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Based on a review of hospital records, Department facility licensing file, observation, and interview, it was determined the hospital failed to meet the requirements for state licensure as demonstrated by:

1. The hospital failed to notify the licensing department of the addition and removal of services provided at its licensed outpatient treatment clinics;
2. The hospital failed to ensure a collocated unit was provided a separate entrance.

These deficient practices pose a risk to the health and safety of patients if the scope of services is not current and risk a breach in patient confidentiality.

Findings include:

1.

Observations during the tour and document review on April 17-20, 2023, revealed the scope of services listed for three of the outpatient treatment centers did not match the licensed services for those facilities.

1. Review of the scope of services for the CSU (Crisis Stabilization Unit) revealed it is licensed to provide Crisis Services, restraint and seclusion and medication services. However, the facility was not providing these services as the facility have the staff, equipment or rooms or stock medications to provide such services.
2. Review of the scope of services for Changepoint Integrated Health, Showlow revealed it is licensed to provide Physical Health, Behavioral Health, Medication Services, Crisis Services, and Clinical Lab services. The facility does not provide these services as evidenced by lack of staff, equipment and documentation required to provide these services and treatments. In addition, the facility provides Respite Services but not in a contiguous building as required by state law.
3. Review of the scope of services for Changepoint Integrated shows revealed it is licensed to provide Pre-petition Services, Crisis Services, and Counseling Services. The facility does not provide these services as evidenced by lack of equipment on the premises, lack of staffing and lack of documentation in patient charts indicating these services were provided.

Review of the state licensing file revealed no evidence of the Hospital notifying the Department of changes in services provided at the outpatient treatment centers.

Employees #1 and #51 confirmed on April 29, 2023 knowledge of the state licensure requirements not being met by the hospital and its licensed outpatient treatment centers.

2.
A hospital tour was conducted on 04/13/2023. The inpatient entrance for the hospital was a door that opened into the collocated Crisis Stabilization Unit (CSU), licensed as an outpatient treatment center. The triage room for hospital inpatients was a shared room with the collocated CSU.

A map of the building with the licensed space of the hospital outlined and signed and dated by Employee #1, showed this entrance and the triage area outside of the hospital's licensed space.

Employee #1 confirmed in an interview conducted on 04/13/2023, that the hospital inpatients come in through the door of the CSU, and patients for the CSU and hospital are triaged in the same area. Employee #1 confirmed this entrance and triage are not part of the hospital licensed space and are part of the CSU.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure the Governing Body evaluated hospital services related to patient rights,nursing services, infection control, and quality management, . This deficient practice poses the risk of the Governing Body being unaware of the overall function and management of the hospital and the inability to improve patient care services.

Cross reference A-0022: The Governing Body failed to ensure that the hospital and its outpatient treatment center provided services it was licensed to provide and that inpatients of the hospital did not receive care in space not licensed to the hospital.

Cross reference A-0057: The Governing Body failed to ensure the Chief Executive Officer (CEO) implemented the Governing Body's policies.

Cross reference A-0131: The Governing Body failed to ensure patients were notified in writing at the time of admission there was not an MD or DO on site at the hospital 24 hours a day, 7 days a week.

Cross reference A-0159: The hospital failed to ensure that patients requiring physical restraints were restrained according to policies and procedures and with an appropriate order.

Cross reference A-0286: The Governing Body failed to ensure corrective action plans were developed and implemented to improve and prevent the amount of patient care incidents.

Cross reference A-0309: The Governing Body failed to ensure there was a Quality Program implemented and maintained to continuously improve on the quality of care inpatients received, reduce medical errors, provide for patient safety, and determine annual improvement projects.

Cross reference A-0392: The hospital failed to ensure there was the correct number of nursing personnel staffing to provide patient care.

Cross reference A-0393: The hospital failed to ensure an RN was immediately available on the premises at all times to supervise nursing care.

Cross reference A-0467: The hospital failed to ensure every 15 minute observation documentation was made available in the medical record after being completed by a staff member.

