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Based on review of facility documents, medical records (MR) and interview with staff (EMP), it was determined the governing body failed to assume responsibility to provide oversight and accountability by failing to ensure delineation of clinical privileges were signed off by the Department Chief/Chair as granted and failed to ensure the delineation of clinical privileges requested were indicated (A0046), failed to ensure medical care provided at the facility was evaluated(A049), failed to ensure specific quality assurance performance improvement projects for the facility (QAPI) were documented, failed to ensure the reasons for conducting the projects, failed to ensure measurable progress was achieved (A0297), failed to maintain and demonstrate evidence of its QAPI program (A0308), failed to determine the number of distinct QAPI projects were conducted annually (A0309), failed to ensure a budget was established for quality assessment performance improvement activities (A0315), failed to ensure a safe care environment was provided on the behavioral health unit, resulting in an Immediate Jeopardy (A0700), failed to ensure the facility disaster plan was updated annually (A0701), failed to ensure long term provisions were provided in the event of a water failure (A0703), failed to ensure fire drills where conducted (A0715), failed to ensure the proper discharge/transfer of care (A0837), failed to ensure properly trained staff worked in the emergency department (A1112).


cross reference with:
482.12(a)(2) Medical Staff - Appointments
482.12(a)(5) Medical Staff - Accountibility
482.21(d) QAPI Performance Improvement Projects
482.21 QAPI Governing Body, Standard Tag
482.21(e)(1), (e)(2), (e)(5), QAPI Executive Responsibilities
482.21(e)(4) Providing Adequate Resources
482.41 Physicial Enviroment - Condition Level
482.41(a) Maintenance of Physical Plant
482.41(a)(2) Emergency Gas and Water
482.41(b)(8) Regular Fire and Safety Inspections
482.43(d) Transfer or Referral
482.55(b)(2) Qualified Emergency Services Personnel
482.12(a)(2) Medical Staff

Based on review of facility document, credential files (CF), and interview with staff (EMP), it was determined the facility failed to ensure the delineation of clinical privileges were signed off by the Department Chief/Chair as granted for two (2) of four (4) credential files (CF16 and CF17).

Findings include:

Review on October 19, 2017, of facility document, "Medical Staff Bylaws" dated August 18, 2017, revealed "... Article V Procedure For Appointment and Reappointment To The Professional Staff ... Section 13. Notice of Final Decision ... 1. Notice of the Governing Board's final decision shall be given through the Chief Executive Officer to the President of the Professional Staff, the chair of each division and department concerned and by Special notice to the applicant. 2. Decision and notice shall include: a. The staff category to which the applicant is appointed; b. The division and department to which he/she is appointed; c. The clinical privileges granted; ... Part 11. Reappointment Procedure ... 1. Each staff who desires reappointment shall ... send completed application to the Chief Executive Officer or Designee ... Section 1. Clinical Privileges 1. Members of the Professional Staff shall be entitled to exercise only those clinical privileges specifically granted by the Governing Board ..."


Review on October 19, 2017, of CF16 revealed a clinical appointment in the category of "Department of Medicine Division of Internal Medicine ... Delineation of Privileges ... Privileges Requested ... Granted ..." Further review revealed privileges requested were not signed off by the Department Chief/Chair as granted.

Review on October 19, 2017, of CF17 revealed a clinical appointment in the category of "Family Medicine Clinical Privileges ... Requested ... Granted ..." Further review revealed privileges requested were not signed off by the Department Chief/Chair as granted.

Interview on October 19, 2017, with EMP2 between 1:40PM and 2:30PM, confirmed the requested clinical privileges were not signed off as granted by the Department Chief/Chair for C16 and CF17.
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Based on review of facility policies and procedures, credential files (CF), and interview with staff (EMP), it was determined the facility failed to ensure the delineation of clinical privileges requested were indicated for one (1) of four (4) credential files (CF14).

Review on October 19, 2017, of CF14 revealed a clinical appointment in the category of "Department of Medicine ... Requested ... Granted ..." and revealed a list of privileges signed off as granted by the Division Chair. Further review revealed no documented evidence of the clinical privileges being requested in CF14.

Interview on October 19, 2017, with EMP2 at 1:40PM, confirmed no documented evidence of the clinical privileges being requested in CF14.

cross reference with:
482.12 Governing Body

Based on a review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure a medical care evaluation committee was provided to review and evaluate care provided by the facility.

