action. Foremost, patient safety is to be ensured by removing the alleged perpetrator from contact with the patient ...When sexual molestation is stated, suspected or identified, or when physical abuse is stated, suspected, or identified, or when psychological/verbal abuse is stated, suspected, or identified, or when neglect, equipment malfunction, or intentional or accidental misuse of patient care equipment is identified: a. Any reports of sexual assault or suspicious findings should be reported to the Nurse Executive or Nursing Supervisor and to the Quality/Risk Manager who will notify the following. The local law enforcement agency will be contacted as soon as possible."
A review of facility documentation provided to the Department on October 22, 2018 at approximately 11:00 AM revealed the facility Chief Executive Officer was contacted by the local police department on August 7, 2018, regarding an allegation against a current employee by a former patient (MR1) of sexual assault.
During interview with on October 22, 2018, EMP2 confirmed the facility was informed by the police department not to conduct an investigation so no investigation into the allegation of sexual was conducted.
Review of MR2 on October 22, 2018, revealed MR2 was admitted to the facility on August 13, 2018, with diagnoses that included panic attacks and major depressive disorder.
Review of MR2 Nurse's Note dated August 15, 2018 at 12:25 AM revealed ' ...pt. came to the Nurse's Station and c/o (complained of) having a problem (with) night-shift staff person. The Charge Nurse immediately took patient aside and spoke (with) her ... "
Review of written statement provided by MR1 dated August 15, 2018, at 12:25 AM revealed " ...so EMP1 comes in my room and starts rubbing my back. I move over and he says let me rub your back you will go to sleep. I got nervous got out of bed and started to walk out the door then he went on tried to rub up and down my back one more time by the door and that ' s why I came to ask for my PRN (as needed). I am so weirded out right now. I told him, no, I didn ' t need a back rub ... "
Review of written statement provided by EMP11 dated August 15, 2018, at 12:25 AM revealed " ...MR2 came up to the Nurse's Station with a piece of paper folded.
Review of facility documentation undated that was provided to this Department on October 22, 2018 at approximately 11:00 AM revealed that on August 15, 2018, the officer investigating the sexual assault allegation by the former patient (MR1) received a phone call from an unnamed facility employee informing him of a complaint made by (MR2) involving EMP1 that involved inappropriate touching. At that time, the police officer specifically requested the address and phone number of EMP1 who was currently on suspension as of August 15, 2018, pending the investigation of the allegation made by MR2.
Further review of facility documentation revealed " ...September 10, 2018, After our investigation into the August 15, 2018, did not substantiate any inappropriate behavior by (EMP1) and the police provided no further information regarding their investigation, EMP1 was returned to work ... "
Further review of facility documentation revealed " ...October 16, 2018, Detective ...showed up onsite with a warrant, and (EMP1) was taken into custody (for the alleged sexual assault of MR1) ... "
During interview on October 22, 2018 at approximately 6:00 PM EMP4 confirmed the above findings and revealed the facility did not conduct an investigation into the allegation of sexual abuse made by the former patient (MR1) to the police which the facility was informed of on August 7, 2018 because the police requested no investigation be conducted. EMP4 also confirmed that the facility became aware EMP1 was a suspect in the MR1 allegation on August 15, 2018, at which time EMP1 had been suspended due to the allegation made by MR2 on August 15, 2018. The facility, according to EMP4 subsequently reinstated EMP1 on September 10, 2018, because the facility did not substantiate the allegation made by MR2 on August 15, 2018. EMP4 further confirmed that upon reinstatement on September 10, 2018, EMP1 continued to work on daylight shift until being served a warrant at the facility by the police and arrested on October 16, 2018.

The facility was not in compliance with the CMS (Center for Medicare/Medicaid Services) Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 183, 10/12/18). Specifically, the facility was not in compliance with 482.21 Quality Assessment and Performance Improvement Program. Significant corrections evidencing compliance will be required.

Complaint (PIT18C046P) was substantiated. Deficient practices, both related to the complaint and unrelated to the complaint were identified and cited with the details noted further in this report.

The CONDITION is not met as evidenced by:
Based on the nature of the standard-level deficiencies related to Quality Assessment and Performance Improvement Program, the facility failed to substantially comply with this condition.

The findings were:

The following standards were cited and show a significant nature of non-compliance with regards to Quality Assessment and Performance Improvement Program as follows:

(482.21 Tag A-0263)
The information reviewed during the survey provided evidence the facility did not maintain and demonstrated evidence of its QAPI program for review.

(482.73 Tag A-0273)
The information reviewed during the survey provided evidence that the facility did not use data collected to monitor the effectiveness and safety of services and quality of care and did not specifying the frequency and detail of data collection.

