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Based on review of facility documents, staff interviews, and observations, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient's Rights
CFR 482.21 Qapi
CFR 482.26 Radiologic Services
CFR 482.28 Dietary Services
CFR 482.42 Infection Control
CFR 482.41 Physical Environment
CFR 482.56 Rehabilitation Services
CFR 482.57 Respiratory Care Services

Based on observation, staff and patient interviews, it was determined that the facility failed to protect and promote the rights of patients.

Findings include:

1. The facility failed to ensure patients were provided care in a safe setting. (Cross refer to Tag 0144)

2. The facility failed to ensure that assessment and monitoring in the use of restraint and/or seclusion through their QAPI program. (Cross refer to Tag 0154)

A. Base on observation, staff interview and review of documentation, it was determined that the facility failed to ensure that patients receive care in a safe setting.

Findings include:

1. Unit B-1 was toured on 2/4/15 at 2:20 PM, in the presence of Staff #99 (Unit Supervisor). The surveyor observed Patient #31, who appeared to be asleep on the bed in the Recovery Suite.

A review of the Medical Record of Patient # 31 revealed the following:

a. A "Psychiatry Note" dated 1/29/15 at 3:10 PM stated, "... Is increasingly agitated ..... (illegible) Inappropriate sexually - insomnia - not redirectable. HS (hour of sleep) Risperdal not overly effective - became more (illegible) at higher doses. Will (illegible) ..... Start Zyprexa .... and have pt (patient) in Recovery Suite for safety - ....."

b. There was no documented evidence of a revised patient care plan that for the use of the Recovery Suite.

c. There was no documented evidence of a safety plan.

d. The Acting Medical Director (Staff #55), at 2:45 PM on 2/6/15, stated to the surveyor that there should have been a written safety plan for the patient and that there was no policy developed for the use of the Recovery Suite.

2. During a tour of Unit A-1 on 2/3/15 at approximately 10:30 AM, in the presence of Staff #29, observed that the door handles on all the patient rooms and bathroom doors were not anti-ligature resistant. Also, the water control knobs attached to the bathroom sink in each of the patient rooms were not anti-ligature resistant.

a. Staff #29 indicated to the surveyor that all of the door handles, door hinges and water control knobs throughout the facility are not anti-ligature resistant.


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3. On 2/3/15 at 10:30 AM, in Unit E-3, Patient #42 and Patient #43 stated to the surveyor that the shower was, "very cold"and the facility did not offer an alternative way to take a shower.
a. The surveyor tested the hot water temperature of the Women's shower room and found the temperature to be 46 degrees Fahrenheit on that day.

4. During an interview on 2/3/15 at 11:00 AM, in Unit A-1, Patient #44 stated, "... he has not been able to shower for three days because he has been waiting for the social worker to bring him his clothes."

5. During an interview on 2/3/15 at 11:15 AM, in Unit A-1, Patient #45 stated, "Water seems cold at the hottest setting" and the facility does not offer an alternative place to shower.

6. During an interview on 2/3/15 at 11:40 AM, in Unit D-1, the hot water temperature of the men's shower was taken at this time by the surveyor and found to be 128 degrees Fahrenheit.

7. On 2/3/15, the surveyor interviewed Staff #100 in Unit E-3 and confirmed no alternate shower options have been provided to the patients.


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B. Based on observation and staff interview conducted on 2/3/15 to 2/5/15, it was determined that the facility failed to provide a safe environment for patient care in compliance with the provisions of N.J.S.A.13:1E-48.1 et seq., the Comprehensive Regulated Medical Waste Management Act, and all rules promulgated pursuant to the aforementioned act.

Findings include:

Reference: Subchapter 3A. Regulated Medical Wastes, of the New Jersey Solid Waste Regulations, N.J.A.C. 7:26-3A.12 Storage of regulated medical waste prior to transport, treatment, destruction, or disposal states in 2 i (c), "Any container that is being used to accumulate or store sharps shall be secured so that the contents are not accessible to any unauthorized person."

1. During a tour of Nursing unit F-2 on 2/3/15, in the presence of Staff #12, two unsecured sharps containers were observed on a counter in the Medication Room and on the floor at 9:50 AM.

a. This finding was confirmed by Staff #12 and Staff #31.

2. On 2/4/15, during an a tour of Central Supply in the presence of Staff #12 at 2:12 PM, Staff #19 (Administrator) and Staff #69 (Central Supply staff) both stated that the large sharps containers "should be secured on the wall" and the smaller sharps containers "are free-standing."

a. Multiple sized containers were observed in the Central Supply area.

b. This finding was confirmed by Staff #12.

3. During a tour of Cottage #14 in the presence of Staff #12, Staff #75 and Staff #76 on 2/5/15 at 10:40 AM, two unsecured sharps containers were observed:

a. One large sharps container was observed stored on the floor near the door, unsecured.

b. One small sharps container was observed stored on a cart,unsecured.

c. This finding was confirmed by Staff #12, Staff #75 and Staff #76.

4. During a tour of Cottage #13 in the presence of Staff #12, Staff #59, and Staff #75 on 2/5/15 at 11:40 AM, two unsecured sharps containers were observed:

a. One large sharps container was observed stored on the floor near the door, unsecured.

b. One small sharps container was observed stored on a cart, unsecured.

c. This finding was confirmed by Staff #12, Staff #59 and Staff #75.





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Based on staff interview, it was determined that the facility failed to assess and monitor restraint and/or seclusion at the facility, through their QAPI program.

Findings include:

On 2/5/15 at 2:45 PM, Staff #15 stated during interview that the facility stopped aggregating restraint data over a year ago. Staff #15 stated that when the facility has a few restraint episodes, they bring a list of restrained patients to the morning meeting with clinical disciplinary heads, section chiefs, the medical director, and nursing staff, and review any deficiencies with the restraint use. Staff #15 confirmed that there was no aggregated data at the facility for the use of restraints/seclusion.

Based on facility document review and staff interview, it was determined that the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, that involves all hospital departments and services, including those services furnished under contract or arrangement.

Findings include:

1. The facility failed to evaluate its outlined interventions for success, or utilize benchmarks to evaluate their success rates for its Quality Assurance Performance Improvement (QAPI) Projects. (Cross refer Tag 0273)

2. The facility failed to ensure that a process designed to measure, analyze, and track quality indicators, including adverse patient events was always implemented. (Cross refer Tag 0273)

3. The facility failed to implement all preventative actions and evaluate all preventative actions it developed in one of the three Root Cause Analyses (RCAs). (Cross refer Tag 0286)

4. The facility failed to ensure all of the hospital departments and services, including those services furnished under contract or arrangement, were incorporated into its Quality Assurance Performance Improvement (QAPI) program. (Cross refer Tag 0308)

Based on review of three Quality Assurance Performance Improvement (QAPI) projects and staff interview, it was determined that the facility failed to evaluate its outlined interventions for success, or utilize benchmarks to evaluate their success rates.

Findings include:

1. On 2/5/15 three QAPI projects were reviewed in the presence of Staff #15 and Staff #27.

a. The facility's project to improve malodors on hospital units was reviewed. The facility could not provide evidence that the interventions that were implemented were evaluated for success.

b. The facility's project to improve foot care/health for patients and expedite podiatry consults was reviewed. The plan outlines that all patients are to be screened on Wednesday evenings to identify patients in need of foot care interventions or a podiatry consult intervention.

(i) The number of identified patients in need of a plan of care/interventions for foot care was not aggregated.

(ii) The number of patients that have seen a podiatrist is reported back into the QA Committee, however, the number of patients that were identified as needing a podiatry consult and have not been able to be seen by the podiatrist is not calculated into the QA for this project. Staff #96 confirmed there are patients that were identified as needing a podiatry consult, but are still waiting for podiatry availability to complete the consult.

c. The facility's project for hand hygiene compliance was reviewed. The facility does not compare its rate for hand hygiene compliance to any performance benchmarks.

2. The findings above were confirmed by Staff #96.








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Based on review of three root cause analyses (RCA) the facility has conducted within the past year and staff interview, it was determined that the facility failed to implement and evaluate all preventative actions it developed in one of the three RCAs reviewed.

Findings include:

1. On 2/4/15, three RCAs were reviewed in the presence of Staff #27. RCA #1 lacked evidence of completion for all the preventative actions the facility developed, or evaluation of the preventative actions for success. RCA #1 was completed for an event that occurred in the fall of 2014.

a. For example, a specific disciplinary consult for this patient was developed as a preventative action to prevent a reoccurrence. This particular consult has not been completed to date for a high risk event that occurred at the facility.

2. RCA #2 and RCA #3 were still in process for full implementation and/or evaluation.

3. These findings were confirmed by Staff #27.

Based on review of the facility's Quality Assurance (QA) Meeting minutes and staff interviews, it was determined that the facility failed to incorporate all of the hospital departments and services, including those services furnished under contract or arrangement, to its Quality Assurance Performance Improvement (QAPI) program.

Findings include:

1. On 2/4/15 at 11:24 AM the facility's Quality Assurance (QA) Program was reviewed in the presence of Staff #15 and Staff #27. Staff #15 and Staff #27 confirmed in interview, that the following departments do not report into QA and there is no evidence of QAPI projects for these departments in the QA meeting minutes:

a. Medical Record Services

b. Radiological Services

c. Food and Dietetic Services

d. Physical Environment

e. Rehabilitation services

f. Respiratory Care Services

2. Staff #15 and Staff #27 confirmed during interview, that the facility does not perform QA of their contracted services. The following are examples of contracted services that with which the facility does not have evidence of QA:

a. The facility's dispensing pharmacy

b. The two contracted pharmacy consultants

c. The service that performs the facility's biological monitoring program

d. The medical data management company that performs the facility's transcription services

e. The company that performs the maintenance/cleaning of the kitchen hoods and exhaust systems

f. Pastoral care services

g. Organ Procurement Organization

3. On 2/5/15 at 2:45 PM, Staff #15 stated in interview, that the facility stopped aggregating restraint data over a year ago.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that all x-ray reports are promptly completed and properly filed in the patients' medical record.

Findings include:

1. The facility failed to file all x-ray reports in the patients' in-patient medical records. (Cross refer Tag 0553)

2. The facility failed to ensure all x-ray test results are completed promptly and authenticated. (Cross refer Tag 0554)

Based on observation, document review and staff interview conducted on 2/6/15, it was determined that the facility failed to ensure implementation of policies and procedures addressing storage of medications.

Findings include:

Reference: Facility policy titled Safe and Proper Storage of Medications states, "... C.2. Patient Units: ... Controlled Substance blister packs are stored in a separately locked drawer in the medication cart. ..."

1. During a tour of medication rooms on Units G1, A1, A2, B1, and D1, noncontrolled drug floor stock, such as haloperidol and chlorpramazine, were found stored with the blister packs of controlled drugs in the locked drawer in the medication cart.

a. Haloperidol and chlorpramazine are not controlled drugs, but were stored inappropriately with the controlled drugs.

A. Based on review of facility policies and procedures, staff interviews, medical record review, and review of facility documentation, it was determined that the facility failed to provide radiological services in accordance with acceptable standards of practice.

Findings include:

1. The facility failed to have radiology policies and procedures readily accessible to radiology staff. (Cross refer Tag 0535)

2. The facility failed to complete quality control checks of all radiology equipment. (Cross refer Tag 0537)

3. The facility failed to monitor all radiology staff for radiation exposure. (Cross refer Tag 0538)

4. The facility failed to have a credentialed radiologist on the medical staff to supervise the radiology service. (Cross refer Tag 0546)

5. The facility failed to file all reports of x-ray testing within the patients' in-patient medical records. (Cross refer Tag 0553)

6. The facility failed to have the evaluating radiologist sign the radiology reports. (Cross refer Tag 0554)

B. Based on facility document review and staff interview, it was determined that the facility failed to integrate the radiology service into the facility's Quality Assurance (QA) program.

Findings include:

1. On 2/3/15, the Radiology Department was toured in the presence of Staff #19 at 11:15 AM. Staff #19 stated during interview that the radiology department reports to him/her. Staff #19 confirmed that he/she does not perform any quality improvement projects for the radiology service.

a. Review of Staff #19's job description indicated under Examples of Work, "... Develops policy guidelines, administrative procedures, and regulations regarding programs. ... Plans, develops and supervises the implementation of program goals, policies, procedures and objectives. Supervises and/or conducts the more difficult onsite evaluations or audits to ensure compliance with prescribed codes, regulations, and/or contract terms; prepares related reports containing findings, conclusions and recommendations. Identifies program deficiencies and develops corrective action strategies in support of established goals."

2. On 2/4/15 at 11:24 AM, the facility's QA Meeting minutes were reviewed in the presence of Staff #15 and Staff #27. Staff #19 reported Biological Sterilizer monitoring for the Midmark and Statim Sterilizers for the Dental Clinic, and the Medical Physicist's report for the Radiology Department.

a. The report of the Biological Sterilizer monitoring for the Midmark and Statim Sterilizers for the Dental Clinic is a report of the biological testing of the equipment by a contracted service. There were no improvement measures or interventions with this report.

b. The Medical Physicist's report for the Radiology Department does not contain improvement measures or interventions within this report.

3. Staff #15 stated during interview that these reports are measures that the facility maintains.

4. Staff #27 confirmed that there are no QA activities for dental or radiology at this time.

Based on observation and staff interview, it was determined that the facility failed to have radiology policies and procedures readily available to radiology personnel.

Findings include:

1. On 2/3/15, the Radiology Department was toured in the presence of Staff #19 at 11:15 AM. Staff #42 was the radiology technician working in the department on this day of survey, and was performing the ordered x-rays for facility patients. Staff #42 stated that he/she was from a staffing agency, and he/she has been working at this facility intermittently through the agency for five (5) years.

2. Staff #42 could not locate the policy and procedure manual when asked to provide it for review.

3. Staff #19 provided three (3) policies by the end of the day on 2/3/15. Those policies included the following:

a. 'Ancillary/Clinical Support Services', which describes the ancillary services provided at the facility.

b. ' --[facility name]-- Department of Ancillary Services Radiology Services', which defines the hours of operation of the Radiology Department, the basic x-ray services provided, and the procedure for sending the x-ray films to the contracted radiologist for review.

c. An infection control policy for the Radiology Department.

4. Staff #19 stated, on 2/3/15 at 2:10 PM, that the facility did not have a policy and procedure for the following:

a. Reading, interpretation, and inclusion of x-ray reports in the medical record

b. Shielding of personnel and patients

c. Testing of equipment

d. Maintenance of personal radiation monitoring devices

e. Identification of pregnant patients

5. On 2/4/15 at 11:02 AM, Staff #19 provided a policy and procedure manual, dated 12/21/00, that included policies and procedures for holding a patient, presence of individuals in the room during radiation exposure, pregnant patients, pregnant employees, and gonad shielding.

6. The above policies and procedures were not readily available to the contracted radiology technician that was coordinating the patient x-ray procedures on 2/3/15.

Based on observation and staff interview, it was determined that the facility failed to maintain the quality control (QC) checks on the radiology x-ray machine and printer.

Findings include:

1. On 2/3/15, the Radiology Department was toured in the presence of Staff #19 at 11:15 AM. Staff #42 was the radiology technician working in the department on this day of survey. Staff #42 stated that he/she was from a staffing agency, and he/she has been working at this facility intermittently through the agency for five (5) years.

2. Staff #42 stated, on 2/3/15 at 11:40 AM, that the only QC check he/she does is a weekly printout of the density and calibration of the printer. He/she then leaves the report on the printer for when the regular staff radiology technician returns.

a. Per Staff #42, the regular radiology technician has been on a leave of absence since December 2014.

3. Staff #42 was not able to provide a policy or evidence of routine QC checks performed in the Radiology Department where x-rays are performed until the afternoon of 2/4/15.

a. Staff #42 provided documentation for QC testing of the x-ray machine's field/alignment every 3 months in 2014, and weekly QC testing of the x-ray printer in 2014.