Cross reference A-0748: The hospital failed to ensure an individual qualified through training or certification in infection control was responsible for maintaining an infection control and improvement program.

Cross reference A-0771: The governing body failed to ensure infectious diseases occurring in the hospital were addressed with QAPI.

Cross reference A-0773: The hospital failed to ensure the infection preventionist had appropriate documentation of infection control activities.

Cross reference A-0802: The hospital failed to ensure discharge summaries were signed by a medical provider.

Cross reference A-1564: The hospital failed to ensure a nurse to nurse report was given to an RN at a receiving hospital to ensure continuity of care.

Cross reference A-1690: The hospital failed to ensure clinical oversight given to hospital staff was provided and documented appropriately.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Governing Body.

Based on review of hospital records, and interview, it was determined the Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures and provide resources to provide care to meet the needs of patients.

Findings include:

Hospital document titled, "Bylaws of Changepoint Integrated Health," received on 04/10/2023, revealed: " ...Powers and Duties of the Board of Directors ...The Board shall have the general responsibility for management of the affairs of the corporation. The Board may, in accordance with these bylaws ...a. Establish policy, maintain quality of patient care, and provide for organizational management and planning ...g. Cause the clinical personnel and management team to create and conduct an annual review of a written clinical service plan and other systems plans to be submitted for Board approval h. Cause the clinical personnel to establish a process of quality management and review the standards and implementation of such process from time to time. i. Require the clinical personnel to provide the board with written reports of clinical care evaluations and improvements, as well as other organizational improvements on a regular basis as such time or times as the board elects ...n ...oversees staff compliance ...p. Requires, approves, oversees, a grievance process ...The Chief Executive Officer shall be delegated with the responsibility to implement the Board's policies and to carry out all other responsibilities as the Board shall set forth in the Chief Executive Officer Job Description ...."

Hospital document titled "Infection Prevention Plan," received on 04/11/2023, revealed: " ...Ultimate responsibility for the Infection Program at ChangePoint Integrated Health, including the allocation of resources necessary to support the program's goals and activities, rests with the Board of Directors. The Board of Directors receives regular reports on infection prevention issues, activities, and outcomes ...."

Hospital document titled "Quality Management Plan," received on 04/11/2023, revealed: " ...The Governing Board has ultimate authority and responsibility through the Chief Executive Officer and Quality Management Manager for overseeing and as appropriate, participating 1. The monitoring and the evaluation of the quality of behavioral health care services and overall organization operations; 2. Problem identification and resolution; 3. Pursuing opportunities for continuous improvement of services and enhanced functioning of the organization ...."

Hospital document titled "Hospital Grievance Policy," received on 04/11/2023, revealed: " ...The Changepoint Integrated Health Governing Board approves this policy and oversees the process ...The CEO will provide a report to the board at least every 4th month (at least three times a year.) ...."

During the survey it was determined the CEO failed to implement the Board's policies as demonstrated by the following:


Cross reference A-0022: The Governing Body failed to ensure that inpatients of the hospital did not receive care in space not licensed to the hospital.

Cross reference A-0131: The Governing Body failed to ensure patients were notified in writing at the time of admission there was not an MD or DO on site at the hospital 24 hours a day, 7 days a week.

Cross reference A-0159: The hospital failed to ensure that patients requiring physical restraints were restrained according to policies and procedures and with an appropriate order.

Cross reference A-0286: The Governing Body failed to ensure corrective action plans were developed and implemented to improve and prevent the amount of patient care incidents.

Cross reference A-0309: The Governing Body failed to ensure there was a Quality Program implemented and maintained to continuously improve on the quality of care inpatients received, reduce medical errors, provide for patient safety, and determine annual improvement projects.

Cross reference A-0392: The hospital failed to ensure there was the correct number of nursing personnel staffing to provide patient care.

Cross reference A-0393: The hospital failed to ensure an RN was immediately available on the premises at all times to supervise nursing care.

Cross reference A-0467: The hospital failed to ensure every 15 minute observation documentation was made available in the medical record after being completed by a staff member.