(482.83 Tag A-0283)
The information reviewed during the survey provided evidence that the facility did not use data collected to identify opportunities for improvement and changes that will lead to improvement.

(482.21(a) Tag A-0286)
The information reviewed during the survey provided evidence the facility did not analyze an adverse patient event and implement preventive actions

(482.21(d) Tag A-0297)
The information reviewed during the survey provided evidence the facility did not document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to use data collected to monitor the effectiveness and safety of services and quality of care and did not specify the frequency and detail of data collection.

Findings include:

Review of facility Performance Improvement Plan, dated February 2018, revealed, "Scope: The Performance Improvement Program of LifeCare Behavioral Health Hospital (LCBHH) is an ongoing program ... The hospital will use data and analysis to identify opportunities for improvement within the hospital. ... Quality Improvement involves two primary activities: 1. Measuring and assessing the performance of services though the collection and analysis of data. 2. Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and/or the improvement of existing services. Leadership: The Governing Body, Medical Staff, and Hospital Administration are responsible and accountable for ensuring: a. That an ongoing program is defined, implemented, and maintained. b. That the ongoing program contains elements of performance improvement, patient safety, and the reduction of medical errors. ... The responsibilities of the Committee include: ... Formally adopting a specific approach to continuous Quality Improvement (such as Plan-Do-Check-Act: PDCA)
Review of Quality Minutes from January 2018 to October 2018 revealed no documentation of Performance Improvement Activities.
Interview with EMP2 on October 24, 2018 at 11:45 am revealed, "I can tell you what we did, but we don't document it."

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to use data collected to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained.

Findings include:

Review of facility Performance Improvement Plan, dated February 2018, revealed, "Scope: The Performance Improvement Program of LifeCare Behavioral Health Hospital (LCBHH) is an ongoing program ... The hospital will use data and analysis to identify opportunities for improvement within the hospital. ... Quality Improvement involves two primary activities: 1. Measuring and assessing the performance of services though the collection and analysis of data. 2. Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and/or the improvement of existing services. Leadership: The Governing Body, Medical Staff, and Hospital Administration are responsible and accountable for ensuring: a. That an ongoing program is defined, implemented, and maintained. b. That the ongoing program contains elements of performance improvement, patient safety, and the reduction of medical errors. ... The responsibilities of the Committee include: ... Formally adopting a specific approach to continuous Quality Improvement (such as Plan-Do-Check-Act: PDCA)
Review of Quality Minutes from January 2018 to October 2018 revealed no documentation of Performance Improvement Activities.
Interview with EMP2 on October 24, 2018 at 11:45 am revealed, "I can tell you what we did, but we don't document it."

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to analyze the cause of an adverse patient event and implement preventive actions.

Findings include:

Review of facility Performance Improvement Plan, dated February 2018, revealed, "Scope: The Performance Improvement Program of LifeCare Behavioral Health Hospital (LCBHH) is an ongoing program ... The hospital will use data and analysis to identify opportunities for improvement within the hospital. ... LCBHH is committed to the ongoing improvement of the quality of care and continuously strives to ensure that: .. Risk to patients, providers and others is minimized.

A review of facility documentation provided to the Department on October 22, 2018 at approximately 11:00 AM revealed the facility Chief Executive Officer was contacted by the local police department on August 7, 2018, regarding an allegation against a current employee by a former patient (MR1) of sexual assault. Further review of facility documents revealed that the facilty did not conduct their own investigation of the incident of sexual assault reported to the facility by the local police.

During interview with on October 22, 2018, EMP2 confirmed the above findings.

Based on review of facility documents and interview with staff interviews (EMP), it was determined the facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Findings include:

Review of facility Performance Improvement Plan, dated February 2018, revealed, "Scope: The Performance Improvement Program of LifeCare Behavioral Health Hospital (LCBHH) is an ongoing program ... The hospital will use data and analysis to identify opportunities for improvement within the hospital. ... Quality Improvement involves two primary activities: 1. Measuring and assessing the performance of services though the collection and analysis of data. 2. Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and/or the improvement of existing services. Leadership: The Governing Body, Medical Staff, and Hospital Administration are responsible and accountable for ensuring: a. That an ongoing program is defined, implemented, and maintained. b. That the ongoing program contains elements of performance improvement, patient safety, and the reduction of medical errors. ... The responsibilities of the Committee include: ... Formally adopting a specific approach to continuous Quality Improvement (such as Plan-Do-Check-Act: PDCA)."

Review of Quality Minutes from January 2018 to October 2018 revealed no documentation of Performance Improvement Activities.

Interview with EMP2 on October 24, 2018 at 11:45 am revealed, "I can tell you what we did, but we don't document it."