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Based on document review and interview, the survey hospital ' s written agreement for distant-site radiology services furnished to its inpatients failed to indicate that the distant-site entity was a contractor of services of the hospital and will provide the radiology services in accordance with all Federal conditions of participation pertaining to contracted services and assure that its medical staff providing radiology services maintained their medical staff membership and privileging requirements in accordance with all Federal conditions of participation pertaining to the governing body requirements for medical providers furnishing the service. The survey hospital failed to document privileging of the radiologists associated with the distant-site entity including evidence of a medical staff recommendation based upon information supplied by the distant-site entity or based upon a credential file review for each distant-site radiologist by the survey hospital.

Findings:

1. Review of the written agreement for radiology services between the survey hospital and the distant-site entity failed to indicate that the distant-site entity was a contracted service and would provide the radiology services in accordance with all Federal conditions of participation pertaining to contracted services. The agreement failed to indicate that its medical staff providing radiology services would maintain their medical staff membership and privileging requirements in accordance with all Federal conditions of participation pertaining to the governing body requirements for medical providers furnishing the service.

2. During an interview on 4-03-14 at 1515 hours, credentialing specialist A15 confirmed that the facility lacked evidence of hospital privileging for the distant-site radiology service practitioners.

3. During an interview on 4-03-14 at 1545 hours, Risk Manager A4 confirmed that the service agreement with the mobile radiology service lacked the indicated provisions and no further documentation was available.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided for 15 of 27 contracted services.

Findings:

1. The list of contracted services failed to indicate the scope and nature for 12 of 24 listed services and failed to indicate a provider for a commercial kitchen dishwasher, fire extinguisher service, and a fire sprinkler service.

2. Review of facility maintenance documentation indicated the following: commercial dishwasher service by CS1, fire extinguisher service by CS2, and fire sprinkler service and certification by CS3.

3. During an interview on 4-03-14 at 1215 hours, staff A4 confirmed that the list of contracted services failed to indicate the scope and nature of services for 12 providers and failed to include the 3 services indicated above. The staff A4 confirmed that the list had not been maintained.

Based on policy and procedure review and medical record review, the facility failed to ensure that the type of restraint was ordered when a restraint order was given for two of three patient records where restraint was ordered (pts. #1 and #2).

Findings:
1. review of the policy and procedure "Seclusion and Restraint of Inpatient Clients", procedure number IV - 502 (R 11), with an approval date of March 25, 2011, indicated:
a. on page 6 under "QRN/Physician/APN Assessment:" (QRN = qualified registered nurse; APN = advanced practice nurse), it reads: ".1...Determination/method of appropriate type of restraint/seclusion (physician order)."

2. review of patient medical records indicated:
a. pt. #1 had an order to "Physically restrain for up to four (4) hours." written on 12/9/13 at 10:45 PM (on form C390)
b. pt. #2 had an order to "Physically restrain for up to four (4) hours." written on 3/10/14 at 10:30 AM (on form C390)
c. both restraint orders lacked indication of the type of physical restraint to be utilized
d. the policy listed in 1. above lacked indication, in the portion of the policy that addresses practitioner orders, that the specific type of physical restraint needed to be included with the order for restraint

Based on policy and procedure review, personnel file review, and staff interview, the facility failed to implement its policy related to CPR (cardio pulmonary resuscitation) certification for 3 of 8 staff members (N1, N2 and N8) and failed to ensure annual training, required per policy, for 8 of 8 staff (N1 through N8)related to the AED (automated external defibrillator).

Findings:
1. review of the policy and procedure "Mandatory Training: Monitoring and Documentation", procedure number VII-521 (R 08), with an approval date of September 17, 2012, indicated:
a. on page 2 under section 4.3, it reads: "Mandatory Training Requirements:....2 Cardiopulmonary Resuscitation CPR/AED: .1 Training is required for all adult and child adolescent rehabilitation service providers, 24 hours staff, and residential staff. .2 Doctors and licensed nurses who are already certified must maintain their CPR/AED certification. .3 Staff shall receive annual training regarding CPR/AED use at worksites where AED machines are available,"

2. review of personnel files indicated:
a. staff members N1 and N2 had CPR certification which expired 1/6/14
c. staff member N8 had CPR certification that expired 3/16/14
d. staff members N1 through N8 lacked any documentation of having had annual CPR/AED education

3. at 3:15 PM on 4/3/14, interview with staff members #50, the director of nursing and inpatient director, and #59, the RN, PI (registered nurse/performance improvement) staff member, indicated:
a. the inpatient unit does have and AED
b. it was unknown that the policy required annual CPR/AED education for staff
c. annual education has not been occurring as indicated in the policy listed in 1. above

Based on document review and interview, the psychiatric facility failed to maintain an effective quality assessment and performance improvement (QAPI) program and assure that all hospital inpatient services were monitored and reviewed in a distinct and organized manner through the program.

Findings:

1. The Performance Improvement Plan FY 2014 (approved 10-13) failed to indicate a process to organize and distinguish the provision of all hospital inpatient services from other mental health services reviewed through the program. The plan failed to indicate the 'Cross Functional Team' or equivalent with responsibility for monitoring and reviewing all inpatient services (including discharge planning, environmental services, laboratory, medical records and radiology services).