Cross reference A-0748: The hospital failed to ensure an individual qualified through training or certification in infection control was responsible for maintaining an infection control and improvement program.

Cross reference A-0771: The governing body failed to ensure infectious diseases occurring in the hospital were addressed with QAPI.

Cross reference A-0773: The hospital failed to ensure the infection preventionist had appropriate documentation of infection control activities.

Cross reference A-0802: The hospital failed to ensure discharge summaries were signed by a medical provider.

Cross reference A-1564: The hospital failed to ensure a nurse to nurse report was given to an RN at a receiving hospital to ensure continuity of care.

Cross reference A-1690: The hospital failed to ensure clinical oversight given to hospital staff was provided and documented appropriately.

Employee #1 confirmed in an interview conducted on 04/10/2023 the CEO was appointed by the Governing Body to fulfill this role.

Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A-0131: The Governing Body failed to ensure patients were notified in writing at the time of admission there was not an MD or DO on site at the hospital 24 hours a day, 7 days a week and all physician services are provided by telehealth only.

Cross reference A-0159: The hospital failed to ensure that patients requiring physical restraints were restrained according to policies and procedures and with an appropriate order.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based upon a review of hospital records and interview, it was determined that the hospital failed to ensure inpatients were notified at the time of admission that all physician services will be provided via telehealth without onsite visit available at the hospital 24 hours a day, seven days a week. This deficient practice poses the risk of patients being unaware that they will not have a physician present to do a face to face examination and is a violation of a patient's right to be informed of healthcare practices at the facility.

Findings include:

A review of 26 patient records (Patients #1 through 26) has no revealed no signed notification that a physician was not present on site.

Employee #1 confirmed in an interview on 04/12/2023, that all services provided by a physician are through telehealth only and there is no notification to patients of any kind that there is not a physician on the premises, nor will they see one face to face during their admission, as the physician is present about once a quarter.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients were only placed in a physical restraint with an order and had documentation, a face-to-face assessment, and an evaluation of the use of restraints. This deficient practice poses the risk of a patient being physically restrained unnecessarily, suffering an injury due to restraint, not having the treatment plan updated for the use of restraints, and a violation of patient rights.

Findings include:

Hospital policy titled " Behavioral Health Interventions (De-escalation; Seclusion/Restraint; Emergency Safety Response," received on 04/12/2023, revealed: " ...Definition of Personal Restraint- The application of physical force without the use of any device, for the purpose of restricting the free movement of behavioral health recipient's body ...The RN may initiate a Seclusion, or a Personal or Mechanical Restraint if a MO is not on the unit, but must have a verbal or written order within 15 minutes of initiation ...The MO or an RN with at least one year behavioral health experience and specialized training must complete a face-to-face assessment and evaluation within one hour of the initiation in all cases even if the member is secluded or restrained for less than a minute ...."

A review of an incident report flowsheet for a non restraint and seclusion incident on 03/18/2023, involving Patient #20, revealed the documentation, " ...three techs were obtained to hold pts arms and torso of the patient while the RN administered the medication in the left deltoid ...."

A note titled "Daily Nursing Flow Sheet," dated 03/18/2023, in Patient #20's medical record revealed: " ...pt received [his] LAI Invega this morning, pt was held down due to resisting the injection. Pt is currently COT. Per [Emi] pt was to receive injections today no exceptions ...."

Employee #3 confirmed in an interview conducted on 04/12/2023, that there was not an order for the physical restraint of Patient #20, because s/he was just held. Restraints are not used, patients are just held occasionally if needed. Employee #3 confirmed that there are no orders or documentation on patients that are held. Employee #3 confirmed that s/he did not know how many or which patients were held, but it did not happen often.

Based on the record review and interviews, it was determined the hospital failed to have a quality assessment and performance improvement program that reflected the complexity of the hospital's organization and services involving all hospital departments as evidenced by:

Cross reference A-0286: The Governing Body failed to ensure corrective action plans were developed and implemented to improve and prevent the amount of patient care incidents.