4. Staff #42 confirmed, on 2/5/15 at 10:30 AM, that there was no evidence of weekly QC testing of the x-ray printer in 2015, or QC testing of the x-ray machine's field/alignment test since 10/31/14.

Based on staff interview and review of facility documentation, it was determined that the facility failed to monitor all of its radiology staff for radiation exposure, as per policy and New Jersey Administrative Code (N.J.A.C.).

Findings include:

Reference #1: Facility's 'Policy and Employee Responsibilities for Personnel Radiation Monitoring' states, "... Additionally, personnel monitoring devices are provided to and are worn by each individual who is likely to exceed the limits in N.J.A.C. 7:28-7. 1. Each personnel monitoring device is assigned to and worn by only one individual. ..."

Reference #2: N.J.A.C. 7:28-7 states at 7:28-7.4, "Use of personnel monitoring equipment (a) Each owner [of the radiation source] shall supply appropriate personnel-monitoring equipment to, and shall require that it be used by: 1. Each individual who enters a controlled area under such circumstances that he receives, or is likely to receive, a dose in excess of 25 miilirems in any period of seven consecutive days; ... 3. Each individual who enters a high radiation area; ... (c) When an individual working on the premises of an owner, but not employed by him is wearing personnel-monitoring equipment provided by his employer, the owner of the radiation source shall not be required to provide additional personnel monitoring equipment."

1. On 2/3/15, the Radiology Department was toured in the presence of Staff #19 at 11:15 AM. Staff #42 was the radiology technician working in the department, and performing the ordered x-rays for facility patients. Staff #42 stated, that he/she was from a staffing agency, and he/she has been working at this facility intermittently through the agency for five (5) years.

a. Staff #42 was not wearing a personal radiation monitoring device.

b. Staff #42 stated he/she was told by his/her agency that he/she is not required to wear one.

c. Staff #19 confirmed that the regularly assigned radiology x-ray technician does have a personal radiation monitoring device. Staff #19 was unable to provide evidence of and/or rational for Staff #42's exclusion from wearing a personal radiation monitoring device by the staffing agency.

d. On 2/3/15, Staff #19 and Staff #44 both stated they do not monitor or get the reports of the readings for the employee personal radiation monitoring devices.

2. On 2/4/15 at 10:48 AM, Staff #19 provided Radiation Dosimetry Reports for all of the employees in the facility that have radiation exposure. Per Staff #19, the employees are the x-ray radiology technician and employees in the dental clinic. The Radiation Dosimetry Reports do not indicate if the results are acceptable, or define the parameters of the results.

a. Staff #19 was not able to determine if the results for the employees were within acceptable range, and was unable to provide anyone from the facility able to interpret the reports.

3. On 2/5/14, Staff #19 provided a 'Policy and Employee Responsibilities for Personnel Radiation Monitoring' document (See Reference #1 above). Staff #19 stated this is the facility's policy and procedure for radiation monitoring devices for its employees.

4. The facility could not demonstrate they implemented their policy for Personnel Radiation Monitoring devices of the employees.

a. It could not be determined if Staff #42 required a monitoring device. There was no documentation from Staff #42's agency indicating he/she would or would not require a monitoring device, and/or if it was the facility's responsibility, or the agency's responsibility to provide one if needed.

b. The facility was unable to determine if the Radiation Dosimetry Reports for its employees were within acceptable ranges.

Based on staff interview and review of facility documentation, it was determined that the facility failed to have a credentialed radiologist on staff to supervise the radiology service.

Findings include:

1. On 2/3/15 at 2:10 PM, the contract for the radiologist was reviewed. The contract term is dated 8/18/14 thru 6/30/16.

2. Staff #55 confirmed during interview on 2/3/15 at 2:30 PM, that the radiologist the facility entered into a contract with, is not credentialed to be on the medical staff. Staff #55 stated the radiologist is in the process of being credentialed.

a. The facility did provide evidence of the radiologist's New Jersey License, Drug Enforcement Agency registration, Controlled Dangerous Substance registration, and board certification.

Based on medical record review and staff interview, it was determined that the facility failed to file all reports of x-ray testing within the patients in-patient medical records.

Findings include:

1. On 2/3/15, the Radiology Department was toured in the presence of Staff #19 at 11:15 AM. Staff #42 provided the surveyor with a log of patient testing procedures and three (3) patient names were selected from the service date of 1/28/15.

a. Medical Record #3 was reviewed on unit A1 on 2/3/15. There was no evidence of an x-ray report of the patient's nasal bones x-ray that was completed on 1/28/15. Staff #46 confirmed that the report of the x-ray was not on the chart.

b. Medical Record #4 was reviewed on Unit A1 on 2/3/15. There was no evidence of an x-ray report of the patient's right knee, hip, and pelvis that was completed on 1/28/15. Staff #45 confirmed the x-ray report was not in the medical record.

(i) Staff #45 stated during interview that the physicians will go to the radiology department to get the results of the radiology tests, then bring a copy of the report to the unit for filing into the medical records.

c. Medical Record #5 could not be reviewed on Unit D3 due to a psychiatric emergency on the unit at the time.

2. Staff #19 confirmed in interview on 2/3/15 that the radiology reports are placed in the ordering physicians mailboxes after the reports are received from the contracted radiologist. Staff #19 stated that the physicians bring the reports to the patient units for filing in the medical records.

a. Staff #19 provided the surveyor with radiology reports for Patient #4 and Patient #5 that he/she obtained within the radiology department.

Based on document review, it was determined that the facility failed to have the evaluating radiologist sign all radiology reports.

Findings include:

1. On 2/3/15 Staff #19 provided the surveyor with radiology reports for Patient #4 and Patient #5 that he/she obtained within the radiology department.

a. The reports indicate the date of the examination, but not the date and time of a preliminary or a final reading by the interpreting radiologist.

(i) The facility contract with the radiologist was reviewed on 2/3/15. The contract states that all results of the radiology testing will be completed in 24 hours. Without the date and time the radiologist completed his/her interpretation, it could not be determined if the results were provided within 24 hours as per the contract for radiology services.

b. The reports are not signed by the interpreting radiologist.

(i) The x-ray report for Patient #4 has the radiologist's name printed on it, but it does not indicate that this is an electronic signature.

(ii) The x-ray report for Patient #5 indicates the report was dictated by the radiologist.

Based on observations, staff interview, document review, it was determined that the facility failed to ensure that the food and dietetic services were organized dietary service that is directed and staffed by qualified personnel. Also, the facility failed to ensure that the nutritional needs of the patients are met in accordance with practitioners' orders and acceptable standards of practice.

Findings include:

1. The facility failed to ensure that the Director of Food & Nutrition provides effective daily management of the Food Service Department. (Cross refer Tag 0620)

2. The facility failed to ensure that the Director of Food & Nutrition assured compliance with established Food Service Department policies and procedures and Chapter XII of the New Jersey State Sanitary Code, Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (N.J.A.C. 8:24). (Cross refer Tag 0620)

3. The facility failed to ensure that the Director of Food & Nutrition develops and implements an effective Quality Assurance Plan. (Cross refer Tag 0620)

4. The facility failed to ensure that all facility staff providing food services are trained and competent in their assigned duties. (Cross refer Tag 0622)

A. Based on document review, staff interview and observation, it was determined that the facility failed to ensure that the Director of Food & Nutrition provided effective daily management of the Food Services Department in accordance with job specifications and job expectations.

Findings include:

Reference #1: Program Specialist 3 Social/Human Services job specifications states, "Supervises or performs the more complex and sensitive administrative, analytical and professional work to promote the planning, operation, implementation, monitoring and/or evaluation of social/human service program areas designed to improve the medical, social or other circumstances of the client population served."

Reference #2: Director of Clinical Nutrition job expectation states, "1. Assures provision of quality nutritional services to all patients ... 2. Provides administrative supervision of the Nutrition Department and Food Service Department ... documents the appropriate orientation of all new staff ... 5. Standards compliance ... Review all other outside survey results ... DOH and develops and implements any required remedial action plans in a timely manner ... 6. Performance Improvement activities within the Nutrition Department and Food Service Department ... Complies and tracks all PI data and develops a PI Plan for the Department in coordination with the Medical Director, the Director of Quality Assurance, and/or Quality Assurance Coordinator in order to address all identified deficiencies and opportunities for improvement ... 7. Staff Development ... Assures that 95% of all staff meets all mandatory training requirements."

Reference #3: Food Services Supervisor 1 job specifications states: "Has charge of the facilities and staff associated with the storage, preparation and service of all food ... Maintains and controls the proper health, sanitary and safety conditions and standards and inspects all areas where food supplies are received, handled, stored, refrigerated, prepared and served ... Knowledge of health, sanitary and safety standards for kitchen personnel, equipment, appliances and routines ... oversee food preparation service and storage areas are maintained in clean, orderly and safe condition."

Reference #4: Assistant Food Services Supervisor 1 job specifications states: "Under direction of Food Services Supervisor 1 or other supervisor ... assists in the general supervision of the food services unit ... instructs, assigns and supervises the employees engaged in handling, storing, preparing, and serving food ... Makes inspections of facilities, equipment, and personnel ..."

Reference #5: Assistant Food Services Supervisor 1 job expectation states: "To maintain the highest standards in food handling and preparation to ensure patient satisfaction, good nutrition and thereby contribute to successful patient care outcomes ... Monitors temperatures of food, refrigerators, freezers, quality of food, timeliness meal service, physical environment ... Provides instructions to employees in the food service unit ... Assures that 95% of all staff meet the mandatory training requirements ... Ensures staff follow SERVSafe and HACCP recommendations for food preparation ... Ensures state recipes are followed. Assures that the department operates within the guidelines set forth by Chapter 24."

1. On 2/3/15, the Director of Food & Nutrition's personnel file contained a job specification titled, "Program Specialist 3 Social/Human Services" and a job expectations form titled, "Director of Clinical Nutrition."

a. The Food Service Department Organizational Chart dated January, 2015 indicated that the Director of Food & Nutrition supervises the Assistant Food Services Supervisor 1/ Acting Food Services Supervisor 1.
b. The Director of Food & Nutrition job specification (Reference #1) and job expectations (Reference #2) are not position specific and do not clearly delineate the responsibility and authority for the direction of the Food Service Department.

2. The Director of Food & Nutrition failed to ensure that the Assistant Food Services Supervisor 1/ Acting Food Services Supervisor 1 was oriented and trained in all Assistant Food Services Supervisor 1/ Acting Food Services Supervisor 1 job specific responsibilities and Food Service Department Policies and Procedures.

a. A interview on 2/6/15 with Staff # 56 (Assistant Food Services 1/Acting Food Services) confirmed no orientation to the Food Service Department. Staff #56 was hired in June 2014. Also a review of the personnel file revealed no documented evidence. There was only documentation of a hospital's new employee orientation.

b. The Director of Food & Nutrition failed to provide evidence of training and orientation for Staff #56 to the Assistant Food Services Supervisor 1/ Acting Food Services Supervisor 1 position.

c. The Assistant Food Services Supervisor 1/ Acting Food Services Supervisor 1's job specification (Reference #4) and job expectations (Reference #5) are titled Assistant Food Services Supervisor 1. The job specification and job expectations are not position specific and do not delineate the Acting Food Services Supervisor 1 job responsibilities (Reference #3).

B. Based on observation, it was determined that the dietary service failed to comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24).

Findings include:

Reference #1: The Prevention and Control of Infection policy states: "I. Purpose: A. To provide a workable guide for Food Service Department Staff for the care and preparation of wholesome, nutritious meals, safe for consumption by patients and staff. B. To prevent infection through food as a multiplier using the Hazard Analysis Critical Control Point (HACCP) and good food handling practices. C. To prevent infection through food as a vehicle by controlling extrinsic environmental factors. D. To comply with Chapter 24 of the New Jersey Administrative Code Governing Food Establishments"

Reference #2: N.J.A.C. 8:24-4.1(a) states, "The operator shall be the person in charge or shall designate a person in charge and shall ensure that a person in charge is present during all hours of operation."

Reference #3: N.J.A.C. 8:24-4.1(b) states, "The Person in Charge shall demonstrate to the health authority knowledge of foodborne disease prevention, application of the Hazard Analysis Critical Control Point (HACCP principles ... the person in charge shall demonstrate compliance with this chapter ... at least one person in charge in Risk Type 3 Food Establishments shall be a certified food protection manager. ..."

Reference #4: N.J.A.C. 8:24-4.2(c)(6) states, "Ambient air and water pressure, and water temperature measuring devices shall be designed to be easily readable and accurate to 3 degrees F (Fahrenheit) in the intended range of use."

Reference #5: The Prevention of Infection Monitoring and Logging of Refrigerator/Freezer Temperature Controls policy states, "Temperatures for all refrigerators and freezers to be checked at least twice a day and recorded ... A five degree deviation in temperature above or below the ideal temperature range shall be reported to Engineering Department within one hour, and recorded on a Food Service Log"

Reference #6: N.J.A.C. 8:24-4.2(c)(2) states, "Temperature measuring devices shall meet the following requirements: ... 2. A temperature measuring device with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin foods such as meat patties and fish filets."

Reference #7: The Food Temperature Monitoring policy states, "An accurate thermometer shall be available and used to monitor required internal cooking, cooling, reheating, hot holding and cold holding temperatures of all potentially hazardous foods. Clean and sanitize thermometers prior to inserting into food."

Reference #8: The Food Storage policy states, "The Food Service Department stores food according to the requirements of Chapter 24 of the NJ State Sanitary Code ... Dry Good storeroom ... Storeroom is swept daily and mopped daily to ensure cleanliness ... In Reach-in-Refrigerators, spills are cleaned immediately ... items that are 24 hours old or older are discarded ... Thermometers are in plain view; temperatures are 41 degrees F or below ... Walk in Refrigerators, a. Spills are cleaned immediately ... Thermometers are monitored throughout the day and temperatures are logged twice daily on the monthly sheet; between 33 - 41 degrees F ... Food is covered and stored on shelves and off floors."

Reference #9: N.J.A.C. 8:24-4.7 (a) states, "Equipment food-contact surfaces and utensils shall be sanitized." 8:24-4.7 (b) states, "Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning."

Reference #10: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately measures the concentration in mg/L of sanitizing solutions shall be provided."

Reference #11: The Prevention and Control of Infection ... Manual Washing & Sanitizing of Equipment & Utensils policy states, "A sink with three compartments is used to manually sanitize equipment and utensils ... After washing, equipment and utensils shall be rinsed free of detergent solution and shall be sanitized and allowed to air dry ... To wash: Pour measured amount of low suds detergent, per manufacturers' suggestion, into first compartment, one (1) ounce of Iodophor to five gallons of water ... To Rinse: After washing, place equipment and utensils in second compartment for rinsing to remove detergent ... To Sanitize: prepare third compartment with a sanitizing solution of Water (75 -120 degrees F) and a measured amount of Iodophor (3 ounces to five gallons) of water ... Immerse equipment and utensils into sanitizing solution for at least one minute ... Remove from solution and allow to air dry on drain board. After equipment and utensils are dry, take to storage area for storing."

Reference #12: N.J.A.C. 8:24-6.5(f) states, "After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies."

Reference #13: N.J.A.C. 8:24-6.7(m) states, "A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees."

Reference #14: N.J.A.C. 8:24-6.7(o) states, "A handwashing facility may not be used for purposes other than handwashing."

Reference #15: NJAC 8:24-6.5(b) states,"The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #16: NJAC 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #17: NJAC 8:24-6.2(k) states, "The presence of insects, rodents and other pests shall be controlled to minimize their presence on the premises by ... eliminating harborage conditions."

