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Based on interview, Governing Body By-laws review, and Medical Staff By-laws Rules and Regulations, the hospital failed to ensure the Medical Staff Bylaws included the privileging process for Allied Health Professionals (AHP) as evidenced by the Medical Staff By-Laws failing to included the privileging process for two Nurse Practitioners hired by the hospital to care for psychiatric patients at the offsite location. Findings:

Record review of Medical Staff Credentialing files revealed incomplete files for Nurse Practitioners S4 and S5.

On 7/10/12 at 10:30 a.m. in an interview with S1 Assistant Administrator, he confirmed the files for Nurse Practitioners S4 and S5 were incomplete and had not been processed the same as the Medical Staff. S1 stated he was unaware that the Medical Staff Bylaws did not include a section addressing the privileging process for Allied Health Professionals.

Record review of Governing By-laws (pg 16 of 20) revealed under #4. Allied Health Professional (AHP) the following: "All applications for appointment to AHP status shall be in writing and addressed to the CEO of the Hospital on such forms as determined by the Hospital. The application shall be processed in the same manner as Medical Staff applications."

The hospital failed to follow the Governing Body By-laws in the privileging process of the two Nurse Practitioners, S4 and S5.

Based on interview and policy review, the hospital failed to ensure the Infection Control Program was being implemented as evidenced by the Infection Control Coordinator not monitoring patients and health care workers for signs of infection and/or colonization, not tracking patients or healthcare workers' infectious events, and not identifying undesirable trends. Findings:

On 7/10/12 at 11:00 a.m. in a face-to-face interview with S6 LPN, she confirmed the Infection Control Data, which was reported by S7 Director of Laboratory, included the following information: "Infection Control 1st Quarter, 14 cultures, 3 staph MRSA, 5 negative cultures, 6 positive cultures, 5 urines, 1 wound, all nosocomial." S6 counted the laboratory reports for the 1st quarter and found only 12 cultures for the months of January (3 cultures), February (3 cultures), and March (6 cultures). S6 LPN confirmed the information submitted by S7 Director of Laboratory was inaccurate.

On 7/11/12 at 12:30 in a face-to-face interview with S7 Director of Laboratory, he confirmed he stopped using the Infection Control Data Collection Log because it was a duplication of work. He stated he makes a copy of all cultures done by the hospital and then determines whether the cultures were positive or negative and where the cultures were obtained (ie. urine, wound). He also added he observed handwashing techniques by the staff and had also obtained lab cultures on different equipment. He stated the cost of culturing the different equipment was high, so administration told him to stop culturing the equipment. S7 confirmed the Infection Control Program was not functioning as a program.

Record review of policy #4001 titled "Clinical Laboratory Performance Improvement Plan" (no reviewed, revised, or approval date) pg 1 of 10 under Responsibility revealed the following: "The Clinical Laboratory Director is responsible for establishing and implementing a Clinical Laboratory performance improvement plan." Under Goals of Performance Improvement, "The primary goal of the Clinical Laboratory performance improvement plan is to continually and systematically plan, design, measure, assess and improve performance functions and processes (pg 2 of 10) relative to patient care and services. (pg 3 of 10) reads "The Clinical Laboratory Department incorporates information related to these elements, when available and relevant, in the design or redesign of processes, functions, or services: The status of identified problems is tracked to assure improvement or problem resolution."

Record review of the policy Subject: IC 1030-Infection Control Plan" (pg 8 of 10) under "Indicators" revealed the following: (1) Monitoring and evaluation of key indicators of infection control surveillance, prevention and management include: Hospital Acquired infections, Communicable diseases, Employee health trends, and Post Discharge Monitoring. (2) Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks." On pg 9 of 10, under "Interaction with Performance/Improvement Programs", reveals the following: "The Performance Improvement Program is recognized as an integral element in the infection control effort....The Infection Control Coordinator also supplies the Performance Improvement Coordinator with information that may be useful in identifying potential quality problems throughout the hospital."

Based on interview, Governing Body By-laws, and Medical Staff By-laws Rules and Regulations, the hospital failed to ensure the Medical Staff Bylaws Rules and Regulations included the duties and scope of medical staff privileges as evidenced by the lack of a description of the duties and scope for the 2 Nurse Practitioners currently providing care for the psychiatric patients at the offsite location. Findings:

Record review of Medical Staff By-laws Rules and Regulations revealed missing information of the duties and privileges for medical staff, specifically, Allied Health Professionals (AHP).

On 7/11/12 at 10:30 a.m. in an interview with S1 Assistant Administrator, he confirmed the Medical Staff By-laws failed to have written criteria for appointments to the medical staff and granting of medical staff privileges for the two (2) Nurse Practitioners (S4, S5) currently under contract with the hospital. S1 added the two (2) Nurse Practitioners (S4, S5)'s credentialed files were not processed in the same way as the medical staff, even though they were considered Allied Health Professionals as outlined in the Governing Body By-laws.