Cross reference A-308: The Governing Body failed to ensure the QAPI program was hospital wide and reflected all hospital departments and services.

Cross reference A-0309: The Governing Body failed to ensure there was a Quality Program implemented and maintained to continuously improve on the quality of care inpatients received, reduce medical errors, provide for patient safety, and determine annual improvement projects.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Quality Assessment and Performance Improvement.

Based on hospital records and staff interviews it was determined the hospital failed to consistently track and analyze patient and staff adverse events. This deficient practice poses a potential risk to the health and safety of patients and staff when not recognizing the frequency of events and errors and not following through with resolutions or putting corrective action into place to prevent the incidents from reoccurring.

Findings include:

Hospital document titled" Reporting Incidents, Accidents, Deaths, and Sentinel Events" revealed: ' ...B. Reporting Requirements. 1. Staff members immediately report to their supervisor al events indicated above, and submit a written account of their involvement or observation on an Incident, Accident, Deaths Report Form. 6. The Administrative Assistant maintains a file of Incident/Accident/Death Reports. Reports are tracked for trending patterns by year and type/frequency/severity/location of occurrence. Trending Summaries and recommendations for further action is reported to the EOC Coordinator for review of possible patterns and problem-solving ...7. All incidents are reviewed by the Clinical Services Committee to determine the need for further action, frequency, possible patterns, and problem-solving. 8. After review, the Clinical Services Committee shall inform appropriate staff of any further recommended actions to be taken ...."

Request to review the file of incident reports maintained by the Administrative Assistant. Employee # 2, Facility Quality Manager stated that [she] now maintains a log.

Request to review the incident reports specific to the hospital, Employee # 2 stated they were unable to provide them.

Employee # 2, facility Quality Manager revealed in an interview dated 04/12/2023 that all the incident reports for the hospital and affiliated outpatient treatment centers are kept on one log. When an incident report is filled out, Employee # 2 receives an email the next morning which includes the incident report. Employee # 2 states that all incidents should have a resolution or outcome documented

Hospital documents "Incident Reports" reviewed: 12 random incident reports reviewed for documentation.
4 reports provided were for the Crisis Unit.
3 reports were filled out according to hospital policy and procedure.
5 reports were filled out without documentation of the time of the incident, the name of the supervisor notified, witnesses involved, and no follow-up or resolution.

Based on a review of hospital records and staff interviews, it was determined the hospital failed to develop, implement and maintain an effective hospital-wide quality assessment and performance improvement program. This deficient practice poses a health and safety risk to patients when the hospital cannot ensure the provision of quality health care and a safe environment

Findings include:

Hospital document titled, "Bylaws of Changepoint Integrated Health," received on 04/10/2023, revealed: " ...Powers and Duties of the Board of Directors ...The Board shall have the general responsibility for the management of the affairs of the corporation. The Board may, in accordance with these bylaws ... h. Cause the clinical personnel to establish a process of quality management and review the standards and implementation of such process from time to time. i. Require the clinical personnel to provide the board with written reports of clinical care evaluations and improvements, as well as other organizational improvements on a regular basis at such time or times as the board elects ...."

Hospital document titled" Quality Management Plan" revealed: " ...The purpose of the QM Department is to establish, organize, monitor, and document evidence that Change Point assesses and implements a quality improvement process ...ORGANIZATION. The Governing Board has ultimate authority and responsibility through the Chief Executive Officer and Quality Management Manager for overusing and, as appropriate, participating in: 1. The monitoring and evaluation of the quality of behavioral health care services and overall organization operations; 2. Problem, identification, and resolution; 3. Pursuing opportunities for continuous improvement of services and enhanced functioning of the organization.
Quality Management meeting minutes requested for 04/2022 through 04/2023. One set of meeting minutes was provided dated 03/31/2023.

A review of Governing Body Meeting Minutes from June 2022, through January 2023, revealed no reporting of infection control, quality indicators, patient care concerns patient grievances, problem identification, and resolution, performance improvement studies, or incident reports to the Governing Body. No recommendations or input from the Governing Body regarding the Quality Assessment Performance Improvement Plan.