1. On 2/3/15, 2/4/15 and 2/6/15, the following observations were made in the facility's food services department main kitchen and employee cafeteria, in the presence of Staff #17 and Staff #79.

a. The PIC (Person in charge), Staff #56, failed to adequately demonstrate control over food safety hazards in accordance with Reference #1, Reference #2 and Reference #3.

b. On 2/3/15 at 2:40 PM, the hand wash sink outside the Food Service Supervisor's office was blocked with cardboard cartons. The hand wash sink had a plastic water bottle and debris in it. The hand wash sink was not maintained in accordance with Reference #13 and Reference #14

c. On 2/3/15, three of three hand wash sinks located through out the main kitchen, contained Brillo type pads and dirty utensils in them. The hand wash sinks lacked soap and paper towels for hand washing and drying. The hand wash sinks were not maintained in accordance with Reference #13 and Reference #14.

d. On 2/3/15 and 2/6/15, the dry storage room (originally designated as a garbage room) located across from the food service supervisor's office, contained a large amount of clutter, blocking access into the area. Various cartons were stored in the center of the room, directly on the floor, blocking access to all areas of the room. The room contains a garbage can washer in the back and a sink on the side wall that were blocked by large cartons, had dust and debris on them and were not maintained clean in accordance with Reference #8, Reference #15 and Reference #16.

e. On 2/3/15 and 2/6/15, two of two ingredient rooms contained litter, food particles and dust on the floors under all the shelving units and were not maintained clean in accordance with Reference #8, Reference #15 and Reference #16.

f. On 2/3/15, the cook's prep counter had food particles and tacky substances on it. The prep counter was not maintained clean in accordance with Reference #8, Reference #15 and Reference #16.

g. On 2/3/15, the milk/dairy box, vegetable box, juice box, and upright sherbet/icecream freezer had food particles and litter on the floors and tacky substances on the interior surfaces. The refrigerators and freezers were not maintained clean in accordance with Reference #8, Reference #15 and Reference #16.

h. On 2/3/15 at 2:55 PM, two large bins containing small pans, trays, lids and food service utensils were stacked upon each other on a crate in a corner behind the dish machine next to the sherbet/ice cream freezer. The two bins were full of standing water that appeared black and had a odor. Ten to twenty (10- 20) small flying insects were observed in this area. The area was not maintained clean and free of flying insects in accordance with Reference #8, Reference #15, Reference #16 and Reference #17. This deficient practice was identified previously on 7/16/14 during the facility's Consumer and Environmental Health Services Food Inspection.

i. On 2/6/15 at 11:30 AM, in the area of a shelving unit outside F013/Ingredient Room, ten to twenty (10- 20) small flying insects were observed. The shelving unit appeared dirty with food particles and dust. Salad and mixing bowls were stored on it. The area was not maintained clean and free of flying insects in accordance with Reference #8, Reference #15, Reference #16 and Reference #17. This deficient practice was identified previously on 7/16/14 during the facility's Consumer and Environmental Health Services Food Inspection.

j. On 2/6/15 at 11:55 AM, in the Cambro food truck storage area, a large quantity of surplus equipment was found. This included 8 cold food trucks, 2 hot food trucks, a Cambro unit with melted ice and water and a out of service blender stored on it. These items were not kept clean to sight and touch. Ten to twenty (10- 20) small flying insects were observed in this area. The area was not maintained clean and free of flying insects in accordance with Reference #8, Reference #15, Reference #16 and Reference #17. This deficient practice was identified previously on 7/16/14 during the facility's Consumer and Environmental Health Services Food Inspection. The fire exit door was propped open with a garbage can containing various grill and shelving parts.

k. On 2/6/15 at 11:30 AM, Staff #85 was observed taking the soup temperature. Staff #85 pulled a food thermometer out of its sleeve from his shirt pocket. Staff #85 placed the thermometer in the soup, pulled it out and wiped it with his/her apron, and then placed it back in the sleeve of the shirt pocket. Staff #85 failed to follow the appropriate sanitation procedures for taking food temperatures in accordance with Reference #7.

l. On 2/6/15, Staff #85 stated that the facility did not provide a thermometer with a small-diameter probe that is designed to measure the temperature of thin masses. This type of thermometer is used to accurately measure the temperature in thin foods such as meat patties and fish filets in accordance with Reference #6.

m. On 2/6/15 at 11:45 AM, Staff #84 was observed washing pots and pans at the three compartment sink. The three compartment sink contained wash water in the first sink, the second sink was empty and the third sink had a large mixing spatula soaking in water. Staff #84 explained to the surveyor that the pans and utensils are washed first, then sanitized and then rinsed with water. After that the pans and utensils are dried.

(i) However, Staff #84 stated a test kit to measure the concentration in mg/L (milligrams per liter) of the sanitizing solution is not provided. This process is not in accordance with Reference #9, Reference #10 and Reference #11.

n. On 2/3/15 and 2/6/15, the cart wash/mop wash area was not organized and maintained clean. The area had four mop buckets with water and mops in them, two dirty carts with tacky surfaces and spatter on them, and a tray rack. Mops were not maintained in accordance with Reference #12. This deficient practice was identified previously on 7/16/14 and 9/30/14 during the facility's Consumer and Environmental Health Services Food Inspections.

o. On 2/4/15, Staff #68 could not provide for review the Daily Refrigerator logs from February 1, 2, 3 and 4, 2015. Staff #68 stated that the Daily Refrigerator logs were not maintained in accordance with Reference #4 and Reference #5.

p. On 2/6/15, Daily Freezer/Refrigerator Log for Unit #1 and Unit #2 were not completed and maintained in accordance with Reference #4 and Reference #5. Fifteen out of twenty two freezer temperatures were recorded out of range. The corrective action space was blank. Staff #58 stated that the out of range temperatures were not reported to maintenance in accordance with Reference #4 and Reference #5.

q. On 2/3/15, the facility main kitchen warewashing machine was observed to rinse the pans and trays at 140 degrees Fahrenheit. The warewashing machine failed to rinse at the required 180 degrees Fahrenheit in accordance with the facility Mechanical Sanitizing policy and procedure.

2. On 2/3/15 and 2/5/15, the following observations were made in the facility's patient cottages, in the presence of Staff #17, Staff #79 and Staff #73.

a. The PIC (Person in Charge) for the facility Cottage Food Service, Staff #73, failed to adequately demonstrate control over food safety hazards in accordance with Reference #1, Reference #2 and Reference #3.

b. On 2/3/15, Cottage #20 kitchen area refrigerator contained 1 package of ham and 2 packages of cheese that were not dated. The dining room, chest freezer contained 2 bags of strawberries and 1 bag of blueberries that were not dated. Three bags of green beans were not rotated, first in first out. The bag on top was dated 1/30/15, below it was a bag dated 1/20/15, and at the bottom was a bag dated 1/12/15. The dining room juice refrigerator contained 20 individual juices that weren't dated. The food items were not maintained in accordance with Reference #8.

c. On 2/3/15, the Cottage #20 kitchen area dining room had tables set for lunch with clear plastic cups with heavy white stains. Staff #60 was observed emptying the unit dish washer and wiping the cups with a paper towel. The cups were not air dried in accordance with Reference #11.

d. On 2/3/15, Cottage #20 kitchen area cabinets, drawers, and two hoods over the stove had wood-like chips/saw dust, food particles and peeling paint on them. The area was not maintained in accordance with Reference #15 and Reference #16.

e. On 2/5/15. Cottage #19 kitchen area refrigerator contained 1 package of ham dated 1/30/15, sliced turkey dated 1/23/15 and 1/27/15, shredded cheese dated 1/23/15 and 2 packages of yellow cheese that were not dated. The food items were not maintained in accordance with Reference #8.

f. On 2/5/15, Cottage #19 kitchen area cabinets, and drawers had wood like chips/saw dust, food particles and dust on them. The area was not maintained in accordance with Reference #15 and Reference #16.

g. On 2/5/15, Cottage #19 lacked a thermometer with a small-diameter probe that is designed to measure the temperature of thin masses to accurately measure the temperature in thin foods such as meat patties and fish filets, in accordance with Reference #6. Staff #80 did not check the temperature of the food served for the lunch meal in accordance with Reference #7.

3. On 2/4/15, the following observations were made in the facility's Park Place Cafe, in the presence of Staff #17 and Staff #64.

a. The PIC (Person in Charge) for the facility Park Place Cafe, Staff #64, failed to adequately demonstrate control over food safety hazards in accordance with Reference #1, Reference #2 and Reference #3.

b. On 2/4/15, the Park Place Cafe refrigerator contained three packages of yellow cheese, two packages of buttered bread, one roll, one tub of margarine, one loaf of whole wheat bread, one bag of seven rolls, sliced tomatoes, peppers, onions, an opened package of hot dogs, cooked turkey bacon, and six cheese pizzas that were not dated. The freezer contained one opened bag of chicken patties that was not sealed, and twenty individually prepared containers of frozen yogurt that were not dated. The food items were not maintained in accordance with Reference #8.

c. On 2/4/15, the Park Place Cafe had two bags of potato chips opened and not sealed, stored on the bottom shelf of a work table next to three bottles of sanitizer, one can of stainless steel cleaner and two cartons of grill bricks. The food items were not maintained in accordance with Reference #8.

d. On 2/4/15, the Park Place Cafe contained three of three hand wash sinks that lacked soap and paper towels for hand drying, in accordance with Reference #13 and Reference #14.

e. On 2/4/15, the Park Place Cafe janitors closet was cluttered. Two cartons of paper towels were placed directly on the floor, blocking access into the janitors closet. One mop and one broom were stored directly on the floor. The closet lacked shelving and hangers to store the mop and broom off the floor in accordance with Reference #12.

4. The following observations were made in the facility's patient units/kitchens.

a. On 2/2/15, during lunch meal observations in the presence of Staff #17 on Units #F1, #F2 and Unit #A1, patients were observed being served meals on paper/Styrofoam plates during the meal services. Staff#17 stated that most of the dishwashers in the facility are out of service, therefore the need to serve meals on Styrofoam.

b. A review of the units dishwasher Temperature Logs, dated June 2014 thru January 2015 revealed that an average of 14 of the 19 patient units had non-functioning dishwashers for the last nine months. The dishwashers were not maintained in accordance with Reference #16.

c. On 2/3/15, in the presence of Staff #10, the Unit F2 refrigerator contained a Styrofoam cup of soy milk, a spread, 4 salads in clear plastic containers and 4 Styrofoam cups of water that were not labeled and dated. The food items were not maintained in accordance with Reference #8.

C. Based on observation, staff interview and document review, it was determined that the facility failed to ensure that the Director of Food & Nutrition develops and implements an effective Quality Assurance Plan that includes identification of problems, data collection, monitoring, data analysis and evaluation, recommendations, implementation of corrective actions and monitoring of corrective actions.

Findings include:

Reference: "Director of Clinical Nutrition" job expectation states, "1. Assures provision of quality nutritional services to all patients ... 2. Provides administrative supervision of the Nutrition Department and Food Service Department ... documents the appropriate orientation of all new staff ... 5. Standards compliance ... Review all other outside survey results ... DOH and develops and implements any required remedial action plans in a timely manner ... 6. Performance Improvement activities within the Nutrition Department and Food Service Department...Complies and tracks all PI data and develops a PI Plan for the Department in coordination with the Medical Director, the Director of Quality Assurance, and/or Quality Assurance Coordinator in order to address all identified deficiencies and opportunities for improvement ... 7. Staff Development ... Assures that 95% of all staff meets all mandatory training requirements."

1. On 2/4/15, Staff #17 could not provide for review a Food & Nutrition services Quality Assurance Plan for 2014 and/or 2015 in accordance with Reference #1.

2. On 2/4/15, Staff #17 provided for review seven months of documents labeled "Food Service and Clinical Nutrition Performance Improvement Committee Meeting Agenda" dated from July 8, 2014 to January 13, 2015. These documents appeared to be general meeting agendas. These meeting agendas did not address problem identification, data collection, monitoring and analyzing data, recommending, implementing and monitoring corrective actions, in accordance with Reference #1.

3. On 2/4/15, Staff #17 provided for review "Clinical Nutrition Department, Performance Improvement, Monthly Summary of Meal Observation Reports, Year 2014" and one for January, 2015.

a. The hot food criterion was documented 6 of 13 times below the facility goal of 90%. The cold food criterion was documented 7 of 13 times below the facility goal of 90%.

b. Staff #17 could not provide an evaluation of the collected food temperature data in accordance with Reference #1.

c. Staff #17 could not provide recommendations, implementation and monitoring of corrective actions regarding food temperature data in accordance with Reference #1.

4. On 2/4/15, Staff #17 provided for review "Food Service Department, Main Kitchen Environmental and Equipment Rounds" reports dated from 6/6/14 to 1/29/15.

a. The reports documented problems with the warmer and cold trucks on 11 of 31 reports. Staff #17 could not provide an evaluation of the problems with the warmer and cold trucks and could not provide recommendations, implementation and monitoring of corrective actions regarding problems with the warmer and cold trucks for the patient care units, in accordance with Reference #1.

b. The reports documented ongoing concerns with a lack of hot water for hand sinks, various issues with broken equipment and additional cleaning. Staff #17 could not provide an evaluation of the various problems identified in the Food Service Department and Main Kitchen Environmental and Equipment Rounds reports. Staff #17 could not provide recommendations, implementation and monitoring of corrective actions regarding various problems identified in the Food Service Department, Main Kitchen Environmental and Equipment Rounds reports, in accordance with Reference #1.

5. On 2/3/15, Staff #17 provided for review "Consumer and Environmental Health Services Retail Food Inspection" reports dated 7/16/14 and 9/30/14. Staff #17 failed to develop and implement remedial action plans for the identified deficient practices identified on these reports, in accordance with Reference #1.

a. The report dated 7/16/14, identified problems with an infestation of fruit flies in several areas of the kitchen, inadequate temperature monitoring for food items such as potato salad, poor organization of mops and the mop cleaning area, and obstruction of hand wash sinks. Staff #17 could not provide a remedial action plan for these findings.

b. The report dated 9/30/14, identified problems with out of service food service equipment including the main dishwasher, steam table and ice machine, poor organization of mops and the mop cleaning area, and a walk in freezer with food storage on the floor. Staff #17 could not provide a remedial action plan for these findings.

Based on observation, staff interview and document review, it was determined that the facility failed to ensure that all facility staff providing food services are trained and competent in their assigned duties.

Findings include:

Reference #1: Facility policy Orientation of New Employees states, "Every new employee ... must complete the hospital's New Employee Orientation ... Once completed, a new employee with the Food Service department will begin work by meeting the supervisory staff ... The new employee will be assigned a Food Service Supervisor of Area Operations who will begin to orient the employee to the department following the Food Service Orientation Checklist ... Basic orientation should be completed within the first week of assignment within the department ... After completing each activity, the instructor of that activity makes the new employee sign an attendance sheet with the title of the subject matter as proof of completion."

Reference #2: Facility policy Prevention of Infection Purpose ... Education states, "I. Purpose: A. To provide a workable guide for Food Service Department Staff for the care and preparation of wholesome, nutritious meals, safe for consumption by patients and staff. B. To prevent infection through food as a multiplier using the Hazard Analysis Critical Control Point (HACCP) and good food handling practices. C. To prevent infection through food as a vehicle by controlling extrinsic environmental factors. D. To comply with Chapter 24 of the New Jersey Administrative Code (N.J.A.C. 8:24) governing Food Establishments ... Education... General new employee orientation is provided to all newly hired employees ... Department Orientation ... All new Food Service Personnel, upon reporting for employment, are trained in departmental policies and procedures, infection control and food sanitation, and the importance of reporting infections and adherence to Employee Health requirements ... Continuing In-service Education ... Formal refresher courses in sanitation and infection control are held annually to re-emphasize to all Food Service personnel their role in preventing the spread of infection. Informal in-service is presented as needed when faulty work habits are observed. In-service training for the safe operation and maintenance of equipment initially, upon employment, and as new equipment is purchased. Training is based on Chapter 24 of the State Sanitary Code for food handling.