Findings include:

Review on October 23, 2017, of facility documents "Suburban Community Hospital Medical Staff Bylaws, revised August 18, 2017," revealed "Article VIII Organization of the Professional Staff - The Professional Staff shall be organized into those departments and divisions as are necessary to carry out the purposes and duties of the Professional Staff ... In order to remain organized, all Divisions must continuously meet the requirements as stated in these Bylaws ... Section 2. Departments ... 2. Surgical and Other Invasive Procedures Review, a. Each relevant department shall conduct, on an ongoing basis, a review of surgical and other invasive procedures. The review shall be directed at evaluating surgeries/procedures performed when there is a disagreement among the perioperative, post-operative and pathological diagnosis, or where a question of the appropriateness of the procedure undertaken has been raised ...".

A request was made to EMP1 on October 23, 2017, at 1:30 PM for the Medical Care Evaluation Committee Meeting Minutes. None provided.

Interview with EMP1 on October 23, 2017, at 1:30 PM confirmed medical care is discussed at the "corporate level" and the results are communicated to the facility. Further interview confirmed meetings are not conducted at the facility to review and discuss medical care.

cross reference with:
482.12 Governing Body

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to document its specific quality improvement projects that are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Findings include:

Review on October 23, 2017, of the facility's "Performance Improvement Plan", dated February 2017, revealed "C. Performance Improvement/Risk Management Committee ... 3. The Performance Improvement/Risk Management Committee of SCH [Suburban Community Hospital] is responsible for ... b. Document what quality projects are being conducted, the reasons for conducting these projects, and measurable progress achieved on these projects."

Review on October 23, 2017, of the facility's Quality Committee meeting minutes for January 2017 through September 2017, revealed no documented evidence of the quality projects that are being conducted, the reasons for conducting the projects, and the measurable progress achieved on these projects.

A request was made on October 23, 2017, of EMP1 to provide the quality projects that are being conducted by the hospital, the reasons for conducting the projects, and the measurable progress achieved on these projects. None was provided.

Interview with EMP1, on October 23, 2017, at 3:45 PM, confirmed there was no documented evidence of the quality projects that are being conducted by the hospital, the reasons for conducting the projects, and the measurable progress achieved on these projects.

cross reference with:
482.12 Governing Body
482.21 Governing Body, Standard Tag
482.21(e)(1), (e)(2), (e)(5) QAPI Executive Respnsibilites
48221(e)(4) Providing Adequate Resources

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to maintain and demonstrate evidence of its QAPI program, specifically its performance improvement projects, for review by CMS.

Findings include:

Review on October 23, 2017, of the facility's "Performance Improvement Plan", dated February 2017, revealed "C. Performance Improvement/Risk Management Committee ... 3. The Performance Improvement/Risk Management Committee of SCH [Suburban Community Hospital] is responsible for ... b. Document what quality projects are being conducted, the reasons for conducting these projects, and measurable progress achieved on these projects."

Review on October 23, 2017, of the facility's Quality Committee meeting minutes for January 2017 through September 2017, revealed no documented evidence of the quality projects that are being conducted, the reasons for conducting the projects, and the measurable progress achieved on these projects.

A request was made on October 23, 2017, of EMP1 to provide the quality projects that are being conducted by the hospital, the reasons for conducting the projects, and the measurable progress achieved on these projects. None was provided.

Interview with EMP1, on October 23, 2017, at 3:45 PM, confirmed there was no documented evidence of the quality projects that are being conducted by the hospital, the reasons for conducting the projects, and the measurable progress achieved on these projects.

cross reference with:
482.12 Governing Body
482.21482.21(d) QAPI Performance Improvement Projects
482.21(e)(1), (e)(2), (e)(5) QAPI Executive Respnsibilites
48221(e)(4) Providing Adequate Resources

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure the determination of the number of distinct improvement projects was conducted annually.

Findings include:

Review on October 23, 2017, of the facility's "Performance Improvement Plan", dated February 2017, revealed "C. Performance Improvement/Risk Management Committee ... 3. The Performance Improvement/Risk Management Committee of SCH [Suburban Community Hospital] is responsible for ... b. Document what quality projects are being conducted, the reasons for conducting these projects, and measurable progress achieved on these projects."