2. The facility Safety Plan (no approval date) heading titled Safety and Risk Management (SARM) Committee duties failed to assure that all inpatient services were monitored and reviewed by the committee. The safety plan indicated that the SARM committee membership included the Medical Director and indicated the commitee would hold monthly meetings.

3. During an interview on 4-02-14 at 1000 hours, Risk Manager A4 indicated that the SARM meetings functioned as the hospital QAPI committee for inpatient services.

4. The SARM meeting minutes dated 3-14-14, 1-14-14, 12-13-13, 11-08-13, 8-09-13, 7-12-13 and 6-14-13 failed to indicate that the Medical Director MD11 attended the meetings. The minutes failed to indicate that the hospital services including discharge planning, environmental services, laboratory, medical records and radiology were periodically evaluated and reviewed. The minutes failed to assure that the inpatient QAPI program monitoring documentation of required services and functions was ongoing and effective.
5. During an interview on 4-03-14 at 1300 hours, staff A4 confirmed that the PI plan failed to assure that hospital services were assessed and reviewed in an organized manner from other mental health services reviewed through the program. The staff A4 confirmed that the SARM minutes failed to assure that all inpatient hospital services were monitored and reviewed through the program and confirmed that no other documentation was available.

Based on personnel file review and interview, the infection control committee failed to ensure the continuing education of the infection preventionist related to infection control practices; and based on observation and interview, the infection control committee failed to ensure the cleanliness of the pantry area refrigerator and a refrigerator and freezer located in the lower level of the building beside the medical records office.
Findings:
1. review of the education file for staff member #52, the infection preventionist, at 10:30 AM on 4/3/14 indicated the only education, related to infection control, for 2013 was one hour for hand hygiene as presented by the WHO (world health organization)-no documentation was found for 2012
2. Interview with staff member #52 confirmed that:
a. there was no other continuing education received, related to infection prevention practices, for this infection preventionist in 2012 or 2013
b. it cannot be determined what epidemiological expertise staff member #52 possesses to act as the infection control preventionist for the facility
3. while on tour of the facility on 4/3/14 at 11:25 AM in the company of staff member #53, the inpatient nursing supervisor, it was observed in the patients' kitchen/pantry area that the industrial sized refrigerator was dirty with crumbs on the lower shelf and the shelf on the door
4. interview with staff member #53 at 11:30 AM on 4/3/14 indicated it is the duty of the MHTs (mental health techs) to see that the kitchen refrigerator gets cleaned
5. while on tour of the facility on 4/3/14 at 12:45 PM in the company of staff member #51, the risk manager, it was observed in the lower level freezer top that the bottom shelf was sticky from a spilled liquid and that the refrigerator was dirty with crumbs/debris under the vegetable drawers
6. interview with staff member #51 at 1:00 PM on 4/3/14 indicated:
a. it is unclear whose responsibility it is to clean the lower level refrigerator and freezer
b. there is no facility policy that addresses cleaning of the refrigerators/freezers

Based on personnel file review and interview, the infection control committee failed to create an effective infection control plan in failing to assure the history of communicable diseases for 8 of 8 staff files reviewed (staff members N1 through N8).

Findings:
1. review personnel files indicated:
a. staff members N1 and N2, housekeeping staff, lacked indication of history of disease, documentation of titer results, or documentation of immunization history for: Rubella, Rubeola, and Varicella
b. staff members N3, N4, and N5 were RNs (registered nurses) who lacked indication of history of disease, documentation of titer results, or documentation of immunization history for: Rubella, Rubeola, and Varicella
c. staff members N6, N7, and N8 were MHTs (mental health techs) who lacked indication of history of disease, documentation of titer results, or documentation of immunization history for: Rubella, Rubeola, and Varicella

2. interview with staff member #50, the director of nursing and the inpatient director, at 2:30 PM on 4/3/14 indicated:
a. the facility currently has no policy related to the requirement of communicable disease history for employees
b. at this time, the facility is not checking communicable disease history of its employees
c. it cannot be determined which staff might be at risk for an outbreak within the community of Rubella, Rubeola, or Varicella

Based on document review and interview, the infection control committee failed to ensure medical staff involvement in the infection control committee, which is part of the SARM (safety and risk management) committee at this facility.

Findings:
1. review of the attendance records for the meetings of March 13, 2013; April 12, 2013; May 10, 2013; June 14, 2013; July 12, 2013; August 9, 2013; November 8, 2013; December 13, 2013; and January 10, 2014 indicated that no member of the medical staff was listed as "present".

2. interview with staff member #50, the Director of Nursing, and #52, the infection preventionist, at 10:30 AM on 4/3/14 indicated:
a. the SARM committee is the infection control committee
b. members of the medical staff are not involved with, and do not attend, the SARM meetings
c. it is unclear how the medical staff is involved in infection control processes and issues without documentation of presence at meetings that include infection control reports, data, and discussion