Reference #3: Facility policy Prevention and Control of Infection states, "I. Purpose: A. To provide a workable guide for Food Service Department Staff for the care and preparation of wholesome, nutritious meals, safe for consumption by patients and staff. B. To prevent infection through food as a multiplier using the Hazard Analysis Critical Control Point (HACCP) and good food handling practices. C. To prevent infection through food as a vehicle by controlling extrinsic environmental factors. D. To comply with Chapter 24 of the New Jersey Administrative Code governing Food Establishments"

Reference #4: N.J.A.C. 8:24-4.1(a) states, "The operator shall be the person in charge or shall designate a person in charge and shall ensure that a person in charge is present during all hours of operation."

Reference #5: N.J.A.C. 8:24-4.1(b) states, "The Person in Charge shall demonstrate to the health authority knowledge of foodborne disease prevention, application of the Hazard Analysis Critical Control Point (HACCP) principles ... the person in charge shall demonstrate compliance with this chapter ... at least one person in charge in Risk Type 3 Food Establishments shall be a certified food protection manager."

1. On 2/6/15, Staff #79 stated that 18 out of 18 new Food Service Personnel, who completed the hospital's New Employee Orientation on 1/12/15, were not oriented within the first week of assignment to the Food Service Department.

a. Staff #79 could not provide for review, Food Service Department orientation forms with staff signatures for 18 out of 18 new Food Service Personnel, in accordance with Reference #1 and Reference #2.

2. On 2/6/15, Staff #79 could not provide current training rosters and/or a syllabus documenting annual Food Service Department training in sanitation and infection control that is based on N.J.A.C. 8:24, the State Sanitary Code for food handling, in accordance with Reference #2.

a. On 2/6/15 the facility could not provide documentation of orientation to the Food Service Department and annual training for food service Staff #56, Staff #57 and Staff #58 in accordance with Reference #2.

3. During interview and observations of lunch meal service on 2/3/15 in Cottage #20, and on 2/5/15 in Cottages #19, #13 and #14, Staff #73 indicated that he/she was the Person in Charge of food services for seven of seven Cottages. Staff #73 stated that the Cottages follow N.J.A.C. 8:24, the State Sanitary Code for food handling.

a. Staff #73 stated that he/she is not a certified food protection manager in accordance with N.J.A.C. 8:24; the State Sanitary Code, Reference #4 and Reference #5.

b. The facility Resident Living Specialists (RLS) staff were observed preparing patient meals in Cottages #20, #19, #13 and #14. Staff #73, stated that the Cottage RLS staff is responsible for the Cottage meal preparation including food storage, cooking meals and clean up.

(i) RLS Staff #30, Staff #59, Staff #60, Staff #61, Staff #62 and Staff #80 stated that they do not have specialized training in food services.

(ii) Staff #73 could not provide documentation of RLS training in sanitation and infection control that is based on N.J.A.C. 8:24; the State Sanitary Code for food handling.

4. During staff interview and observations of Park Place Cafe, Staff #64 is the Person in Charge of food services for the Park Place Cafe. Staff #64 stated that the Park Place Cafe staff follow the principles of N.J.A.C. 8:24, the State Sanitary Code for food handling.

a. Staff #64 stated to the surveyor, has no certified food protection manager in accordance with N.J.A.C. 8:24; the State Sanitary Code, Reference #4 and Reference #5.

b. Staff #64 could not provide for 5 out of 6 Park Place Cafe staff documentation of orientation and training in sanitation and infection control that is based on N.J.A.C. 8:24, the State Sanitary Code for food handling.

Based on observation, staff interview and document review, it was determined that the facility failed to ensure that all patients received meals that meet their basic nutritional needs according to the approved menus and standardized recipes.

Findings include:

1. On 2/3/15 at 11:50 AM, Resident Living Specialists (RLS) Staff in Cottage #20 were observed preparing macaroni and cheese for the lunch meal. Staff #60 stated that the facility provided a standardized macaroni and cheese recipe, but does not use the recipe since "... knows how to cook."

a. Two out of three staff (Staff #60 and Staff #62) in Cottage #20 stated that they do not use the standardized recipes.

2. On 2/5/15, the lunch meal menu included shaved roast beef and garlic spinach. Staff #73 stated that the facility failed to provide a standardized recipe for the shaved roast beef and garlic spinach. Each cottage staff made the shaved roast beef according to their own personal preference. The meals weren't prepared according to the facility menu and standard recipes.

a. RLS Staff #80, in Cottage #19, stated that since they lacked a recipe for the shaved roast beef, chopped beef was prepared instead.

b. The cottage staff failed to follow standardized recipes to ensure the patients basic nutritional needs are met according to the approved menus and standardized recipes.

Based on observation and staff interview, it was determined that the facility failed to ensure the safety of patients.

Findings include:

1. Patient care areas of the facility were observed to be in disrepair and unclean. (Cross refer to Tag 0701)

2. The facility failed to maintain the hot water system per manufacturer's requirements. (Cross Refer to Tag 0701)

3. The facility failed to comply with the minimum requirements of the 2000 edition of NFPA's Life Safety Code. (Cross Refer to Tag 0709)

4. The facility failed to develop and implement policies and procedures for the destruction of medications in a safe manner. (Cross Refer to Tag 0713)

5. The facility failed to maintain adequate facilities for its services. (Cross Refer to Tag 0722)

6. The facility failed to maintain safe hot water temperatures. (Cross Refer to Tag 0722)

7. Supplies and equipment were not maintained to ensure an acceptable level of safety and quality. ( Cross Refer to Tag 0724)

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B. Based on document review and staff interview, it was determined that the facility failed to ensure physical plant maintenance is conducted in accordance with the manufacturer's requirements.

Findings include:

Reference #1: Tyco HWAT System Installation and Operation Manual states, "... 9.2, Insulation Resistance Test. Frequency, ... as part of the regular system inspection ... after any maintenance or repair work. Procedure, Insulation resistance testing (using a megohmmeter) should be conducted at three voltages; 100, 1000, and 2500 Volts direct current. Potential problems may not be detected if testing is done only at 500 and 1000 volts. First measure the resistance between the heating cable bus wires and the braid and the metal pipe (Test B) ..."

Reference #2: Tyco HWAT System Installation and Operation Manual states, "... 9.5, Temperature test. When testing an HWAT system for temperature, it is important to test in an appropriate sequence ..."

Reference #3: HWAT System Installation and Operation Manual states, "... 8, Commissioning and Preventive Maintenance, Tyco Thermal requires series of tests be performed on the HWAT System. These tests are also recommended at regular intervals for preventive maintenance. Results must be recorded and maintained for the life of the system, utilizing the Installation and Inspection Record (refer to Section 11). ... Tests ... Visual inspection ... Insulation Resistance ... Power Check ... Ground-Fault Test ..."

1. On 2/4/15, a review of facility maintenance logs, provided evidence that the facility was not following the recommended maintenance procedures and recording the required testing information, as required by the HWAT System Installation and Operation Manual.

2. On 2/3/15, a review of the facility HWAT Maintenance Log, provided no evidence of resistance testing being conducted in accordance with manufactures guidelines.

a. Staff #1 and Staff #6 confirmed these findings.

3. On 2/3/15, Staff #6 confirmed he/she was not aware of the requirement that a specific sequence be utilized when taking water temperatures

a. During an interview on 2/3/15, Staff #1 and Staff #6 confirmed that no policy and procedure exists explaining the procedure of how to test water temperatures in water pipes that utilize the HWAT system.

4. During an interview on 2/3/15, Staff #1 and Staff #6 confirmed ongoing maintenance problems with the hot water system. A system called the HWAT (Hot Water Temperature Maintenance System) is used to maintain hot water due to the long distance that exists between the water heater to the sinks and showers.

a. Staff #6 added, "... the system is used to maintain hot water in the pipes to reduce the amount of time the water needs to be run to get hot water at the taps."

Based on observation, it was determined that the facility failed to ensure compliance with the 2000 edition of the Life Safety Code.

Findings include:

Reference: 2000 edition of NFPA's Life Safety Code, 101:18.3.7.6 Doors in smoke barriers ... and shall be self-closing or automatic-closing in accordance with 8.2.2.6

1. On 2/4/15 in the presence of Staff #6, the following corridor doors were blocked open preventing the self-closing devices from operating and positive latching the doors:

a. At 11:35 AM, one 1 3/4 hour rated fire door to the Basement Elevator Room H007, was held open by a wet floor sign.

b. At 11:40 AM, one 1 3/4 hour rated fire door to the Shop, was held open by a plastic cart.

c. At 11:50 AM, one 1 3/4 hour rated fire door to the Cleaning Supply Room, was held open by a cardboard box.

d. At 11:55 AM, one 1 3/4 hour fire rated kitchen door F-005C, was held open by a plastic garbage can.

e. At 12:00 PM, one 1 3/4 hour fire rated kitchen door F016, was held open by a plastic garbage can.

2. On 2/4/15 at 11:35 AM, in the presence of Staff #6, the 3/4 hour fire-rated door to the Repair Shop was held open by a plastic wedge.

Based on observation, staff interview and document review on 2/6/15, it was determined that the facility failed to develop and implement policies and procedures for the destruction of medications in a safe manner.

Findings include:

Reference: Facility policy Destruction and Disposal of Unused, Expired and Contaminated Controlled Medications states, "Procedure A. All unused, expired and contaminated medications are logged in the wasted medication log before placing in the designated medical waste container in the unit. ... C. All medications for disposal are placed in the designated medical waste container as follows: 1. Tablets, Capsules and Liquids: Remove tablets, capsules and oral/topical liquids from their original packaging and place in the medical waste container. 2. Vials and Inhalers: Place all unused, expired or contaminated inhalers in the medical waste container to prevent reuse. 3. Ointment tubes: Squirt the content of the ointment/cream tubes into the medical waste container and then discard tubes in regular trash. D. When the medical waste container is 3/4 full, close and seal and treat as medical waste ..."

1. During tours of the medication rooms throughout the facility, red containers that were not marked as medical waste were found. The containers contained a slurry and were not secured or capped to prevent spillage.

a. Some of the containers emitted a noxious odor.

2. Upon interview, Staff #87 stated that all medications (tablets, capsules, liquids, ointments, lotions) were wasted by placing them inside of this red container, with some water, in accordance with the policy referenced above.

3. The practice of mixing all medications together does not address potential incompatibilities. Such incompatibilities can cause chemical reactions, leading to the formation of toxic and potentially volatile gases and solutions.

Based on observation, it as determined that the facility failed to maintain adequate facilities for its services.

Findings include:

Reference: 2010 edition, Facilities Guideline Institute, Table 2.1-5, Hot water use for clinical areas shall be between 105-120 degrees Fahrenheit.
1. On 2/3/15 at 11:00 AM, in the presence of Staff #1 and Staff #6, the hot water temperature was taken at the following locations:

a. 2nd Floor Men's Restroom, outside Administration, 123 degrees Fahrenheit at the hand washing sink.

b. Room #A115, 126 degrees Fahrenheit at the hand washing sink.

c. Room #D115, 128 degrees Fahrenheit in the Center Women's Shower.

d. Room #D115, 131 degrees Fahrenheit at the hand washing sink.

e. Room #133A, 130 degrees Fahrenheit at the hand washing sink.

f. B1 Break Room, 128 degrees Fahrenheit at the hand washing sink.

A. Based on a tour of 7 patient care units and interview, it was determined that equipment and environmental surfaces were not kept clean to sight and touch.
Findings include:
1. A tour of Cottage #14 was conducted on 2/5/15 at approximately 10:00 AM in the presence of Staff #72 the following was observed:
a. The exterior surfaces on the kitchen cabinets had dirt and grime.

b. The kitchen cabinet under the sink,contained pots and pans was dirty.

c. The above was confirmed by Staff #72.
2. A tour of Cottage #13 was conducted on 2/5/15 at approximately 11:00 AM in the presence of Staff #77 the following was observed:

a. The exterior surfaces on the kitchen cabinets had dirt and grime.

b. The pantry floor was dirty.

c. The Men's shower room had eight 1"x1" tile blocks missing from the floor.

d. The above was confirmed by Staff #72.

3. A tour of Unit F2 was conducted on 2/3/15 in the presence of Staff #10
. The following was observed:
a. The Patient Information Center:
(i) A locked computer cabinet with a heavy accumulation of dust around the surfaces.
b. Chart Room
(i) On the top of the wall shelf heavy accumulation of dust and grit.

(ii) The floor was dusty.

c. Medication Room:

(i) A metal cabinet located on the left beneath the metal window cover was heavily stained.

(ii ) The shelves in the wall cabinets containing medications and patient care items, had grit.

(iii) The food refrigerator was stained on the interior surfaces and the freezer section had a heavy accumulation of frost.

(iv) The medication refrigerator exterior surfaces were dusty.

d. The Clean Line Closet ( Room#F243) had heavy accumulation of dust beneath the bottom wire shelves.

e. The Recovery Room (Room #F233A)

(i). The floor was dusty and contained girt.

(ii). The restraint chair had a heavy accumulation of dust and grit.
f. The Food Servery (Room #F227):

(i) The floor was dusty and contained grit.

(ii). The wall next to the sink had sections of peeling paint.

(iii). The left side of the wall next to the refrigerator had two gouged holes.

j. The following issues were found in the Clean Storage Room (Room #F245):

(i.) The floor was dusty with girt.

4. A tour of Unit B1 was conducted on 2/4/15 with Staff #10 that revealed the following:

a. The Medication Room (Room #B141):

(i). The top shelf of the "Medication Only" cabinet had a black substance on the top surface.


(ii). The Medication cart had tape and tape residue on exterior and interior surfaces. The "Internals" drawer had raised, thick brown stains inside of it.


(iii). The insulation strip at the top of the food refrigerator door had an approximately 10 inch tear with a black particulate accumulation on the interior of the insulation. The back of the interior of the refrigerator had a heavy accumulation of frost and there were stains throughout the interior.

5. A tour of D2 was conducted on 2/5/15 with Staff #10 that revealed the following:

a. The following issues were found in the Chart Room:


(i). The metal cabinet nearest the door had dust and dried stains on the interior of the drawers.


(ii). The metal cabinet beneath the counter, to the left of the cabinet nearest the door, had grit in the
drawers.


(iii). Medical records shelf: There was tape residue on the face of and atop the shelf. The face of the shelf had an approximately 3 inch section where the Formica had been broken off.

b. The following issues were found in the Recovery Suite:

(i). The bed in the interior room had dust clumps, dust, grit, and paper scraps beneath and behind it. The mattress on the bed had eight small holes on the cover.


(ii). A wall telephone in the exterior room had a heavy accumulation of dust on it.


c. In the Servery (Room #D227) the freezer section of the refrigerator had a heavy accumulation of frost. The middle drawer on the interior had brown particulate inside of it.

d. The Medication Room:

(i). Beneath the medication refrigerator were eight plastic lancet pieces, one needle cap, dust, grit, paper scraps. The insulation on top of the door was separated. An accumulation of brown and black particulate was observed on the interior of the insulation.

(ii). Beneath the food refrigerator were two empty pill packages, a needle cap, an alcohol pad, one lancet piece, dust, grit, and paper scraps. There was dust atop the refrigerator.

e. The following issues were found in the Exam Room (Room #D232):
(i). The wall above the wall-mounted sphygmomanometer had three small nail holes not filled in. There was exposed joint compound and sheet rock paper.

f. The following issues were found in the Shower Room:

(i). There were large areas of unpainted joint compound on the back wall and the left wall as one enters the room.

(ii). The joint compound above Stall #3 was not painted.

6. A tour of Unit A3 was conducted on 2/6/15 with Staff #10 that revealed the following:

a. The following issues were found in the Medication Room:

(i). The food refrigerator had a heavy accumulation of frost on the back interior wall. The insulation strip on the door was torn on the left top and side.

(ii). The insulation strip on the medication refrigerator door was torn at the top left.