Review on October 23, 2017, of the facility's Quality Committee meeting minutes for January 2017 through September 2017, revealed no documented evidence of the quality projects that are being conducted, the reasons for conducting the projects, and the measurable progress achieved on these projects.

A request was made on October 23, 2017, of EMP1 to provide the quality projects that are being conducted by the hospital, the reasons for conducting the projects, and the measurable progress achieved on these projects. None was provided.

Interview with EMP1, on October 23, 2017, at 3:45 PM, confirmed there was no documented evidence of the determination of the number of distinct improvement projects that were conducted annually.

cross refernce with:

482.12 Governing Body
482.21(d) QAPI Performance Improvement Projects
482.21 QAPI Governing Body, Standard Tag
48221(e)(4) Providing Adequate Resources

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to establish a budget for quality assessment and performance improvement activities.

Findings include:

A request was made on October 23, 2017, to EMP1 for the facility's QAPI budget. None was provided.

Interview on October 23, 2017, with EMP1, at 3:55 PM, confirmed the facility did not establish a budget for quality assessment and performance improvement activities.

cross reference with:
482.12 Governing Body
482.21(d) QAPI Performance Improvement Projects
482.21 QAPI Governing Body, Standard Tag
482.21(e)(1), (e)(2), (e)(5) QAPI Executive Responsibilities

Based on observation, policy and procedure review and interview with staff (EMP) it was determined the facility failed to ensure a safe environment was provided for patients admitted to the Senior Behavioral Health Unit (SBHU).

Findings includes:

Review on September 28, 2017, of facility documents "Suburban Community Hospital Medical Staff Bylaws, revised August 18, 2017," revealed " ... Article IX Committees ... Section 1 Standing Committees ...11. Environment of Care (EOC), a. Purpose: 1) Primary oversight of the safe operation of the hospital for patients, visitors, physicians and staff. 2) ... "
Review on October 23, 2017, of facility policy "Safety management Plan," revised October 15, 2016, revealed "Purpose: This policy establishes a management process to provide a physical environment free of hazards and for managing staff activates to reduce the risk of human injuries ... Policy: 1. Monitoring and Evaluation, A. Regular hazard surveillance surveys ad departmental safety audits will be conducted to monitor all aspects of the safety management plan as prescribed by the Safety manual ..."
Review on October 19, 2017, of facility policy "Senior Behavioral Health Unit Safety Policy" reviewed 6/4/17, revealed "Purpose: The Behavioral Health Unit will adopt process to maintain a safe environment for patients and staff members ... Life Safety: 3. Patient beds on the unit will be compliant with current standards for psychiatric use. 4. All doors, windows, fixtures and furniture will be compliant with current safety and anti-ligature requirements ..."
Review on October 19, 2017, of facility document "Enviroment of Care Rounds, dated September 13, 2016, and October 12, 2016," revealed no documetnation the Commitee received or reviewed reports for enviromental safety issues on the SBHU. No further meeting minutes were available from 2016.

Review on October 19, 2017, of facility document Enviromental Care Committee Meeting Minutes, dated January 31, 2017, April 5, 2017 and July 26 2017, revealed no documentation the Committee received or reviewed reports for enviromental safety issues on the SBHU.

Observation of the Senior Behavioral Health Unit on October 19, 2017, between 10:00 AM and 11:20 AM revealed a 15 bed senior adult behavioral health patient care unit. Further observation of the SBHU revealed the following environmental safety concerns:

1. Day Room- contained the following: patient chairs with loopable arms, loopable door handles on all doors, accessible television wires, dry erase board not attached to wall to prevent removal, dry erase board had sharp edges.

2. Patio - surrounding concrete wall approximately 5 feet tall. Unsecured, light-weight moveable chairs (could be easily thrown, used as a weapon or placed in front of the concrete wall for possible elopement), loopable metal gate, two insect nests.

3. Patient Rooms 148, 150, 152, 154, 158, 160, 162 and the seclusion room all had door hinges and door handles that were loopable. Loopable heating/air-conditioning (HVAC)units were located in all patient rooms and public areas accessible to all patients. HVAC units located in all patient rooms and public areas accessible to all patients had 2 access panels on the top of each unit that were not attached to prevent patient access. Unsecured light-weight chairs that could be used as a barricade, weapon or attachment point, were located in each patient room. Wall clocks, located in each patient room were not properly attached to the wall. Moveable high-low electric beds that can be activated by patients and bed frames had 4 loopable restraint tie-downs on each side of the bed. Towel dispensers and soap dispensers were light-weight plastic easily broken and used for self injury. Towel dispensers were loopable and located in patient bathrooms and public areas accesible to patients. Patient bathroom heating vents were loopable.