Record review of the Governing Body By-laws (pg 16 of 20) #4. Allied Health Professionals (AHP) revealed the following: "The terms and conditions of AHP status, and of the exercise of clinical privileges, shall be specified in the appropriate section of Medical Staff By-laws or as more specifically defined in the notice of individual appointment."

Record review of the Medical Staff By-laws Rules and Regulations' Definitions (no page number) #5 revealed the following: "Health Professional Affiliate or Affiliate or Specified Professional Personnel means a consulting scientist and any other individual, other than a physician or dentist who is associated with the Hospital, whose patient care activities require (by mutual agreement between Hospital and Medical Staff) that his authority to perform specified patient care services be processed through the Credentials Committee of the Medical Staff." Under Definitions #2, the following was noted: "Clinical privileges or privileges means the permission granted to a practitioner to render specific diagnostic, therapeutic, medical, dental, or surgical services."

Record review of the Medical Staff By-laws Rules and Regulations Article III. The Medical Staff 3.2 (no page number) revealed the following: "The Medical Staff shall be limited to individuals who are licensed to practice medicine, osteopathy, or dentistry in the State of Louisiana and such other practitioners as determined by the governing body. Such members must be appropriately licensed or certified and shall be professionally and ethically qualified for the positions to which they are appointed."

Record review of the Medical Staff By-laws Rules and Regulations Article V. Categories of the Medical Staff revealed the following categories: "5.1. The Medical Staff: The Medical Staff shall be divided into honorary, active, associate, courtesy, consulting, and emergency medicine categories. 5.2 The Honorary Medical Staff; 5.3. The Active Medical Staff; 5.4. The Associate Medical Staff; and 5.5. The Consulting Medical Staff and the Courtesy Medical Staff.

Based on interview and policy review, the hospital failed to ensure the Infection Control Program was being maintained as evidenced by the lack of infection control events being logged related to infections and communicable diseases since December 2010. Findings:

Record review of the Infection Control Data Collection Log revealed the last date the Data Collection Log was used to capture "the type of culture, whether the culture was positive or negative, the results and whether the organism was to be reported to state" was December 2010.

On 7/10/12 at 10:30 a.m. in a face-to-face interview with S2 RN, Director of Nurses (DON), he stated S7 Director of Laboratory was the Infection Control coordinator for the hospital. S2 also confirmed as of June 22, 2012, the Governing Body Minutes reflected that S8 RN would be assuming the position of Infection Control Coordinator. S8 is currently employed at the offsite facility.

Record review of S8 RN's personnel folder revealed S8's job description failed to include the function of Infection Control Coordinator.

On 7/10/12 at 11:00 a.m. in a face-to-face interview with S6 LPN, she confirmed the Infection Control Data, which was reported by S7 Director of Laboratory, included the following information: "Infection Control 1st Quarter, 14 cultures, 3 staph MRSA, 5 negative cultures, 6 positive cultures, 5 urines, 1 wound, all nosocomial." S6 counted the laboratory reports for the 1st quarter and found only 12 cultures for the months of January (3 cultures), February (3 cultures), and March (6 cultures).

On 7/11/12 at 12:30 in a face-to-face interview with S7 Director of Laboratory, he confirmed he stopped using the Infection Control Data Collection Log because it was a duplication of work. He stated he makes a copy of all cultures done by the hospital and then determines whether the cultures were positive or negative and where the cultures were obtained (ie. urine, wound). He also added he observed handwashing techniques by the staff and has also obtained lab cultures on different equipment. He stated the cost of culturing the different equipment was high, so administration told him to stop culturing the equipment. S7 confirmed the Infection Control Program was not functioning as a program.

Record review of policy #4001 titled "Clinical Laboratory Performance Improvement Plan" (no reviewed, revised, or approval date) pg 1 of 10 under Responsibility revealed the following: "The Clinical Laboratory Director is responsible for establishing and implementing a Clinical Laboratory performance improvement plan." Under Goals of Performance Improvement, "The primary goal of the Clinical Laboratory performance improvement plan is to continually and systematically plan, design, measure, assess and improve performance functions and processes (pg 2 of 10) relative to patient care and services. (pg 3 of 10) reads "The Clinical Laboratory Department incorporates information related to these elements, when available and relevant, in the design or redesign of processes, functions, or services: The status of identified problems is tracked to assure improvement or problem resolution."

Record review of policy titled "Infection Control Program" approved by the Governing Body on 6/12/12 (pg 8 of 10) cites under Program Elements, the following: "Review of positive cultures. All positive cultures are investigated and categorized as to: Hospital or community acquired; Cluster of pathogens or single significant pathogen; Location involved; and Health care workers/medical staff involved."

Based on interview and policy review, the hospital failed to ensure the Infection Control Program was being implemented as evidenced by the Infection Control Coordinator not monitoring patients and health care workers for signs of infection and/or colonization, not tracking patients or healthcare workers' infectious events, and not identifying undesirable trends. Findings:

On 7/10/12 at 11:00 a.m. in a face-to-face interview with S6 LPN, she confirmed the Infection Control Data, which was reported by S7 Director of Laboratory, included the following information: "Infection Control 1st Quarter, 14 cultures, 3 staph MRSA, 5 negative cultures, 6 positive cultures, 5 urines, 1 wound, all nosocomial." S6 counted the laboratory reports for the 1st quarter and found only 12 cultures for the months of January (3 cultures), February (3 cultures), and March (6 cultures). S6 LPN confirmed the information submitted by S7 Director of Laboratory was inaccurate.