Employee #1 Hospital COO, Administrator confirmed in an interview conducted on 04/12/2023, that the Governing Body Meeting Minutes did not reflect reporting on these subjects.

Based on a review of hospital records and interviews, it was determined that the Governing Body failed to provide evaluation and oversight to the Quality Assurance and Performance Improvement (QAPI) program. This deficient practice poses a significant risk for patients' health and safety when the hospital's Governing Body and Quality Management committees fail to ensure that quality improvement, quality assessment, quality of care, and performance improvement projects are evaluated and follow-up recommendations are provided.

Findings include:

Hospital document titled" Quality Management Plan" revealed: " ...The purpose of the QM Department is to establish, organize, monitor, and document evidence that Change Point assesses and implements a quality improvement process ...ORGANIZATION. The Governing Board has ultimate authority and responsibility through the Chief Executive Officer and Quality Management Manager for overusing and, as appropriate, participating in: 1. The monitoring and evaluation of the quality of behavioral health care services and overall organization operations; 2. Problem, identification, and resolution; 3. Pursuing opportunities for continuous improvement of services and enhanced functioning of the organization.

Hospital document titled, "Bylaws of Changepoint Integrated Health," received on 04/10/2023, revealed: " ...Powers and Duties of the Board of Directors ...The Board shall have the general responsibility for the management of the affairs of the corporation. The Board may, in accordance with these bylaws ... h. Cause the clinical personnel to establish a process of quality management and review the standards and implementation of such process from time to time. i. Require the clinical personnel to provide the board with written reports of clinical care evaluations and improvements, as well as other organizational improvements on a regular basis at such time or times as the board elects ...."

A review of Governing Body Meeting Minutes from June 2022, through January 2023, revealed no reporting of infection control, quality indicators, patient care concerns patient grievances, problem identification, and resolution, performance improvement studies, or incident reports to the Governing Body. No recommendations or input from the Governing Body regarding the Quality Assessment Performance Improvement Plan.

Employee # 1, COO, Hospital Administrator, confirmed in an interview dated 04/12/2023, the hospital Quality Management meeting minutes were not being reported to the Governing Board.
The Governing Board meeting minutes do not show that the hospital Quality Management Program was being discussed during the meetings.

Based on review of hospital records and staff interviews, it was determined the hospital failed to provide organized nursing services 24-hours per day to assess the individual needs of each patient and deliver and supervise the care required in accordance with physician orders, policies and procedures and nursing standards of care as evidenced by:

Cross reference A-0392: The hospital failed to ensure an RN was immedately available to provide patient care in the hospital.

Cross reference A-0393: The hospital failed to ensure an RN was immediately available on the premises at all times to supervise nursing care provided by an LPN.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation in Nursing Services.

Based on a review of hospital records and interview, the Department determined the hospital failed to ensure the only Registered Nurse available in the hospital, did not have to assume the care of patients at a collocating Crisis Stabilization Unit Outpatient Treatment Center (CSU). This deficient practice leaves the hospital without a Registered Nurse available to patients in the hospital, 24 hours a day/seven days a week.

Findings include:

Hospital document titled, "Acuity Plan," received on 04/10/2023, revealed: " ...Day-to-day operations that assess and determine the shift allocation of nursing resources to ensure adequate staffing on each shift ...Part time staff are called to fill shifts when there is a known staffing need or when call-offs occur. Part time staff is contacted first to full the acuity or the staffing need of the unit (up to 29 hours/week), then full time staff ...."

A review of hospital schedules and staffing sheets from 11/01/2022, through 04/10/2023, revealed there was not an RN available in the hospital for the entirety of the shift, on two night shifts in November 2022 (11/21/2022, 11/29/2022), five night shifts in December (12/04/2022, 12/05/2022, 12/24/2022, 12/27/2022, 12/30/2022), eight night shifts in January (01/03/2023, 01/06/2023, 01/07/2023, 01/10/2023, 01/13/2023, 01/17/2023, 01/27/2023, 01/28/2023), one day shift in January (01/08/2023), and four night shifts in February (02/03/2023, 02/09/2023, 02/14/2023, 02/18/2023).