4. Bath tub room located between rooms 150 and 152 had exposed loopable plumbing, light weight and loopable soap and paper towel dispenser that were made from lightweight plastic easily broken and used for self injury. Ceiling speaker in hallway was loopable

5. Nurse Manager office, located in a secluded alcove and not immediately visible to staff had a loopable door handle.

6. Exit door from the unit had a latch release that was loopable.

7. Staff lounge door exposed to the patient hallway had a loopable door hinge and loopable door handle.

8. Patient toilet Room had a 3 hinge loopable door and loopable handle, ceiling vents were loopable, ceiling light was loopable.

9. Secluded alcove contained a supply closet and patient exam room with loopable hinges, loopable handles and a loopable ceiling fixture.

10. Exam room sink had loopable plumbing and fixtures, loopable HVAC unit vents had 2 unattached access panel doors, loopable cabinet handles.

11. Ceiling exit sign was loopable.

12 Medical Director office door had loopable door hinges and door handle.

13. Seclusion room-loopable door handles, loopable ceiling vent.

14. Thermostat cover was loopable.

15. Social Service office had loopable a door hinges and a loopable door handle

16. Housekeeping closet had loopable a door hinge and a loopable door handle.

17. Shower room- shower plumbing handles and 2 shower heads were loopable. Doors and door handles were loopable.

18. Fire extinguisher door cover had loopable handles.

19. Kitchen/dining room- loopable HVAC unit with detached access door panels, wall clock easily removed from wall for self injury, door handle and door hinges were loopable.

20. Kitchen utility room accessible to patients had loopable door hinges and door handle.

21. Soiled utility room door, accessible to patients, had loopable door hinges and loopable handle.

22. Laundry room door, accessible to patients, has loopable hinges and door handle.

23. Ceiling safety mirrors were not placed to visualize secluded hallways or alcoves.


Interview on October 19, 2017, at 12:00 PM with EMP1 confirmed the above findings.

cross reference with:
482.12 Governing Body
482.41(a) Maintenance of Physical Plant
482.41(a)(2) Emergency Gas and Water
482.41(b)(8) Regular Fire and Safety Inspections

Based on review of facility docuemnts and interview with staff (EMP) it was determined the facility failed to ensure the disaster plan was updated annually.

Findings include:

Review on October 24, 2017, of facility document "Suburban Community Hospital Emergency Operation Plan," no date given, revealed "Emergency Operation Plan ... 2009 Emergency Management and Operation ... Section 4. Program Implementation and Processes ... Annual Evaluation of the Emergency Management Plan-The Safety Officer is responsible for the coordinating the annual evaluation of the seven functions assocoated with Management of the Enviroment of Care. The Safety Officer is responsible for performing the annual evaluation of the Emergency Management Program ..."

Interview on October 23, 2017, at 4:55 PM with EMP5 confirmed the Emergency Operation Plan has not been reviewed annually.

cross reference with:
482.12 Governing Body
482.41 Physical Environment - Condition Level

Based on review of facility documents and interview with staff it was determined the facility failed to ensure provisions were made to provide patient care and maintain necessary systems in the event of a water system failure.

Findings include:

Review on October 24, 2017, of facility policy "Non-Potable Water System Failure" last revised March 2017, revealed "Plan: In the event of a failure of the non-potable [non-drinking] water system [boiler, cooling tpwer, chilled water system], and it is determined that the problem cannot be rectified in-house, the on-duty engineer shall proceed with the procedure listed below ... If the problem cannot be corrected in a timely manner, all departments affected by the failure shall be informed of the problem and the apporoximante time when the system or equipment shall be operational again ... "

Interview on October 24, 2017, at 2:15 PM with EMP4 confirmed if needed emergency non-potable water is not available in the event of systems failure, and confirmed plans to provide system sustaining services and patient services in the event of a prolonged outage were not provided in the policy.

cross reference with:
482.12 Governing Body
482.41 Physical Environment - Condition Level

Review of facility documents and interview with staff (EMP), it was determined that the facility failed to conduct quarterly fire drills for each shift.