(iv). The drawers of the medication cart had tape, tape residue, dried spilt liquids, stains, dust, grit, and paper scraps on and in them.

b. The following issues were found in the Serving Area (Room #A327):

(i). On the floor beneath the refrigerator was observed a dislodged floor tile, paper scraps, paper clips, and stains.

(ii). A drawer under the stainless steel counter had crumbs at the bottom of the drawer.

7. A tour of Unit F3 was conducted on 2/6/15 with Staff #10 that revealed the following:

a. A black Stanley tool box in the Chart Room had multiple pieces of individually wrapped hard candies that had melted and seeped onto the bottom of the box.


b. The emergency equipment cabinet had stains on all three shelves.

(i). The emergency kit on the emergency equipment cart was heavily stained. One of the two latches used to close the kit was broken off.



21496

Based on observation, facility documentation review, and staff interviews conducted between 2/2/15 and 2/5/15, it was determined that the facility failed to ensure that a sanitary environment, to avoid sources and transmission of infections and communicable diseases, was provided.

Findings include:

1. The facility failed to provide a functional and sanitary environment for the provision of dental and podiatry services by adhering to professionally acceptable standards of Asepsis and Sterilization is implemented. (Cross refer to Tag 0749)

2. The facility failed to ensure that an active Infection Control program for the prevention, control and investigation of infections and communicable diseases is implemented. (Cross refer to Tag 0749)

3. The facility failed to ensure that a qualified Infection Control Professional (ICP) is designated to oversee the facility's Infection Control program. (Cross refer to Tag 0748)

Based on observation, staff interviews and employee personnel file review conducted on 2/4/15, it was determined that the facility failed to ensure that a qualified Infection Control Professional (ICP) was designated to oversee the facility's Infection Control Program.

Findings include:

Reference: CMS [Centers for Medicare and Medicaid Services] Interpretive Guidelines for 42 CFR 482.42 states, "CDC [Centers for Disease Control and Prevention]
has defined 'infection control professional' as a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control. ... In designating infection control officers hospitals should assure that the individuals so designated are qualified through education, training, experience, or certification (such as that offered by the Certification Board of Infection Control and Epidemiology Inc. (CBIC), or by the specialty boards in adult or pediatric infectious diseases offered for physicians by the American Board of Internal Medicine (for internists) and the American Board of Pediatrics (for pediatricians)."

1. Upon review of the employee personnel file for Staff #25 (Infection Control Nurse) at 10:55 AM, the file contained no evidence of CBIC certification and/or recent specialized training in Infection Control.

2. Upon review of the employee personnel file for Staff #12 (Infection Control Nurse) at 11:05 AM, the file contained no evidence of CBIC certification and/or recent specialized training in Infection Control.

3. Upon review of the employee personnel file for Staff #8 (Infection Control Committee Chairperson) at 11:15 AM, the file contained no evidence of Infection Control specialty certification through the American Board of Internal Medicine and/or recent specialized training in Infection Control.

4. The facility failed to ensure that personnel designated to oversee the facility's Infection Control program were qualified.

A. Based on observation, staff interview and facility document review conducted on 2/4/15, it was determined that the facility failed to ensure that the infection control officer implemented the facility Environmental Rounds policy and procedure.

Findings include:

Reference: Environmental Rounds policy and procedure states, "Environmental rounds is [sic] made on patient care units and support services areas by the Infection Control Practitioner, Safety Officer and the Housekeeping Department Supervisor or designee. Findings are documented and discussed ... A written report is sent to the Hospital Administrator, Housekeeping, Safety and other disciplines impacted by the findings. Findings are submitted to the responsible individual for corrective action ... The following Support Services are monitored for environmental issues related infection control ... Dietary/Food Service - storage of foods, maintenance and monitoring of prepared food temperature in the kitchen and at serving sites, pest control and the storage and disposal of food garbage. Monitoring and documenting temperature of food refrigerators."

Staff #12 could not provide written Environmental Rounds reports related to Dietary/Food Services. During interview, Staff #12 stated that Environmental Rounds are not completed on a regular basis, and he/she does not write them up as required in accordance with Reference #1.



33800

B. Based on observation, staff interview and facility document review conducted on 2/2/15 through 2/5/15, it was determined that the facility failed to ensure that its policies on Hand Hygiene and Personal Protective Equipment (PPE) were implemented.

Findings include:

Reference #1: Facility document titled, Hand Hygiene states, "IV. INDICATIONS FOR HAND HYGIENE: ... 2. Before donning gloves and after the removal of gloves."

Reference #2: Facility document titled, Disease Transmission/ Precaution states, "... b. Wash hands immediately with soap and water before and after any contact with blood, body fluids and contaminated items, whether or not gloves are worn. ... d. Personal Protective Equipment (PPE) serves as protective barrier and must be worn during patient care when coming in contact with blood/ or other body fluids, mucous membrane and non-intact skin when potential for exposure is likely."

Reference #3: Facility document titled, DENTAL SERVICES- POLICIES FOR INFECTION CONTROL states, "...V. Personal Protective Equipment (PPE) ... A. PPE USE ... Supervisory personnel who oversee the related patient care shall ensure that the employee uses appropriate PPE except in rare and extenuating circumstance. ... C. PPE DISPOSAL ... 2. ... All PPE will be removed prior to leaving the work area."

1. During a tour of the Dental Clinic on 2/3/15, in the presence of Staff #8, Staff #12, Staff #19, Staff #32 and Staff #33 at 11:20 AM, Staff #26 was observed while he/she performed decontamination of soiled dental instruments.

a. Staff #26 removed his/her soiled gloves at 11:20 AM without sanitizing his/her hands. He/she then left to obtain a denture brush from another area of the dental clinic, returned, and continued to touch other surfaces before donning another pair of gloves.

b. At 11:35 AM, Staff #26 removed his/her soiled gloves after completion of the instrument decontamination without sanitizing his/her hands.

2. While performing decontamination of soiled dental instruments, Staff #26 was observed to wear a disposable lab coat, gloves, and goggles.

a. The gloves worn by Staff #26 during decontamination was observed to expose his/her wrists and the bracelets that he/she kept on while decontaminating instruments.

(i) Wearing jewelry while performing decontamination of instruments increases the risk of cross-contamination.

b. When asked about available PPEs for decontamination, Staff #26 stated that the facility has face masks with face shields and disposable headcovers available but, "I don't wear them when I do this. I just don't like wearing them."

c. At 11:40 AM, Staff #26 and Staff #34 stated that they wear the same lab coat worn while assisting in dental procedures during decontamination of soiled dental instruments.

3. These findings were confirmed by Staff #8, Staff #12, Staff #19, Staff #32 and Staff #33.

4. On 2/4/15, during an observation of unit F2 at 10:20 AM in the presence of Staff #12, Staff #51 was observed cleaning the Dining Room.

a. At 10:23 AM, after completing cleaning in the Dining Room, Staff #51 proceeded to the Nurses' desk still wearing the soiled gloves he/she wore while cleaning.

b. At 10:25 AM, Staff #51 removed his/her gloves without sanitizing his/her hands.

c. A hand sanitizer was observed hanging on a lanyard that Staff #51 was wearing around his/her neck.

d. When Staff #51 was asked about the hand sanitizer, he/she replied, "I don't want to use this thing."

e. This finding was confirmed by Staff #12.

5. On 2/5/15, during a tour of Cottage #14, in the presence of Staff #12 and Staff #73, Staff #72 was observed while preparing lunch for the residents.

a. At 10:10 AM, Staff #72 was observed removing a soiled glove without sanitizing his/her hands.

b. This finding was confirmed by Staff #12.

C. Based on observation, staff interview and facility document review conducted on 2/3/15 and 2/4/15, it was determined that the facility failed to ensure that its Infection Control practices adhered to the facility's policies and to nationally recognized standards of practice.

Findings include:

Reference #1: Facility document titled DENTAL SERVICES- POLICIES FOR INFECTION CONTROL states, "...VII. STERILIZATION & DISINFECTION ... A. ... 1. a. ... On the MidMark M11 Ultraclave & Statim Model 2000 autoclaves, the date, time, temperature, pressure sterilization time and load content is recorded."

Reference #2: Facility document titled DENTAL SERVICES- POLICIES FOR INFECTION CONTROL states, "...VII. STERILIZATION & DISINFECTION ... A. ... 1. c. A biological monitor is used routinely for the sterilizer on a weekly basis ... These weekly tests are documented in a log book and the sterility test reports are filed. d. Instruments are held pending an acceptable monitoring report. e. A sterilizer log is maintained for the MidMark M11 Ultraclave and Statim autoclaves."

1. A tour of the Dental Clinic was conducted on 2/3/15 between 11:10 AM to 11:58 AM. At 11:23 AM, Staff #26 was observed cleaning dental instruments in the Decontamination/ Instrument Reprocessing area of the Dental Clinic.

a. At 11:27 AM, Staff #26 was asked what cleaning supplies/products are used to remove debris from the soiled instruments.

(i) Staff #26 replied that he/she uses his/her fingers to remove debris from the instruments.

(ii) The facility failed to ensure that its Infection Control practices adhere to nationally accepted standards.

2. At 11:25 AM, a MidMark M11 Ultraclave table top autoclave and a Statim 2000 autoclave were observed in the Decontamination/ Instrument Reprocessing area.

a. The two autoclaves did not have a printer to document the mechanical parameters of each sterilization cycle.

b. According to Staff #26 and Staff #34, they do not monitor or document the date, time, temperature, pressure sterilization time and load content of each sterilization cycle.

(i) The facility failed to ensure that its Dental Clinic Infection Control policy is implemented.

3. At 11:40 AM, Staff #26 and Staff #34 were interviewed regarding the process for sterilization. Both stated that they operated and monitored the sterilizers.

a. Staff #26 and Staff #34 stated that they were not aware of the mechanical parameter settings for the sterilization cycles programmed on both autoclaves.

b. Upon request, Staff #26 and Staff #34 were unable to provide documentation of the current settings for both sterilizers.

4. Sterilization records for the Dental Clinic's MidMark M11 Ultraclave and the Statim 2000 autoclaves were requested at 11:40 AM.

a. The facility was unable to provide the requested records.

b. Staff #26 and Staff #34 stated that they perform Chemical Indicator (CI) testing but do not document the CI testing results.

c. The facility failed to maintain sterilization records according to nationally recognized standards of practice in Infection Control.

5. Upon interview at 11:50 AM, Staff #26 and Staff #34 were unable to articulate understanding of the sterilization monitoring procedures, i.e., Biological Indicator (BI), Chemical Indicator (CI), and Mechanical parameter monitoring for the sterilizers that they operate.

6. Staff #26 and Staff #34 were unable to articulate nationally accepted standards of practice in Sterilization.

a. The facility failed to ensure that qualified and appropriately trained personnel are designated to perform Sterilization.

7. The manufacturer's instructions for use (IFUs) for the reprocessed dental instruments were requested at 11:52 AM.

a. According to Staff #26, Staff #32, Staff #33 (Dentist), and Staff #34 (Dentist), the Dental Clinic does not have the manufacturers' instructions for use (IFUs) for the dental instruments that they sterilize.

(i) The Dental Clinic failed to follow manufacturers' IFUs for the instruments that they sterilize.

(ii) The facility failed to ensure that its Infection Control practices adhere to nationally accepted standards.

8. These findings were confirmed by Staff #8, Staff #12, Staff #19, Staff #32 and Staff #33.

These findings resulted in an Immediate Jeopardy which immediately curtailed the Dental Clinic.

D. Based on observation, staff interviews and facility document review conducted on 2/3/15 and 2/4/15, it was determined that the facility failed to ensure that a sanitary environment to avoid sources and transmission of infection was provided.

Findings include:

1. During an interview in the Dental Clinic on 2/3/25 at 11:38 AM, Staff #26 and Staff #34 stated that they do not clean and terminalize the cleaning implements, sink and counters in the Decontamination/ Instrument Reprocessing area of the Dental Clinic at least daily.

a. The facility failed to ensure a sanitary environment in the Dental Clinic.

E. Based on observation, staff interviews and facility document review conducted on 2/2/15, 2/3/15 and 2/4/15, it was determined that the facility failed to ensure that all personnel are screened for tuberculosis (TB), Rubella and Rubeola upon hire and conduct ongoing TB screening annually according to its policy and the CDC (Centers for Disease Control and Prevention) Guidelines. CDC is the nationally-recognized guideline the facility has selected for its Infection Control program.

Findings include:

Reference #1: Facility document titled Employee Health Services (EHS) states, "I. Policy: ... In accordance with Administrative Bulletin 3:26 of October 20, 2006. (sic) TB testing, hepatitis B and influenza vaccines will be done at GPPH. ... II. Procedures ... D. Routine Care: ... Annual PPD testing will be encouraged for all employees. Annual PPD testing will be performed by the EHS nurse. If a staff has a history of a positive Mantoux or Quantiferon Gold, and has been appropriately treated, the staff member will be required to complete a TB symptomatology form."

Reference #2: CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report (MMWR) May 22, 1998/ 47 (RR-8);1-57 states, "All persons who work in health-care facilities should be immune to measles and rubella ... . Because any health-care worker (i.e., medical or nonmedical, paid or volunteer, full- or part-time, student or nonstudent, with or without patient-care responsibilities) who is not immune to measles and rubella can contract and transmit these diseases, all health-care facilities (i.e., inpatient or outpatient, private and public) should ensure that those who work in their facilities are immune to measles and rubella."

1. On 2/2/15 during an interview between 12:00 to 12:50 PM, Staff #12 stated that the facility follows CDC and APIC guidelines.

2. On 2/3/15, while conducting a review of Employee Health files at 2:45 PM, Staff #44 (EHS nurse) stated, "We are not testing employees for Rubella and Rubeola."

a. Upon review of Employee Health files on 2/3/15 and 2/4/15, 9 of 9 Employee Health files reviewed contained no evidence of Rubella and Rubeola testing.

3. On 2/3/15 at 2:50 PM, Staff #44 was asked about Employee Health TB testing. He/she stated, "PPD [purified protein derivative] questionnaires are not done for PPD positive employees. These are done only for staff who receive PPD annually. TB testing is not mandatory here."

a. Upon review of Employee Health files on 2/3/15 and 2/4/15, 9 of 9 Employee Health files contained no evidence of TB testing upon hire and annually.

4. These findings were confirmed by Staff #44 on 2/3/15 and Staff #13 on 2/4/15.

F. Based on observation, lack of documentation, and staff interview conducted on 2/2/15, it was determined that the facility failed to review and approve the disinfectants that are used within the facility.

Findings include:

1. On 2/2/15 a request was made for Staff #12 to produce a list of facility-approved disinfectants.

a. Staff #12 was unable to provide the list as requested.

G. Based on observation, staff interview and review of manufacturer's instructions for use (IFUs) conducted on 2/4/15, it was determined that the facility failed to ensure that it follows the manufacturers' instructions.

Findings include:

Reference #1: 3M ESPE Attest 1262/1262P biological indicator manufacturer's IFU states, "...Directions for Use: ... 12. Incubate processed and control biological indicators for 48 hours at 56 +/- 2 degrees C (133 +/- 3 degrees F)."

1. During an interview in the Dental Clinic on 2/3/15 at 11:40 AM, Staff #26 and Staff #34 stated that they incubate the 3M ESPE Attest biological indicator (BI) for 3 days.

2. The facility failed to ensure that the manufacturer's IFUs for 3M ESPE Attest BI testing are followed.

3. This finding was confirmed by Staff #8, Staff #12, Staff #19, Staff #32 and Staff #33.

Reference #2: National Chemical Laboratories manufacturer's IFU contained on the label of a Neutral Disinfectant Detergent bottle states, "Directions for Use: ... Preparation of Disinfection/Fungicidal/Virucidal * Use Solution: ... Add 2 ounces of this product to 1 gallon of water to disinfect hard, nonporous surfaces."

1. On 2/4/15 at 10:25 AM, in the presence of Staff #12, Staff #52 was observed preparing a bucket of "Neutral Disinfectant Detergent" in the Housekeeping Closet of unit F2.