Employee #3 confirmed in an interview on 04/12/2023, that the RN who is assigned to the hospital will go to the collocating CSU to assume care of those patients if there is no RN scheduled in the CSU. Employee #3 also confirmed there were multiple nights in March and April with no RN in the CSU, and if the CSU had received any patients, the hospital RN would have had to leave the hospital to take care of the CSU patients.

Based on a review of hospital records and interview, the Department determined the hospital failed to ensure the only Registered Nurse available in the hospital, did not have to assume the care of patients at a collocating Crisis Stabilization Unit Outpatient Treatment Center (CSU). This deficient practice leaves the hospital without a Registered Nurse available 24 hours a day/seven days a week to perform RN related duties, and to supervise Licensed Practical Nurses who are providing patient care at the hospital.

Findings include:

Hospital document titled, "Acuity Plan," received on 04/10/2023, revealed: " ...Day-to-day operations that assess and determine the shift allocation of nursing resources to ensure adequate staffing on each shift ...Part time staff are called to fill shifts when there is a known staffing need or when call-offs occur. Part time staff is contacted first to full the acuity or the staffing need of the unit (up to 29 hours/week), then full time staff ...."

A review of hospital schedules and staffing sheets from 11/20/2022, through 04/10/2023, revealed there was not an RN available in the hospital for the entirety of the shift, on two night shifts in November 2022 (11/21/2022, 11/29/2022), five night shifts in December (12/04/2022, 12/05/2022, 12/24/2022, 12/27/2022, 12/30/2022), eight night shifts in January (01/03/2023, 01/06/2023, 01/07/2023, 01/10/2023, 01/13/2023, 01/17/2023, 01/27/2023, 01/28/2023), one day shift in January (01/08/2023), and four night shifts in February (02/03/2023, 02/09/2023, 02/14/2023, 02/18/2023).

Employee #3 confirmed in an interview on 04/12/2023, that the RN who is assigned to the hospital will go to the collocating CSU to assume care of those patients if there is no RN scheduled in the CSU. Employee #3 also confirmed there were multiple nights in March and April with no RN in the CSU, and if the CSU had received any patients, the hospital RN would have had to leave the hospital to take care of the CSU patients.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure that every 15 minute observations documentation was available in the patients medical record after being completed by staff. This deficient practice poses the risk of patient safety observations not being completed and the inability to evaluate and audit patient observation activities.

Findings include:

Hospital policy titled "Suicide/Homicide Inpatient Protocol," received on 04/12/2023, revealed: " ...Suicide precautions or prevention strategies are determined by risk factors categorized under Low, Medium, or High-risk categories ...Low risk is when a member is able to deny thoughts of suicide/self-harm, denies having suicidal thoughts, and does not score in the high or medium range on the Suicide Risk Assessment, Low risk precautions require every 15-minute observation ...."

A review of 22 medical records revealed 10 patients (Patients #2, 3, 7, 8, 10, 11, 12, 13, 14, and 15) did not have every 15 minute observations documented in the medical record for all or part of the hospital admission.
Employee #3 confirmed in an interview on 04/11/2023, that every patient should have every 15 minute observations documented in the medical record.

Employee #1 confirmed in an interview on 04/12/2023, that every 15 minute observations were completed on these patients, however, the information did not transfer over to the medical record because of the format it was documented in. Employee #1 confirmed the patient information was in a database which could not be viewed in the medical record.

Based on review of hospital records and interview, it was determined that the hospital does not have an active hospital wide program for surveillance, prevention and control of hospital acquired infections and other infectious diseases. This deficient practice poses a risk to the health and safety of the patients as evidenced by:

Cross reference A-0748: The hospital failed to ensure an individual qualified through training or certification in infection control was responsible for maintaining an infection control and improvement program.

