HospitalInspections.org

Based on review of facility policy, review of medical records, and interview with staff (EMP), it was determined the facility failed to provide each Medicare beneficiary notice of 'An Important Message from Medicare' (IM) upon admission or before discharge for two of three medical records reviewed (MR8 and MR12).

Findings include:

Review of facility policy, Medicare Notice of Discharge Appeal Rights, last reviewed May 2019, revealed, "... Procedures: 1. Medicare patients will be presented with 'An Important Message from Medicare About Your Rights' form in Admissions or within 2 days of admission. ... 2. Medicare patients should be presented with a second copy of this form 2 days before the projected discharge date. ... "

Review of MR8 revealed a medicare patient with an admission date of July 9, 2019 and discharge date of July 13, 2019. Further review of MR8 revealed no documentation that an IM was provided upon admission or prior to discharge.

Review of MR12 revealed a medicare patient with an admission date of May 9, 2019 and discharge date of May 19, 2019. Further review of MR12 revealed no documentation than an IM was provided prior to discharge.

Interview with EMP 11 on February 13, 2020 at 2:00 PM confirmed the above findings.

Based on a review of facility policy and credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure medical staff were trained on the facility seclusion and restraint policy for 11 of 12 credential files reviewed (CR1-CR11).

Findings included:

Facility policy, "Subject: seclusion and restraint." Revised date 2/20. "Purpose:...Medical Staff, Clinical Psychologists, Nursing staff and Counseling staff will receive annual training on use of restraints regarding who has the authority to: Has the right to order restraint and seclusion.Who has the authority to discontinue a restraint or seclusion. Who can initiate the use of restraint or seclusion.The circumstances under which restraint or seclusion is discontinued. The requirement that the restraint or seclusion is discontinued as soon as safely possible. Determination of who can assess and monitor patients in restraint or seclusion. Timeframes for assessing and monitoring patient in restraint or seclusion. Definitions of restraint, seclusion, description of what constitutes the use of medications as a restraint."

A review of the facility's credential files was completed on February 11 and 12, 2020. CR1, CR2, CR3, CR4, CR5, CR6, CR7, CR8, CR9, CR10, and CR11 contained no evidence that the physcians, physicians' assistants, and certified registered nurse practitioners received training on the facility's policy on seclusion and restraints.
During an interview on February 13, 2020, at 11:30 AM, EMP1 confirmed that medical staff CR1 - CR11 were not trained on the facility policy on seclusion and restraint.

Based on a review of facility documentation and staff interviews (EMP), it was determined that the facility failed to ensure the Medical Staff Bylaws, Rules And Regulations were approved by the governing body.

Findings include:

A request for current Medical Staff Bylaws Rules and Regulations was requested and non was provided.

Review of facility documentation "Eagleville Hospital Medical Staff Bylaws, Rules And Regulations...approved by the Board of Directors on June 23, 2016 revealed, "6.1.2 Function. The Executive Committee shall: ... (f) serve in the role of a Bylaws Committee by reviewing the Bylaws (including the Rules and Regulations) in whole at least every other year, and make recommendations to the Medical Staff for adoption of amendments, as necessary to the Bylaws, Rules and Regulations (in accordance with these Bylaws)."

Review of facility documentation "Joint Meeting of the Board of Directors of Eagleville Hospital Minutes" dated September 25, 2019, revealed, "Review of Bylaws...is working actively through challenges and struggle with the Medical Staff...The Medical Staff bylaws continue to be a challenge as they are circular and difficult to manage for a small organization like Eagleville...as well as options and recommendations for...reconstituting the Medical Staff and the Medical Staff bylaws...The Hospital is unable to amend the Bylaws to allow Medical Staff functions to continue...Active medical staff members will collectively present reconstituted Medical Staff Bylaws to the Joint conference Committee and Board of Directors for final review and approval."

Review of facility documentation "Joint Meeting of the Board of Directors of Eagleville Hospital" meeting minutes dated December 19, 2019, revealed no documented evidence that the Medical Staff Bylaws Rules and Regulations were discussed.

Review of facility documentation "Medical Staff Executive Committee Meeting" dated February 27, 2019, and May 15, 2019, revealed no documented evidence that the Medical Staff Bylaws Rules and Regulations were discussed.

Interview with EMP2 on February 12, 2020, at 11:55 AM confirmed the above findings. EMP2 stated, "We are working under the auspices of the draft of the medical staff bylaws...a draft of the medical staff bylaws was presented to the medical staff at the January [2020]meeting and we are now awaiting comments/suggestions."

On February 12, 2020, at 11:55 AM, EMP2 confirmed there is presently a draft of medical staff bylaws that was presented to the medical staff at the January 2020 meeting and the facility is now awaiting comments/suggestions. Upon further interview, EMP1 confirmed that the facility is "working under the auspices of the draft" of medical staff by-laws. The draft is to be presented for approved in the middle part of March 2020.

Interview with EMP2 on February 12, 2020, at 3:00 PM confirmed that the Medical Staff Bylaws Rules and Regulations were last reviewed/revised,/approved by the Governing Board "probably two years ago."

Based on a review of facility documentation and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure patient medical records were completed by the person responsible for providing the service for four of four medical records reviewed (MR1, MR2 MR15, MR16)

Findings include:


Review of facility policy and procedure "Transfer of a Patient to Another Facility Including Emergency Transfer" dated May 2019, revealed "2) The physician, PA-C, or CRNP will ... Provide an order for the transfer of the patient."