2. Staff #52 was asked what the proper dilution was for the disinfectant that he/she was preparing. He/she stated, "I mix 2 cups of detergent to 2 ounces of water."

3. The facility failed to ensure that Housekeeping personnel follow manufacturer's IFU for the "Neutral Disinfectant Detergent."

4. This finding was confirmed by Staff #12.

Reference #3: PDI Super Sani-Cloth Germicidal Disposable Wipe label instructions state, "Contact Time (minutes) ... Disinfects in two minutes."

Reference #4: Facility document titled Accu-Chek Inform II Meter Cleaning and Disinfecting Instructions states, "Disinfecting Procedure ... 3. Remove a Super Sani-Cloth wipe from its container and squeeze out excess solution. ... 5. Allow the surface of the meter to remain damp with the disinfecting solution for One Full Minute."

1. On 2/4/15 at 10:50 AM, a review of the Infection Control procedure guidelines for cleaning and disinfecting its multiple-patient use Accu-Chek glucometer was conducted.

2. The facility procedure guidelines indicated the use of Super Sani-Cloth wipes allowing for the surface of the meter to remain damp with the disinfecting solution (i.e., "contact time") for One Full Minute. The manufacturer's label for the PDI Super Sani-Cloth wipes contained instructions for contact time of "two minutes".

3. The facility failed to ensure that the manufacturer's IFU for the PDI Super Sani-Cloth wipes are followed.

4. This finding was confirmed by Staff #12 and Staff #25.

H. Based on observation and staff interview conducted on 2/5/15, it was determined that the facility failed to ensure that all disinfectant/chemicals are labeled.

Findings include:

1. During a tour of Cottage #14 at 10:00 AM, in the presence of Staff #12, Staff #72 and Staff #73, a bottle of unlabeled clear solution was observed on the kitchen sink counter.

a. Staff # 72 stated that the bottle contained liquid dishwashing soap.

2. During a tour of Cottage #13 at 11:15 AM, in the presence of Staff #12, Staff #72 and Staff #73, a bottle of unlabeled clear solution was observed on the kitchen sink counter.

a. Staff # 77 stated that the bottle contained liquid dishwashing soap.

3. These findings were confirmed by Staff #12, Staff #72 and Staff #73.

I. Based on observation and staff interview during a tour of Cottage #13 and
Cottage #14 conducted on 2/5/14, it was determined that the facility failed to ensure a sanitary and safe environment.

Findings include:

1. During a tour of Cottage #14 in the presence of Staff #12, Staff #72, Staff #73 and Staff #74, between 10:00 AM to 10:50 AM, the following items were observed:

a. The cabinets throughout the kitchen contained wooden shelves that were soiled with an accumulation of greasy residue and brown debris.

b. The cabinet doors were observed to be misaligned, scratched and gouged.

(i) The cabinet door surfaces cannot be adequately cleaned.

c. The floors throughout the cottage were soiled with brown and black streak marks. Portions of the vinyl floors contained cracks and missing tiles.

d. The Dining Room wall contained torn, missing and peeling wallpaper.

(i) The surface underneath the peeling wallpaper cannot be adequately cleaned.

e. The vent louvers in the Day Room contained a layer of dust.

f. The floor lamp shade in the hallway was cracked.

(i) The cracked lampshade cannot be adequately cleaned.

2. At 11:25 AM, in the Cottage #14 Medication Room, in the presence of Staff #12, Staff #59, Staff #75 and Staff #76, a Mindray PM 50 pulse oximeter device was observed to have soiled cloth surgical tape on its surface.

a. The surgical tape surface cannot be adequately cleaned and disinfected.

b. The facility failed to ensure that its multiple-patient use medical device is adequately clean and disinfected between patient use.

c. This finding was confirmed by Staff #12, Staff #59, Staff #75 and Staff #76.

3. At 11:30 AM, in the Cottage #14 Medication Room, a Mindray oxygen sensor was observed.

a. Staff #75 stated, "We don't clean these because they are sensitive."

b. The facility failed to ensure that its multiple-patient use medical device is adequately clean and disinfected between patient use.

c. This finding was confirmed by Staff #12, Staff #59 and Staff #76.

4. During a tour of Cottage #13, in the presence of Staff #12, Staff #73 and Staff #74, conducted between 11:15 AM to 11:50 AM, the following were observed:

a. The kitchen cabinet shelves were observed to be coated with a layer of black, greasy residue and dust. The bottom of the wooden cabinets were crumbling and in general disrepair.

b. The cabinet doors were misaligned.

c. Three upholstered chairs in the kitchen area contained rips and tears. The padding underneath was observed to be exposed.

(i) The surface of the ripped chairs cannot be adequately cleaned.

d. These findings were confirmed by Staff #12, Staff #73 and Staff #74.

J. Based on observation and staff interviews conducted on 2/4/15 and 2/5/15, it was determined that the facility failed to ensure that single-patient use glucometers and lancet devices are not available for multiple patient use.

Findings include:

1. During a tour of unit F2 Medication Room on 2/4/15 at 9:50 AM, in the presence of Staff #12, two kits containing single-patient use glucometers with lancet devices were observed to be stored in a table drawer.

a. Staff #31 (Charge Nurse) stated, "We discharge patients with their own glucometer kits."

b. After inquiry, Staff #31 confirmed that the two glucometer kits have been used by patients that have been discharged.

(i) The kits did not contain patient labels.

c. The facility failed to ensure that used single-use glucometers and lancet devices are not available for reuse on other patients.

d. This finding was confirmed by Staff #12.

2. During a tour of Cottage #14 Medication Room on 2/5/15 at 10:40 AM, in the presence of Staff #12, Staff #59, Staff #75 and Staff $76, a kit containing a single- patient use One Touch Ultra glucometer and lancet device was observed to be stored in an overhead cabinet along with other reusable medical devices such as BP monitor and cuffs, pulse oximeters, etc.

a. Staff #75 stated that the kit has been used for a patient.

(i) The kit did not contain a patient label.

b. The facility failed to ensure that used single-patient use glucometers and lancet devices are not available for reuse on other patients.

c. This finding was confirmed by Staff #12 and Staff #59.

Based on medical record review, staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that the Quality Assurance (QA) of rehabilitation services was performed, and that all policies and procedures are implemented.

Findings include:

1. On 2/4/15 at 11:24 AM, the facility's QA Meeting minutes were reviewed in the presence of Staff #15 and Staff #27. Staff #27 confirmed during interview that there was no report of QA for the Rehabilitation service.

2. On 2/5/15, the rehabilitation service areas were toured in the presence of Staff #64. Staff #64 stated the rehabilitation services are under his/her direction. Staff #64 stated he/she does not perform QA for the rehabilitation services. He/she stated that the occupational therapists (OT) are under his/her direction, but because the physical therapy service is contracted, it falls under medical.

a. On 2/5/15 at 11:15 AM, the Physical Therapy Room, Room #J108, was observed in the presence of Staff # 64. Staff #64 stated that Staff #91 supervises the physical therapy. Staff #91 is an OT that reports to Staff #64.

3. Staff #64's job description was reviewed and indicated under Examples of Work, "... provides leadership to the department to address any deficiencies or areas needing improvement to comply with Joint Commission standards and Center for Medicare and Medicaid Services (CMS) regulations. Responsible for the implementation of a Quality Improvement (QI) system within the Rehabilitation Services which reviews therapeutic environment, programming, clinical documentation, staff competencies and follows up on the corrective action steps to assure remediation of the identified problems. Participates in Continuous Quality Improvement (CQI) task groups as appropriate. ..."

4. Staff #91 confirmed in interview on 2/5/15 at 12:00 PM that he/she does not collect any data for QA purposes.

5. The facility failed to ensure physical therapy was provided under a current order of a physician. (Cross refer to Tag 1132).

6. The facility failed to ensure their scope of service policy was implemented and current. (Cross refer to Tag 1134).

Based on review of one medical record and staff interview, it was determined that the facility failed to provide physical therapy services under the orders of a physician that is responsible for the care of the patient.

Findings include:

1. On 2/5/15 at 11:15 AM, the Physical Therapy Room, Room #J108 was observed in the presence of Staff #64. Patient #41 was receiving physical therapy instruction and treatment from Staff #91. A review of Medical Record #41 was conducted in the presence of Staff #64 and Staff #91 and the following was observed:

a. A Physical therapy Consult dated 9/4/14 had an 'X' marked next to the box that recommended "3/week X 8 weeks."

b. A Physician order dated and timed 9/16/14 at 11:31 AM, for "Physical therapy 3X/wk [three times per week] for 8 weeks Per Therapist for treatment for 30 days."

(i) Staff #91 confirmed during interview that this is the most current order for physical therapy (PT).

2. The initial order by the physician was not clear. It could not be determined if the patient should have only received PT for eight weeks for a total of 24 treatments, or if the patient should have a total of 30 treatments, without a delineated completion date.

a. Eight (8) weeks of treatment would have ended by November 8, 2014. This date of survey is twelve (12) weeks past an eight week completion date.

b. Review of all of the PT treatments for Patient #41, from September thru this date, indicated the patient was provided with 24 treatments.

3. Without a clear order for PT, it could not be determined if the patient was or was not receiving treatment without a physician order.

4. Staff #91 stated that the physicians will write orders to hold and resume treatment when the patient is not able to go to therapy.

a. Staff #91 and Staff #92 confirmed that there were not any orders by a physician to hold and resume PT, and there were no nursing notes indicating PT was on hold.

Based on medical record review, staff interview, and review of facility policies and procedures, it was determined that the facility failed to implement its policy and procedure for their scope of service for physical therapy (PT).

Findings include:

Reference: Facility's PHYSICAL THERAPY SCOPE OF SERVICE states, "... POLICY: ... I. EVALUATIONS A. The Physical therapist will screen all patients 65 years of age and older within 72 hours of the admission date. ... II. TREATMENT ... C. Physical therapy staff will provide weekly treatment log to the Chief of Medicine either by inter-office mail or e-mail attachments. ... IV. DOCUMENTATION ... D. the Therapist is to attend the patient Treatment Team Meeting as necessary."

1. On 2/5/15 at 11:15 AM, the Physical Therapy Room, Room #J108, was observed in the presence of Staff #64. Patient #41 was receiving physical therapy instruction and treatment from Staff #91. A review of Medical Record #41 was conducted in the presence of Staff #64 and Staff #91.

a. A Physician order dated and timed 9/16/14 at 11:31 AM for "Physical therapy 3X/wk [three times per week] for 8 weeks Per Therapist for treatment for 30 days," was evident in the medical record.

b. The 'INTERDISCIPLINARY DOCUMENTATION FORM' lacked evidence of attendance or participation from the PT department since September of 2014.

2. During interview, Staff # 91 stated that he/she does not maintain a log of patient treatments that is submitted to the Chief of Medicine.

3. Staff #91 and Staff #92 confirmed during interview that the PT staff do not screen all patients over the age of 65 within 72 hours of admission for PT service needs.

4. There was not an effective date, or any revision date indicated on the above referenced policy/scope of services provided by Staff #92. This was confirmed by Staff #92.

Based on document review and staff interview, it was determined that the facility failed to meet the Condition of Respiratory Services.

Findings include:

1. The facility failed to have a physician directing the program. (Cross refer to Tag 1153)


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2. The facility failed to integrate its respiratory service into the hospital wide Quality Assurance Performance Improvement (QAPI) program.

a. On 2/4/15 at 11:24 AM, the facility's Quality Assurance (QA) Meeting minutes were reviewed in the presence of Staff #15 and Staff #27. Staff #27 confirmed that there is no report of QA for the respiratory service.

Based on a review of medical staff documentation and staff interview, it was determined that the facility failed to ensure that there is a physician director administering the respiratory care services.

Findings include:

1. Medical staff documentation was reviewed at approximately 10:00 AM on 2/4/15.

a. This review revealed that there was no physician director in place for the respiratory care services.

b. This finding was confirmed by Staff #24 at 11:53 AM on 2/4/15.

Based on record review and interview, the facility failed to ensure that appropriate treatment planning occurred and was initiated timely for the care and treatment for one (1) of two (2) active sample patients on Unit B2 (Patient P7). Specifically, when this patient was transferred from the Admission Unit, a written treatment plan was not developed to reflect the patient's current assessed needs, the goals to be accomplished by the patient and interventions to be implemented by Unit B2's clinical staff. Therefore, there was no written plan of care developed by B2's clinical staff that outlined targeted problems or symptoms based on the patient's current level of functioning. In addition, the facility failed to follow its own policy regarding updating treatment plans after this patient was transferred to another unit. This failure results in patients being without any written treatment plan to provide guidance for staff to assist them after a patient is transferred from another unit, potentially resulting in patients' treatment needs not being met.

Findings Include:

A. Record Review:

1.Record Review: A review of P7's medical record revealed that after being transferred from the Admission to Unit B2 on 1/23/15, there was no written plan developed that could be used to provide guidance for Unit B2's clinical staff. The only treatment plan found in the record contained the names of staff from the Admission Unit who were assigned to deliver several interventions listed on a MTP dated1/5/15.

2. The facility's Policy titled "Patient Movement," dated June 2000 and last revised May 2012, stated, "Ensures that an interim treatment plan is written within 24 hours of the transfer, as per the Treatment Planning Policy." The facility's "Treatment Planning Policy" corroborated this and stated, "Upon the movement of a patient to a new unit, an updated Treatment Plan must be completed by the receiving Treatment Team within 24 hours of the transfer. It should reflect a review of the patient's current level of functioning, an interim program schedule for the new unit, and the responsible staff on the new unit."

B. Interview:

During interview on 1/27/15 at 1:45 p.m., the Program Coordinator agreed that there was no written plan developed by B2's Treatment Team. She noted that they complete a Special Team note when a patient is transferred to the unit but a written treatment plan was not developed until 14 days after the patient's transfer.

Based on record review and interview, the facility failed to include in the Master Treatment Plans (MTPs) active treatment interventions with a specific focus based on individual needs of each patient for 16 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). Most interventions for the psychiatric problems were just a list of groups. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. Facility policy, titled "Treatment Planning Policy," last revised 12/13, stated, "Interventions: these are the actions that staff and the patient will take together in assisting the patient to reach the shared objectives and goals. Interventions must specify the modality or approach being provided (for example, psychotherapy, group program, medication education), the method or technique needed (i.e. didactics, role modeling, feedback), the duration and frequency of the intervention, and the responsible staff." The policy did not include the specific problems or focus that would be addressed in each intervention.

2. Active sample patient P1, MTP dated 1/13/15, had a Recovery Goal (long-term goal) of "Improved insight and judgment" and an objective (short term goal): "[Name of patient] will engage in recreational and leisure activities and will shower at length every other day to maintain proper hygiene by active participation in the following therapeutic interventions/services - Group Life Management, physical activities, take 10[sic], communication and leisure skills, expressive music, physical activities."

3. Active sample patient P2, MTP dated 1/22/15, had a Recovery Goal of "Improved frustration tolerance" and an objective of "[Name of patient] will be able to recognize frustration level and maintain self-control by practicing at least two safe alternative ways to manage stress over the next 30 days by active participation in the following therapeutic interventions/services- Groups: Life Management, physical activities, Take 10, communication and leisure skills, leisure activities, expressive music, physical activities."

4. Active sample patient P3, MTP dated 1/20/15, had a Recovery Goal of "[Name of patient] will appropriately manage [his/her] psychiatric symptoms and maintain safe behavior so that [s/he] can successfully interact integrate into the community." The objective was "[Name of patient] will be able to identify at least two (2) benefits of taking psychiatric medication as prescribed by active participation in the following therapeutic interventions/services - "Individual 1:1 [one to one] with nurse, Individual Psychopharmacology. Group: Medication Education." A second objective was "Name of patient] will not have ideas of hurting [him/herself] and if [s/he] does [s/he] will use active appropriate coping skills in order to stay safe by active participation in the following therapeutic interventions/services: Individual 1:1 with nurse, Individual Psychopharmacology. Groups: Medication Education, Creative Arts, Leisure Activities, Medication Education, Self-help Support Group, Stress Management, Spirituality Group, Social Skills Group."