Cross reference A-0771: The governing body failed to ensure infectious diseases occurring in the hospital were addressed with QAPI.

Cross reference A-0773: The hospital failed to ensure the infection preventionist had appropriate documentation of infection control activities.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship and provide a safe environment for patients to protect them from harm.

Based on a review of hospital records and interview, the Department determined the hospital failed to have an Infection Preventionist trained in infection control practices and procedures. This deficient practice poses the risk of infectious organisms not being identified, contagions spreading throughout staff and patient populations, the inability to track trends throughout the hospital, and no monitoring of infection control mitigation.

Findings include:

Hospital document titled "Infection Control Program," received on 04/10/2023, revealed: " ...Overall responsibility for the management of the organization's Infection Prevention Program rests with the Infection Preventionist designated by the Chief Executive Officer with specialized training and experience in the prevention, identification, and management of healthcare acquired infections ...."

Hospital document titled "Infection Control Coordinator," received on 04/12/2023, revealed: " ...Qualifications and Experience Required: High School diploma/GED ...."

Employee #1 confirmed in an interview on 04/11/2023, that Provider #1 was the Infection Preventionist.

Provider #1 confirmed in an interview on 04/13/2023, that s/he has been the Infection Preventionist since January, and has not completed, nor is enrolled in an infection control training or certification program.

Based on a review of hospital records and interview it was determined the hospital failed to report infectious diseases found within the hospital, as well as infection control programs and goals to the Governing Body and QAPI. This deficient practice poses the risk of hospital leadership being unaware of infectious risks in the hospital, the outcome of infection control activities, and the spread of communicable diseases or hospital acquired infections among patients and staff.

Findings include:

Hospital document titled "Infection Prevention Plan," received on 04/11/2023, revealed: " ...Ultimate responsibility for the Infection Program at ChangePoint Integrated Health, including the allocation of resources necessary to support the program's goals and activities, rests with the Board of Directors. The Board of Directors receives regular reports on infection prevention issues, activities, and outcomes ...."

A review of Governing Board Meeting Minutes revealed no infection control reporting.

A review of QAPI Meeting Minutes revealed no infection control reporting.

Infection Control Meeting Minutes were requested and none provided.

Employee #1 confirmed in an interview on 04/12/2023 that there were no Infection Control Meeting Minutes, and no infection control reporting was reflected in the QAPI and Governing Body Meeting Minutes.

Based on a review of hospital documents and interview, it was determined the hospital failed to ensure the infection preventionist performed surveillance and documentation of infectious diseases within the hospital. This deficient practice poses the risk of communicable disease going unnoticed and untreated, as well as proper precautions to prevent the spread of disease among patients and hospital staff.

Findings include:

Hospital document titled "Infection Prevention Plan," received on 04/10/2023, revealed: " ...Specific duties of the Infection Preventionist include, but are limited to {sic} the following ...Coordination of the collection, tabulation, and reporting of infection related data ...."

Hospital document titled "Infection Control Coordinator," received on 04/11/2023, revealed: " ...Conducts ongoing surveillance of infection, gathers and interprets data and keeps accurate records of all infections ...."

Four documents titled "Changepoint Integrated Health Monthly Facility Infection Analysis," were received on 04/11/2023, one each, for the months of January, February, March, and April. All four documents were signed and dated by Employee #1 and Provider #1 on 04/11/2023.

Employee #1 confirmed in an interview on 04/11/2023, the January, February, and March documents were signed and dated on 04/11/2023. Employee #1 also confirmed these were the only infection control documents available.

Based on Hospital Records and interviews, it was determined the hospital failed to ensure the Patient Discharge information was reviewed and signed by a medical provider. This deficient practice poses a risk to the health and safety of patients, that upon discharge they may not have appropriate services in place.

Findings include:

Hospital document titled, "Bylaws of the Medical Staff of Change Psychiatric Hospital" received on 04/10/2023, revealed" " ...14.1(c) General Rules and Regulations ...5. Time Frames for clinical documentation are: d. Discharge summary is completed prior to discharge and is signed by the Medical Doctor or Doctor of Osteopath within 72 hours of discharge;...."