Findings include:

Review on October 19, 2017, of facility policy "Senior Behavioral Health Unit Safety Policy" reviewed 6/4/2017, revealed "The Behavioral Health Unit will adopt processes to maintain a safe environment for patient sand staff members ... Fire Safety ... 5. Fire Drills are conducted at lest once per quarter on each shift ..."

Review on October 24, 2017, of facility document "Completed 2017 Fire Drill Matrix" revealed a fire drill for the Senior Behavioral Health Unit was scheduled and documented April 2, 2017 at 11:32 AM. further review revealed no other dates or times were scheduled to conduct quarter fire drills each shift.

Interview on October 24, 2017, at 1:45 PM with EMP2 confirmed fire drills were not conducted each shift for each quarter.

cross reference with:
482.12 Governing Body
482.41 Physical Environment - Condition Level

Based on review of facility documents, medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure
Findings include:
Request was made on October 19, 2017, to EMP1 for a policy regarding the use and completion of facility document " Behavioral Health Unit Interdisciplinary Discharge Progress Notes. " None provided.
Review on October 19, 2017, of facility document "Behavioral Health Unit Interdisciplinary Discharge Progress Notes" revealed a two-part document to be completed by the physician and a member of the interdisciplinary treatment team. At the time of the patient ' s discharge the document is required to be transmitted to the next level of care for the continuity of the patient ' s treatment. Further review revealed the physician information to be transmitted included the following: the use of 2 or more antipsychotic medications with a justification of use, reason for hospitalization on the behavioral health unit, principle discharge diagnosis and recommendations for (treatment) at next level of care. The interdisciplinary treatment team information was to provide: list of medications to include dose and rational for each medication that was provided to the patient, discharge progress notes, discharge instructions, medication list, name of the provider the information was transmitted to and the signature and date Continued review of the discharge progress note revealed the completed document was to include the name of the care provider the patient information was transmitted to and the date with the signature of the team member transmitting the information and the date of the transmission.
Review on October 19, 2017, of MR3 progress note documentation "Behavioral Health Unit Interdisciplinary Discharge Progress Notes " revealed the sections of the document that were not completed were the physician ' s section, the multidisciplinary treatment team section, the receiving provider and the date of transmission and signature of the team member transmitting the information.
Review on October 19, 2017, of MR4 progress note documentation "Behavioral Health Unit Interdisciplinary Discharge Progress Notes" revealed the sections of the document that were not completed were the physician ' s section, the multidisciplinary treatment team section, the receiving provider and the date of transmission. Further review revealed the document was signed and dated by the social worker.
Review on October 19, 2017, of MR11 progress note documentation "Behavioral Health Unit Interdisciplinary Discharge Progress Notes" revealed the required physician information and the interdisciplinary treatment team section of the document were completed. Further review revealed the section with the receiving provider information and the date and signature of the person transmitting with discharge documents was not completed.
Interview on October 19, 2017, at 4:30 PM with EMP1 confirmed the discharge progress note document were not completed in their entirety for MR3, MR4, MR11.

cross reference with:
482.12 Governing Body

Based on review of facility documents, review of personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure that nursing staff met education, experience and training requirements for two of five Emergency Department (ED) personnel files reviewed (PF3, PF5).


Findings include:

Review on October 23 2017, of facility document "Job Description/Evaluation Form ... Registered Nurse ... Emergency Department ... Education, Experience, Training .... 4. Current PALS (AHA) certificate ... 30 days upon hire and maintain current ... ".

Review on October 23, 2017, of PF3, date of hire January 23, 2017, revealed it contained a signed six month Job Description/Evaluation form dated August 21, 2017. Further review of PF3 revealed no documented evidence of a current PALS certificate.

Review on October 23, 2017, of PF5, date of hire February 13, 2017, revealed it contained a signed six month Job Description/Evaluation form dated August 23, 2017. Further review of PF5 revealed no documented evidence of a current PALS certificate.

Interview with EMP3 on October 24, 2017, confirmed there was no documented evidence in PF3 and PF5 of a current PALS certificate required for these nursing staff in the facility's ED.

cross reference with:
482.12 Governing Body