5. Active sample patient P4, MTP dated 11/25/14, had a Recovery Goal of "[Name of patient] will display realistic thinking and safe behavior." The objective was "[Name of patient] will comply with medications and attend therapeutic programming demonstrating realistic thinking by active participation in the following therapeutic interventions/services- Groups: Life Management, Creative Arts, Healthy Living, Leisure Activities, Leisure Skills, Rehabilitation - Computer Skill Group, Stress Mgt. [management] Group Nursing, Self-help Support Group Nursing, Physical Activities-Gym, Medication Education, ADLs [activities of daily living], Deaf Club, Social Group Nursing, Medication Education - Nursing, Community Integration Skills" --- "Psychopharmacology, 1:1 with nurse, Individual Treatment Plan Review Meeting." --- "Groups: Didactic, Current Events."

6. Active sample patient P5, MTP dated 12/12/14, had a Recovery Goal of "Within the next 12 months, [name of patient] will demonstrate improved emotion regulation skills in order to remain free from self-harm and suicidal ideation." The objective was "In the next 90 days, [name of patient] will identify two behaviors/techniques (slowing down [his/her] thoughts by deep breathing: refocusing by asking [him/herself] questions about the initial thoughts/feelings, etc.) that will help [him/her] appropriately communicate [his/her] thoughts and the feelings they promote (and vice-versa) by active participation in the following therapeutic interventions/services- Individual: Psychiatric intervention & [and] monitoring, nursing intervention, intervention & monitoring by psychologist. Groups: Social Skills, Illness Management and Recovery, Life Management, Medication Education Part2, Self-help Support Group, Supervised Socialization Group, Stress Management Part II, Medical Intervention, Individual Therapy, Spirituality Group."

7. Active sample patient P6, MTP dated 11/24/14, had a Recovery Goal of " In the next 12 months, [name of patient] will demonstrate a decrease in reactive, psychotic symptoms and a gradual return to normal functioning in affect, thinking and relating. " The objective was "During the next 90 days, [name of patient] will take medications daily as prescribed and will allow staff to check for compliance by opening [his/her] mouth after taking medication by active participation in the following therapeutic interventions/services - Individual: Psychopharmacology. Groups: Current Event Group, Life Management, Medication Education Part 2, Stress Management 2, Supervised Socialization Group, Health Issues, Illness Management and Recovery, Nutrition Education 2nd & 4th Wed [second and fourth Wednesday], Mental Health Issues, Symptom Management, Exercise Group, Cultural Awareness, Physical Activities, Social Skills Group" --- "Individual: Treatment Team Meetings" --- "Group: Spirituality Group. "

8. Active sample patient P7, MTP dated 1/5/15, had a Recovery Goal of "[Name of patient] follows treatment so [s/he] can function in the community." The objective was "[Name of patient] will not take off [his/her] clothes in public by active participation in the following therapeutic interventions/services - Group: Mental Health Issues, DBT [Dialectical Behavioral Therapy] Skills Group, Life Management, Medication Education, Self-help Support Group, Stress Mgt. Group Nursing, Supervised Socialization Group, Communication & Leisure Skills, Creative Arts, Communication Skills, Leisure Activities, Leisure Skills, Life Management, Physical Activities." --- "Individual: Individual Intervention, Psychopharmacology, 1:1 Nurse."

9. Active sample patient P8, MTP dated 12/22/14, had a Recovery Goal of "Uses realistic thinking to avoid unsafe behavior." The objective was "Everyday take medication as prescribed to help [ him/her] think realistically and have emotional control by active participation in the following therapeutic interventions/services - Individual: Psychopharmacology, 1:1 with nurse. Groups: Mental Health Issues, Medication Education, Supervised Socialization, Individual contact, Creative Arts, Physical Activities, Life Management, Life Management - Eve [evening], Self-help Support Group, Stress Management, Medical Health Issues, Symptom Management, Current Events, Social Skills, Healthy Living Skills, Socialization Skills Group, Goal Setting, Community Integration Skills, Leisure Activities, Leisure Skills Group."

10. Active sample patient P9, MTP dated 1/21/15, had a Recovery Goal of "[Name of patient] will express realistic thinking and will attain approval for discharge." The objective was "[Name of patient] will exhibit reality based thinking for at least 5 min. [minutes] by active participation in the following therapeutic interventions/services - Group: Life Management, Mental Health Education, Leisure Skills, and Supervised Socialization. Individual: Treatment Planning, Psychiatry, Social Work, Nursing " --- "Groups: Relaxation Skills, Expressive Music, Stress Management, Medication Education, Medication Education Part 2, Mental Health Issues, Legal Status Group."

11. Active Sample Patient P10, MTP dated 12/30/14, a Recovery Goal of "Medication compliance and maintain adequate reality ties." An objective was "[Name of patient] will continue to demonstrate improved contact by staying oriented to task and maintaining reality based conversations with peers and staff and [sic] for 30 to 35 minutes during daily therapy groups by active participation in the following therapeutic interventions/services- Individual: Psychiatric Medications. Groups: Mental Health Issues, Activities of Daily Living, Life Mgmt - Eve, Life Management, Life Management - Weekend, Coping with Everyday Problems, Stress Management 2, Supervised Socialization, Self-help Support Group, Expressive Music - Evening, Leisure Skills, Social Hour, Relaxation Music Appreciation, Community Integration Skills, Creative Arts, Physical Activities, Relaxation Skills, Rehabilitation - Computer Skills, Digital Art, Art Therapy."

12. Active sample patient P11, MTP dated 12/18/14, had a Recovery Goal of "[name of patient] will remain free from self-inflicted physical harm..." The objective was "Within the next 90 days, [name of patient] will refrain from attempts or gestures of self injurious behavior and display more improved mood by active participation in the following therapeutic interventions/services- Individual: Medication." "Groups: Life Management, Self-Help Support, Supervised Socialization, Mental Health Education, Physical Activities, Team Sports, Dual Sports, Community Integration Skills, Spirituality Group, Group readiness, Leisure Skills."

13. Active sample patient P12, MTP dated 12/26/14, had a Recovery Goal of "[Name of patient] will find housing that is supportive of [his/her] mental health needs so [s/he] can safely live in the community." The objective was "Everyday [name of patient] takes prescribed psychiatric medication to help [him/her] have more reasonable thinking and less anxiety by active participation in the following therapeutic interventions/services - Groups: Mental Health Issues, Life Management, Medication Education, Self-help Support Group Nursing, Stress Mgt Group Nursing, Supervised Socialization Group, Physical Activities." --- "Individual: Psychopharmacology, 1:1 with Nurse" --- "Groups: Gym, Goal Setting Group, Mental Health Education."

14. Active sample patient P13, MTP dated 6/25/14, had a Recovery Goal of "[Name of patient] will display behaviors indicating improved contact with others, [s/he] will make eye-contact, will respond to questions and will interact more socially. [S/he] will also develop and maintain self-control by active participation in the following therapeutic interventions/services - "Individual: Psychiatry, Nursing." "Groups: Life Management, Mental Health Issues, Self-help Support Group, Coping Strategies, Mental Health Education, Stress Management, Life Management - Eve."

15. Active sample patient P14, MTP dated 10/22/14, had a Recovery Goal of "[Name of patient] will display a more consistent euthymic mood and remain free of suicidal thoughts and gestures; no self-inflected injures; minimize contentiousness and frequency of demands: minimize rule violations (staying in bed) and verbal aggressiveness; avoid acting out in socially inappropriate/self-stimulating ways i.e.: stripping in public, blatantly sexualized dancing by active participation in the following therapeutic interventions/services- Individual: Psychotropic medications, Nursing Interventions." --- "Groups: Life Management, Life Management - Eve, Mental Health Issues, Symptom Management, Changes." --- "Individual: Behavioral/Safety Plan." --- "Groups: Spirituality Group, Self-awareness, Social Skills (Karaoke [sic]), Self-help."

16. Active sample patient P15, MTP dated 1/2/15, had a Recovery Goal of "[Name of patient] will demonstrate stable behavior to attain approval for discharge into the community." The objective was "[Name of patient] will display reality based thinking and behavior everyday by active participation in the following therapeutic interventions/services- Groups: Life Management, Medication Education, Community Integration Skills." --- "Individual: Medication Monitoring, Psychology Intervention, Social Services, Nursing."

17. Active sample patient P16, MTP dated 12/16/14, had a Recovery Goal of "[Name of patient] will demonstrate stable behavior to attain approval for discharge." An objective was "[Name of patient] will take [his/her] medication as prescribed everyday by active participation in the following therapeutic interventions/services- Groups: Life Management, MED [medication] Education Part 2" --- "Individual: Psychology Intervention, Nursing, Social Services."

B. Interviews

1. In an interview on 1/27/15 at 1:30 p.m., the lack of focus for the groups listed on the patients' Master Treatment Plans as interventions was discussed with RN 3. She stated, "I understand what you mean."

2. In an interview on 1/28/15 at 9:45 a.m., the absence of a focus for the groups listed on the Master Treatment Plans as interventions was discussed with the Nursing Director. Her reply, "I am working on this problem with the nursing staff."

Based on record review and interview, the facility failed to identify both the name and discipline of the staff responsible for providing treatment interventions for 16 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). Either there was no staff listed as responsible for interventions (P15 and P16), or staff listed was not identifiable (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). Failure to assign specific staff members by both name and discipline results an inability to determine the discipline of the staff responsible for ensuring that interventions are implemented, potentially hampering the effective coordination of treatment modalities.

Findings include:

A. Record Review:

1. Facility policy, titled "Treatment Planning Policy," last revised 12/17/13, stated, "Interventions: these are the actions that staff and the patient will take together in assisting the patient to reach the shared objectives and goals. Interventions must specify the modality or approach being provided (for example, psychotherapy, group program, medication education), the method or technique needed (i.e. didactics, role modeling, feedback), the duration and frequency of the intervention, and the responsible staff who will assist the patient. Each intervention must be identified with a specific recovery objective listed in the Treatment Plan and clearly list the responsible staff."

2. Active sample patient P1, MTP dated 1/13/15, had a Recovery Goal (long-term goal) of "Improved insight and judgment" and an objective (short term goal): "[Name of patient] will engage in recreational and leisure activities and will shower at length every other day to maintain proper hygiene by active participation in the following therapeutic interventions/services - Group Life Management, physical activities, take 10[sic], communication and leisure skills, expressive music, physical activities." Staff listed as responsible for the Group "Life Management" was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

3. Active sample patient P2, MTP dated 1/22/15, had a Recovery Goal of "Improved frustration tolerance" and an objective of "[Name of patient] will be able to recognize frustration level and maintain self-control by practicing at least two safe alternative ways to manage stress over the next 30 days by active participation in the following therapeutic interventions/services - "Groups: Life Management, physical activities, Take 10, communication and leisure skills, leisure activities, expressive music, physical activities." Staff listed as responsible for the Group Life Management was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

4. Active sample patient P3, MTP dated 1/20/15, had a Recovery Goal of "[Name of patient] will appropriately manage [his/her] psychiatric symptoms and maintain safe behavior so that [s/he] can successfully interact integrate into the community." The objective was "[Name of patient] will be able to identify at least 2 benefits of taking psychiatric medication as prescribed by active participation in the following therapeutic interventions/services" - "Individual 1:1 [one to one] with nurse/HST, Individual Psychopharmacology. Group: Medication Education." Staff listed as responsible for the Groups: Individual 1:1 [one to one] with nurse/HST, Individual Psychopharmacology was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

5. Active sample patient P4, MTP dated 11/25/14, had a Recovery Goal of "[Name of patient] will display realistic thinking and safe behavior." The objective was "[Name of patient] will comply with medications and attend therapeutic programming demonstrating realistic thinking by active participation in the following therapeutic interventions/services- Groups: Life Management, Creative Arts, Healthy Living, Leisure Activities, Leisure Skills, Rehabilitation - Computer Skill Group, Stress Mgt. [management] Group Nursing, Self-help Support Group Nursing, Physical Activities-Gym, Medication Education, ADLs [activities of daily living], Deaf Club, Social Group Nursing, Medication Education - Nursing, Community Integration Skills" --- "Psychopharmacology, 1:1 with nurse, Individual Treatment Plan Review Meeting." --- "Groups: Didactic, Current Events." Staff listed as responsible for Groups: Rehabilitation - Computer Skill Group, Physical Activities-Gym, Medication Education - Nursing, Community Integration Skills was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

6. Active sample patient P5, MTP dated 12/12/14, had a Recovery Goal of "Within the next 12 months, [name of patient] will demonstrate improved emotion regulation skills in order to remain free from self-harm and suicidal ideation." The objective was "In the next 90 days, [name of patient] will identify two behaviors/techniques (slowing down [his/her] thoughts by deep breathing: refocusing by asking [him/herself] questions about the initial thoughts/feelings, etc.) that will help [him/her] appropriately communicate [his/her] thoughts and the feelings they promote (and vice-versa) by active participation in the following therapeutic interventions/services- Individual: Psychiatric intervention & [and] monitoring, nursing intervention, intervention & monitoring by psychologist. Groups: Social Skills, Illness Management and Recovery, Life Management, Medication Education Part2, Self-help Support Group, Supervised Socialization Group, Stress Management Part II, Medical Intervention, Individual Therapy, Spirituality Group." Staff listed as responsible for Groups: Illness Management and Recovery, Life Management, Medication Education Part2, Self-help Support Group, Supervised Socialization Group, Stress Management Part II was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

7. Active sample patient P6, MTP dated 11/24/14, had a Recovery Goal of "In the next 12 months, [name of patient] will demonstrate a decrease in reactive, psychotic symptoms and a gradual return to normal functioning in affect, thinking and relating." The objective was "During the next 90 days, [name of patient] will take medications daily as prescribed and will allow staff to check for compliance by opening [his/her] mouth after taking medication by active participation in the following therapeutic interventions/services - Individual: Psychopharmacology. Groups: Current Event Group, Life Management, Medication Education Part 2, Stress Management 2, Supervised Socialization Group, Health Issues, Illness Management and Recovery, Nutrition Education 2nd & 4th Wed [second and fourth Wednesday], Mental Health Issues, Symptom Management, Exercise Group, Cultural Awareness, Physical Activities, Social Skills Group" --- "Individual: Treatment Team Meetings" --- Group: Spirituality Group." Staff listed as responsible for the Groups: Medication Education Part 2, Supervised Socialization Group, Illness Management and Recovery, Mental Health Issues, Physical Activities was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

8. Active sample patient P7, MTP dated 1/5/15, had a Recovery Goal of "[Name of patient] follows treatment so [s/he] can function in the community." The objective was "[Name of patient] will not take off [his/her] clothes in public by active participation in the following therapeutic interventions/services - Group: Mental Health Issues, DBT [Dialectical Behavioral Therapy] Skills Group, Life Management, Medication Education, Self-help Support Group, Stress Mgt. Group Nursing, Supervised Socialization Group, Communication & Leisure Skills, Creative Arts, Communication Skills, Leisure Activities, Leisure Skills, Life Management, Physical Activities." --- "Individual: Individual Intervention, Psychopharmacology, 1:1 Nurse." Staff listed as responsible for the Groups: Life Management, Medication Education, Self-help Support Group, Stress Mgt. Group Nursing, Supervised Socialization Group was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