Patient # 13's medical record dated 01/09/2023, titled Patient Discharge Information, revealed that the Patient Discharge Information was not signed by a medical provider.

Employee # 3, Director of Nursing confirmed in an interview dated 04/12/2023 that the Patient Discharge Information forms do not contain a signature line for the medical provider. Patient Discharge Information forms are not signed by the medical provider.

Citation Text for Tag 0752, Regulation 0121

Based on facility records and staff interview the facility failed to ensure that the continuity of patient care needs has been facilitated when transferring a patient to another facility by performing a transfer report of RN to an RN. This deficient practice poses a potential risk to the health and safety of patients if a transfer report is not completed to ensure continuity of patient care needs when transferring patients.

Findings include:

Hospital record titled "Patient Transfer/Transport Policy" revealed: " ...Procedure, A. transports 1. Transport from Changepoint Psychiatric Hospital to another Hospital ...b. The treating Physician must write an order indicating a transport is needed ...f. Documentation in the member's medical record includes i. consent for transport by the member or member representative or why the consent could not be obtained ii. The acceptance of the member by and communication with an individual at the receiving health care institution, iii. The date and time of the transport to the receiving health care institution, iv the mode of transportation, and ... B. Transfers ...1. Transport from Changepoint Psychiatric Hospital to another hospital ...b. The treating physician then must write an order indicating a transfer is indicated.

Patient # 13's medical record dated 01/09/2023 did not reveal documentation of a transfer order by the physician. No documentation of the acceptance of the patient by the receiving hospital. No documentation that a patient report was given to the receiving hospital. No documentation of transfer consent.

Patient # 12's medical record dated 02/03/2023 "received verbal orders to discharge the patient from the facility and discontinue precautions, which was not signed by the nurse or physician. The patient was discharged from the facility at 1230, patient was picked up by MTBA and transported to live well group home ..." No documentation of a report given to the group home, no documentation of transfer consent.

Employee # 3, Director of Nursing, stated in an interview conducted on 04/12/2023 that patient # 12 and Patient # 13's medical records do not contain documentation of a report given to the receiving facility.

Based on a review of hospital documents, it was determined the hospital failed to provide and document clinical oversight received by residential techs who were involved in patient care. This deficient practice poses the risk of residential techs not receiving the appropriate number of clinical oversight hours necessary to provide competent patient care.

Findings include:

Policy titled "Clinical Supervision, Clinical Oversight and Directional Supervision" requires: "...Clinical Supervision involves direct observation of skills and services proved to members and/or family of members...Clinical Oversight involves direct interaction (non-electronic) between the Behavioral Health Professional and the staff member receiving clinical oversight and may include direct observation, communication from the treatment team and record reviews in order to verify the needs of members are met...Clinical Supervision...Behavioral health paraprofessionals shall receive a minimum of one (1) hours of direct (face-face observation) clinical supervision every two weeks. Documentation of supervision will be recorded by a person who: Is one of the following: behavioral health professional ...or behavioral health technician with a combination of full-time behavioral health work experience and education in a field related to behavioral health totaling at least six years...."

Proof of clinical oversight for employees was requested multiple times on 04/11/2023, 04/12/2023, and 04/13/2023. A spreadsheet was provided titled "Copy of BHPP Training Observations-2023," on 04/18/2023. The documentation on the spreadsheet revealed Employees #17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, received training titled "Importance of Attendance and the impact on Safety," with a date of training on 02/25/2023 and a date completed documented for these employees as 02/15/2023. It was documented Employees # 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, and 30 received training titled "Q15 Training & Observation," with a date of training on 04/14/2023 and a date completed documented as 04/04/2023. It was documented Employees #18, 19, 20, and 29, received training titled "Infection Control: Beg Bugs {sic}," with a date of training on 04/14/2023, and the date completed documented as 04/04/2023.

A sign in sheet for these trainings to verify dates was requested on 04/18/2023, from Employee #2 and none was provided.