On 7/11/12 at 12:30 in a face-to-face interview with S7 Director of Laboratory, he confirmed he stopped using the Infection Control Data Collection Log because it was a duplication of work. He stated he makes a copy of all cultures done by the hospital and then determines whether the cultures were positive or negative and where the cultures were obtained (ie. urine, wound). He also added he observed handwashing techniques by the staff and had also obtained lab cultures on different equipment. He stated the cost of culturing the different equipment was high, so administration told him to stop culturing the equipment. S7 confirmed the Infection Control Program was not functioning as a program.

Record review of policy #4001 titled "Clinical Laboratory Performance Improvement Plan" (no reviewed, revised, or approval date) pg 1 of 10 under Responsibility revealed the following: "The Clinical Laboratory Director is responsible for establishing and implementing a Clinical Laboratory performance improvement plan." Under Goals of Performance Improvement, "The primary goal of the Clinical Laboratory performance improvement plan is to continually and systematically plan, design, measure, assess and improve performance functions and processes (pg 2 of 10) relative to patient care and services. (pg 3 of 10) reads "The Clinical Laboratory Department incorporates information related to these elements, when available and relevant, in the design or redesign of processes, functions, or services: The status of identified problems is tracked to assure improvement or problem resolution."

Record review of the policy Subject: IC 1030-Infection Control Plan" (pg 8 of 10) under "Indicators" revealed the following: (1) Monitoring and evaluation of key indicators of infection control surveillance, prevention and management include: Hospital Acquired infections, Communicable diseases, Employee health trends, and Post Discharge Monitoring. (2) Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks." On pg 9 of 10, under "Interaction with Performance/Improvement Programs", reveals the following: "The Performance Improvement Program is recognized as an integral element in the infection control effort....The Infection Control Coordinator also supplies the Performance Improvement Coordinator with information that may be useful in identifying potential quality problems throughout the hospital."

Based on interview and policy review, the hospital failed to ensure the Infection Control Program was being implemented as evidenced by the Infection Control Coordinator not monitoring patients and health care workers for signs of infection and/or colonization, not tracking patients or healthcare workers' infectious events, and not identifying undesirable trends. Findings:

On 7/10/12 at 11:00 a.m. in a face-to-face interview with S6 LPN, she confirmed the Infection Control Data, which was reported by S7 Director of Laboratory, included the following information: "Infection Control 1st Quarter, 14 cultures, 3 staph MRSA, 5 negative cultures, 6 positive cultures, 5 urines, 1 wound, all nosocomial." S6 counted the laboratory reports for the 1st quarter and found only 12 cultures for the months of January (3 cultures), February (3 cultures), and March (6 cultures). S6 LPN confirmed the information submitted by S7 Director of Laboratory was inaccurate.

On 7/11/12 at 12:30 in a face-to-face interview with S7 Director of Laboratory, he confirmed he stopped using the Infection Control Data Collection Log because it was a duplication of work. He stated he makes a copy of all cultures done by the hospital and then determines whether the cultures were positive or negative and where the cultures were obtained (ie. urine, wound). He also added he observed handwashing techniques by the staff and had also obtained lab cultures on different equipment. He stated the cost of culturing the different equipment was high, so administration told him to stop culturing the equipment. S7 confirmed the Infection Control Program was not functioning as a program.

Record review of policy #4001 titled "Clinical Laboratory Performance Improvement Plan" (no reviewed, revised, or approval date) pg 1 of 10 under Responsibility revealed the following: "The Clinical Laboratory Director is responsible for establishing and implementing a Clinical Laboratory performance improvement plan." Under Goals of Performance Improvement, "The primary goal of the Clinical Laboratory performance improvement plan is to continually and systematically plan, design, measure, assess and improve performance functions and processes (pg 2 of 10) relative to patient care and services. (pg 3 of 10) reads "The Clinical Laboratory Department incorporates information related to these elements, when available and relevant, in the design or redesign of processes, functions, or services: The status of identified problems is tracked to assure improvement or problem resolution."

Record review of the policy Subject: IC 1030-Infection Control Plan" (pg 8 of 10) under "Indicators" revealed the following: (1) Monitoring and evaluation of key indicators of infection control surveillance, prevention and management include: Hospital Acquired infections, Communicable diseases, Employee health trends, and Post Discharge Monitoring. (2) Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks." On pg 9 of 10, under "Interaction with Performance/Improvement Programs", reveals the following: "The Performance Improvement Program is recognized as an integral element in the infection control effort....The Infection Control Coordinator also supplies the Performance Improvement Coordinator with information that may be useful in identifying potential quality problems throughout the hospital."