9. Active sample patient P8, MTP dated 12/22/14, had a Recovery Goal of "Uses realistic thinking to avoid unsafe behavior." The objective was "Everyday take medication as prescribed to help [ him/her] think realistically and have emotional control by active participation in the following therapeutic interventions/services - Individual: Psychopharmacology, 1:1 with nurse. Groups: Mental Health Issues, Medication Education, Supervised Socialization, Individual contact, Creative Arts, Physical Activities, Life Management, Life Management - Eve [evening], Self-help Support Group, Stress Management, Medical Health Issues, Symptom Management, Current Events, Social Skills, Healthy Living Skills, Socialization Skills Group, Goal Setting, Community Integration Skills, Leisure Activities, Leisure Skills Group." Staff listed as responsible for Individual: Psychopharmacology, 1:1 with nurse and for Groups: Mental Health Issues, Creative Arts, Community Integration Skills, Leisure Activities was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

10. Active sample patient P9, MTP dated 1/21/15, had a Recovery Goal of "[Name of patient] will express realistic thinking and will attain approval for discharge." The objective was "[Name of patient] will exhibit reality based thinking for at least 5 min. [minutes] by active participation in the following therapeutic interventions/services - Group: Life Management, Mental Health Education, Leisure Skills, and Supervised Socialization. Individual: Treatment Planning, Psychiatry, Social Work, Nursing" --- "Groups: Relaxation Skills, Expressive Music, Stress Management, Medication Education, Medication Education Part 2, Mental Health Issues, Legal Status Group." Staff listed as responsible for the Groups Supervised Socialization, Expressive Music, Medication Education, Medication Education Part 2was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

11. Active Sample Patient P10, MTP dated 12/30/14, a Recovery Goal of "Medication compliance and maintain adequate reality ties." An objective was "[Name of patient] will continue to demonstrate improved reality contact by staying oriented to task and maintaining reality based conversations with peers and staff and [sic] for 30 to 35 minutes during daily therapy groups by active participation in the following therapeutic interventions/services- Individual: Psychiatric Medications. Groups: Mental Health Issues, Activities of Daily Living, Life Mgmt - Eve, Life Management, Life Management - Weekend, Coping with Everyday Problems, Stress Management 2, Supervised Socialization, Self-help Support Group, Expressive Music - Evening, Leisure Skills, Social Hour, Relaxation Music Appreciation, Community Integration Skills, Creative Arts, Physical Activities, Relaxation Skills, Rehabilitation - Computer Skills, Digital Art, Art Therapy." Staff listed as responsible for the Groups: Activities of Daily Living, Life Mgmt - Eve, Supervised Socialization, Expressive Music - Evening, Social Hour, Relaxation Music Appreciation, Community Integration Skills, Creative Arts, Physical Activities, Rehabilitation - Computer Skills, Digital Art, and Art Therapy was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

12. Active sample patient P11, MTP dated 12/18/14, had a Recovery Goal of "[name of patient] will remain free from self-inflicted physical harm..." The objective was "Within the next 90 days, [name of patient] will refrain from attempts or gestures of self injurious behavior and display more improved mood by active participation in the following therapeutic interventions/services - Individual: Medication." "Groups: Life Management, Self-Help Support, Supervised Socialization, Mental Health Education, Physical Activities, Team Sports, Dual Sports, Community Integration Skills, Spirituality Group, Group readiness, Leisure Skills." Staff listed as responsible for the Groups: Supervised Socialization, Physical Activities, Team Sports, Dual Sports, Community Integration Skills, Leisure Skills was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

13. Active sample patient P12, MTP dated 12/26/14, had a Recovery Goal of "[Name of patient] will find housing that is supportive of [his/her] mental health needs so [s/he] can safely live in the community." The objective was "Everyday [name of patient] takes prescribed psychiatric medication to help [him/her] have more reasonable thinking and less anxiety by active participation in the following therapeutic interventions/services - Groups: Mental Health Issues, Life Management, Medication Education, Self-help Support Group Nursing, Stress Mgt Group Nursing, Supervised Socialization Group, Physical Activities." --- "Individual: Psychopharmacology, 1:1 with Nurse" --- "Groups: Gym, Goal Setting Group, Mental Health Education." Staff listed as responsible for the Groups: Medication Education, Supervised Socialization Group, Physical Activities, and Gym was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

14. Active sample patient P13, MTP dated 6/25/14, had a Recovery Goal of "[Name of patient] will display behaviors indicating improved contact with others, [s/he] will make eye-contact, will respond to questions and will interact more socially. [S/he] will also develop and maintain self-control by active participation in the following therapeutic interventions/services - "Individual: Psychiatry, Nursing." "Groups: Life Management, Mental Health Issues, Self-help Support Group, Coping Strategies, Mental Health Education, Stress Management, Life Management - Eve." Staff listed as responsible for Individual: Nursing and for Groups: Life Management, Self-help Support Group, Coping Strategies, Mental Health Education, Stress Management, Life Management - Eve was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

15. Active sample patient P14, MTP dated 10/22/14, had a Recovery Goal of "[Name of patient] will display a more consistent euthymic mood and remain free of suicidal thoughts and gestures; no self-inflected injures; minimize contentiousness and frequency of demands: minimize rule violations (staying in bed) and verbal aggressiveness; avoid acting out in socially inappropriate/self-stimulating ways i.e.: stripping in public, blatantly sexualized dancing by active participation in the following therapeutic interventions/services- Individual: Psychotropic medications, Nursing Interventions." --- "Groups: Life Management, Life Management - Eve, Mental Health Issues, Symptom Management, Changes." --- "Individual: Behavioral/Safety Plan." --- "Groups: Spirituality Group, Self-awareness, Social Skills (Karaoke [sic]), Self-help." Staff listed as responsible for Groups: Life Management - Eve and Spirituality was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

16. Active sample patient P15, MTP dated 1/2/15, had a Recovery Goal of "[Name of patient] will demonstrate stable behavior to attain approval for discharge into the community." The objective was "[Name of patient] will display reality based thinking and behavior everyday by active participation in the following therapeutic interventions/services - Groups: Life Management, Medication Education, Community Integration Skills." --- "Individual: Medication Monitoring, Psychology Intervention, Social Services, Nursing." No Staff was listed as responsible for any Group. Staff listed as responsible for the Individual: Social Services was not clarified by credentials, and was not identified under the section Treatment Plan Signatures.

17. Active sample patient P16, MTP dated 12/16/14, had a Recovery Goal of "[Name of patient] will demonstrate stable behavior to attain approval for discharge." An objective was "[Name of patient] will take [his/her] medication as prescribed everyday by active participation in the following therapeutic interventions/services - Groups: Life Management, MED [medication] Education Part 2" --- "Individual: Psychology Intervention, Nursing, Social Services." No Staff was listed as responsible for either Group. Staff listed as responsible for the Individual: Psychology Intervention, Nursing, Social Services was not clarified by credentials, and was not identified under the section Treatment Plan Signatures

B. Interview:

In an interview on 1/27/15 at 4:20 p.m., the Medical Director agreed that in the MTP for Patient P16 dated 12/16/14, there was no staff name listed in the "staff" column as being responsible for interventions of "Life Management" and "Medication Education." She also agreed that in the MTP for Patient P5 dated 12/12/14, the staff listed as responsible was not identifiable either by credentials, or by being listed in the staff signature sheet at the end of the MTP. The Medical Director stated that she understood that this failure to identify specific staff responsible for providing treatment interventions could be a problem for monitoring treatment.

Based on observation, record review, and interview, the facility failed to ensure that all interventions listed on the Master Treatment Plans (MTPs) were documented by registered nurses for 12 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P12, P15 and P16). Specifically, for nursing interventions identified on MTPs, there was no documentation showing patients' attendance or non-attendance in group sessions; the topic(s) discussed; and/or patients' level of response to the treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to nursing interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed.

Findings include:

A. Observation:

During observation on 1/27/15 from 2:10 p.m. to 2:50 p.m., Patients P7 and P8 were in a group entitled "Healthy Living Skills" conducted by RN4. During discussion with RN4 after the group session on 1/27/15/14 at 3:00 p.m., Patients P7's and P8's medical records were reviewed to locate treatment notes written regarding the patient's attendance and non-attendance in the Healthy Living Skills group and other nursing groups. RN4 admitted that there were no treatment notes written about these patients' level of participation and their response to the information provided during nursing groups.

B. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): P1 (1/13/15), P2 (1/22/15), P3 (1/20/15), P4 (11/25/14), P5 (12/12/14), P6 (11/24/14), P7 (1/5/15) , P8 (12/22/14), P9 1/21/15), P10 (12/30/14), P11 (12/18/14), P12 (12/26/14), P13 (6/25/14), P14 (10/22/14), P15 (1/2/15), and P16 (12/16/14). The weekly and monthly progress notes recorded during the periods of November 2014 through January 2015 were reviewed. According to facility staff, these progress notes were also used to record treatment notes. These notes revealed that there were no treatment notes or insufficient information documented for interventions assigned to be delivered by registered nurses.

1. Twelve (12) patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P12, P15 and P16) all had "Medication Education" or a similarly worded group regarding medications assigned to be delivered by the registered nurse.

2.Eight (8) patients P1, P2, P3, P4, P6, P7, P8 and P14 all had "Healthy Living Group" or similarly worded groups regarding health assigned to be delivered by the registered nurse.

3. Notes written by RNs were primarily progress and event notes. Under the "Attendance in Groups" section of the "Licensed Nurse Monthly/Weekly Progress Note" Form, there were only the following check boxes: "Consistent", "Independent", "Needs Encouragement", "Sporadic", and "other." There was no Treatment notes found on this form or in the medical record written by registered nurses for the patients above that recorded: (1) the number of groups attended or not attended, (2) information provided or topic discussed during the group session(s), and (3) the patients' responses, including the patient's behavior during group sessions, level of participation and/or level of understanding.

Based on record review and interview, the facility failed to ensure that a face to face evaluation by a physician was completed within one hour of placement in a physical (manual) hold for two (2) of five (5) sample patients (N1 and N3) whose records were reviewed for seclusion/restraint policy and procedure compliance. Three (3) of five (5) patients (N2, N4 and N5) had no documentation in the progress notes of a face to face evaluation. None of these patients had a physician's order for the holds in the medical records. These failures result in a restriction of patients' rights without adequate documented justification.

Findings include:

A. Medical Records

1. Facility Policy, titled "Seclusion and Restraint", last revised 2/12, stated "A manual physical hold can be used to apprehend a committed patient who is attempting elope. This is a restraint and must be documented as such." - "The treating psychiatrist must enter a progress note within one hour of any hold episode, documenting his/her assessment of the patient following the hold episode" --- "If the physician is not available, the RN [registered nurse] can direct the patient assessment and notify the physician as soon as practical. If physical holding for forced medication is necessary with a violent patient, the one hour face to face evaluation would also apply.

2. Patients in manual hold with late one to one evaluations:

a. N1 was "placed in a manual hold for 3 minutes for separation of patient during a fight" on 12/1/14 at 8:45 p.m. and released on 12/1/14 at 8:48 p.m. The face to face evaluation by the physician was documented in the progress notes on 12/2/14 at 10:45 p.m.

b. N1 was "placed in a manual hold for 2 minutes for separation of patient during a fight" on 1/17/15 at 8:17 a.m. and released on 1/17/15 at 8:19 a.m. The one to one evaluation by the physician was documented in the progress notes on 1/17/15 at 1:00 p.m.

c. Patient N1 was "placed in a manual hold for 2 minutes for separation of patient during a fight" on 1/27/15 at 8:03 a.m. and released on 1/27/15 at 8:05 a.m." The face to face evaluation by the physician was documented in the progress notes on 1/25/15 at 1:35 p.m.

d. Patient N3 was "placed in a manual hold for 2 minutes for emergency administration of medication" on 12/29/14 at 12:50 a.m. and released on 12/29/14 at 12:52 a.m. The face to face evaluation by the physician was documented in the progress notes on 12/29/15 at 6:30 a.m.

3. Patients in manual holds without documentation of one to one evaluation by a physician:

a. Patient N2 was "placed in a manual hold for 2 minutes for emergency administration of medication" on 12/1/14 at 11:48 a.m. and released on 12/1/14 at 11:50 a.m. There was no documentation in the progress notes of a one to one by a physician.

b. Patient N4 was placed in a "manual hold for 2 minutes, patient climb down the PIC [Patient Information Center], patient attempted to throw chair on the staff. Manual hold applied on him to take him out of PIC." Patient placed in hold on 12/7/14 at 4:25 p.m. and released on 12/7/14 at 4:27 p.m. There was no one to one evaluation by a physician documented in the progress notes.

c. Patient N5 was "placed in a manual hold for 2 minutes for emergency administration of medication" on 12/20/14 at 9:30 a.m. and released on 12/20/14 at 9:32 a.m. There was no documentation in the progress notes of a one to one evaluation by a physician.

None of the five (5) patients (N1, N2, N3, N4 and N5) had physicians' orders for the manual holds documented in their medical records.

B. Interviews

1. In an interview on 1/27/15 at 9:45 a.m., the records of the five (5) patients who had been placed in manual holds were reviewed with RN2. He agreed that the physicians' documentation in the progress notes were late for patients N1 and N3 and that documentation of the one to one evaluations for manual holds for patients N2, N4 and N5 were not in the progress notes...

2. In an interview on 1/27/15 at 1:30 p.m., the use of a manual hold was discussed with MD4 and RN4. They both stated that they did not consider holding a patient who was involved in a fight a restraint. They also stated that manual holds were not treated the same as when a patient is placed in seclusion or mechanical restraints. MD4 stated, "The regular face to face assessment is completed in those cases on a form titled 'Psychiatric Progress Note For One Hour Seclusion or Restraint', but for the manual hold, we write a note in the progress notes."

3. In an interview on 1/27/15 at 3:50 p.m., the absence of physician orders for the manual holds was discussed with MD2. She agreed that the orders were absent, but stated that she felt it was due to a computer glitch.

Based on record review and interview, the Medical Director failed to ensure the quality and appropriateness of clinical care provided by medical staff. Specifically, the Medical Director failed to:

A. Include in the Master Treatment Plans (MTPs) active treatment interventions with a specific focus based on individual needs of each patient for 16 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). The interventions for the psychiatric problems were just a list of groups. This failure potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

B. Ensure that staff responsible for interventions were clearly identified, either by credentials, or by inclusion in the section Treatment Plan Signatures, in the Master Treatment Plans (MTPs) of 16 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16).Either there was no staff listed as responsible for interventions (P15 and P16), or staff listed was not identifiable (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). This failure to assign specific staff members by both name and discipline results an inability to determine the discipline of the staff responsible for ensuring that interventions are implemented, potentially hampering the effective coordination of treatment modalities. (Refer to B123)

C. Ensure that physician staff complied with established policy for the timeliness of a face to face evaluation when a restrictive measure was utilized in patient management. (Refer to B125)

Based on record review and interview, the Nursing Director failed to ensure the quality and appropriateness of patient care provided by nursing staff. Specifically, the Nursing Director failed to:

A. Include in the Master Treatment Plans (MTPs) active treatment interventions with a specific focus based on individual needs of each patient for 16 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). The interventions for the psychiatric problems were just a list of groups. This failure potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

B. Ensure that staff responsible for interventions were clearly identified, either by credentials, or by inclusion in the section Treatment Plan Signatures, in the Master Treatment Plans (MTPs) of 16 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16).Either there was no staff listed as responsible for interventions (P15 and P16), or staff listed was not identifiable (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15 and P16). This failure to assign specific staff members by both name and discipline results an inability to determine the discipline of the staff responsible for ensuring that interventions are implemented, potentially hampering the effective coordination of treatment modalities. (Refer to B123)

C. Ensure that all interventions on the Master Treatment Plans (MTPs) were documented by registered nurses for 12 of 16 active sample patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P12, P15 and P16). Specifically, for the nursing interventions identified on MTPs, there was no documentation showing patients' attendance or non-attendance in group sessions, the topic(s) discussed, and/or patients' level of response to the treatment interventions provided. This failure potentially hampers the treatment team's ability to determine patients' response to nursing interventions, evaluate whether there are measurable changes in patients' condition, and revise the treatment plan if/when needed. (Refer to B124)