Review of facility policy and procedure "Medical Records Documentation Requirements" dated May 2019, revealed "4. All medications, laboratory or other diagnostic tests, medical assessment and treatment ... must only be completed following the order of an AMP."


Review of MR1 on February 13, 2020, revealed a transfer form dated March 16, 2019. Further review revealed no documentation of a physician order to transfer the patient.


Interview with EMP4 on February 13, 2020, at 10:12 AM confirmed the above findings.


Review of MR2 on February 13, 2020, revealed a transfer form dated March 19, 2019. Further review revealed no documentation of a physician order to transfer the patient.


Interview with EMP4 on February 13, 2020, at 2:00 PM confirmed the above findings.


Review of MR15 on February 13, 2020, at 1:00 PM revealed a nursing note dated December 23, 2019, which indicated, "... Pt continued to be unresponsive and paramedics took pt to ... ER at 1915. ..." Further review revealed no documentation of a physician order to transfer the patient.


Review of MR16 on February 13, 2020, at 1:30 PM revealed a transfer form dated December 23, 2019. Further review revealed no documentation of a physician order to transfer the patient.


Interview with EMP4 on February 13, 2020, at 2:15 PM confirmed that there were no transfer orders for MR15 and MR16.

The facility was not in compliance with the CMS (Center for Medicare/Medicaid Services) Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 183, 10/12/18). Specifically, the facility was not in compliance with 482.30 Utilization Review. Significant corrections evidencing compliance will be required.

The CONDITION is not met as evidenced by:
Based on the nature of the standard-level deficiencies related to Utilization Review, the facility failed to substantially comply with this condition.

The findings were:

The following standards were cited and show a significant nature of non-compliance with regards to Utilization Review as follows:

(482.30(b) Tag A-0654)
The information reviewed during the survey provided evidence the facility did not maintain composition of Utilization Review committee

(482.30(c) Tag A-0655)
The information reviewed during the survey provided evidence that the facility failed to provide review for Medicare and Medicaid patients with respect to the medical necessity of admissions, durations of stays, and professional services furnished.

(482.30(d) Tag A-0656)
The information reviewed during the survey provided evidence that the facility failed to provide determination regarding admissions or continued stays.

(482.30(f) Tag A-0658)
The information reviewed during the survey provided evidence that the facility failed to provide review of professional services.

Based on review of facility documentation and interview with staff, it was determined the facility failed to establish a Utilization Review (UR) committee.

Findings include:

Review of Utilization Review Plan, last reviewed February 2020 revealed, " ....Support the UR activities of the Concurrent Review Staff. The physician members of the UR committee will serve as advisors for the Concurrent Review (UR Staff). ... The Concurrent Review (CR) Staff will conduct admission and concurrent reviews on all patients and all units. These individuals are responsible, as are members of the UR Committee, for the daily activity necessary to meet the regulations for review and responsibilities of the UR Plan. ..."
On February 11, 2020, a review of Utilization Review Committee documentation revealed no Utilization Review activity since the last meeting on July 23, 2019.
Interview with EMP3 on February 13, 2020 at 12:00 PM confirmed that the committee has not been active since the July 23, 2019 meeting.

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to comply to the established Utilization Review (UR) Plan.

Findings include:

Review of facility UR plan, last reviewed February 2020, revealed, " ...Utilization Review Process. ... The Concurrent Review (CR) reviewers shall: Review all admissions for appropriateness; Review pertinent medical records to obtain information necessary to make UR decisions; Apply criteria objectively for admissions, continued stay, level of care and discharge readiness regardless of payor; Screen and coordinate admissions, transfers, and other conversions of status as appropriate; Review all continued stays at a scheduled frequency, but not less than every three days; Screen for timeliness, safety and appropriateness of the rendering or use of hospital services or resource; ... "
Review of committee documentation revealed no documentation of reviews since July 23, 2019.
Interview with EMP3 on February 13, 2020 at 12:00 PM confirmed that the committee has not been active since the July 23, 2019 meeting.

Based on review of faciity documentation and staff interview (EMP), it was determined that the facility's Utilization Review (UR) Committee failed to provide documented evidence for evaluating the appropriateness/clinical necessity of admissions/continued stays; failed to provide written notification of cases determined to be medically unnecessary was given to appropriate staff and patients.

Findings include:

Review of facility Utilization review plan, last reviewed February 9, 2020, revealed, " ...Utilization Review Process. ... The CR reviewers shall: Review all admissions for appropriateness; Review pertinent medical records to obtain information necessary to make UR decisions; Apply criteria objectively for admissions, continued stay, level of care and discharge readiness regardless of payor; Screen and coordinate admissions, transfers, and other conversions of status as appropriate; Review all continued stays at a scheduled frequency, but not less than every three days; Screen for timeliness, safety and appropriateness of the rendering or use of hospital services or resource; ... "
Review of facility UR committee documenation revealed no evidence of review of continued stays since July 23, 2019.
Interview with EMP3 on February 13, 2020 at 12:00 PM confirmed that the committee has not been active since the July 23, 2019 meeting.

Based on review of faciity documentation and staff interview (EMP), it was determined that the facility failed to review professional services provided, to determine medical necessity and to promote the most efficient use of available services.

Findings include:

Review of facility Utilization Review (UR) plan, last reviewed February 2020, revealed, "... Provide follow-up chart review and physician/clinical service education for issues, when necessary."

Review of facility's UR committee documentation revealed no documentation of review of professional services provided since July 23, 2019.

Interview with EMP3 on February 13, 2020, at 12:00 PM confirmed that the committee has not been active since the July 23, 2019 meeting.