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Based on policy and procedure review, observation , and interview, the facility failed to provide an emergency suite, policy and procedures on governing medical care provided in the emergency suite, and continuing responsibility of the medical staff.

During a tour of the unit on 5/28/13 at 2:00 PM, revealed there was no designated treatment room for emergencies, policy and procedures on governing medical care provided in the emergency suite, and continuing responsibility of the medical staff.

An interview was conducted on 5/28/13 at 2:00 PM with staff #6. Staff #6 reported that if a patient or family member had a emergency or fall they would be assessed where ever they fell. If it was not possible for the visitor or patient to be assessed they would call 911. Staff #6 was unable to provide a policy and procedure for emergency services and confirmed there was no designated treatment room for emergencies.

Based upon record review and interview, the facility failed to ensure documentation of training of 12 of 14 (#2, #6, #8, #15, #24, #26, #29, #31, #38, #39, #40, #41) direct care staff for the use of restraints and seclusion.

Review of personnel records for direct care staff #2, #6, #8, #15, #24, #26, #29, #31, #38, #39, #40, #41 revealed no documentation that staff had been trained in the use of restraint or seclusion and no documentation of competencies.

Interview was conducted with staff #6 on 6/5/2013 at 2:30 pm in the classroom. Staff #6 reported that he was responsible for the training for restraint and seclusion. Staff #6 reported there was no formal training materials from which he taught restraint/seclusion and that he taught from his own personal experience with restraint/seclusion. Staff #6 further reported he provided the training for staff that was a behavior management program with curriculum, post tests, and competency checklist but it did not include restraint/seclusion.

Based on interviews and document review the Governing Body (GB) failed to ensure the Quality Assessment Performance Improvement (QAPI) program included all departments within the scope of services provided over a 12 month period.

refer to tags A 273, A 286, A 297, A 308, A 309, A 315.

Based on review of documentation and interviews the facility's Governing Board (GB) failed to monitor the effectiveness, safety of services, quality of care, and the implementation of measurable processes and goals in the Quality Assessment/ Performance Improvement Plan (QAPI).

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

On 5/30/13 a record review of the QAPI plan and QAPI meeting for 4/9/2013 was reviewed. The "2013 HQC" reporting schedule had the departments below marked to participate in the QAPI process.

1.) The hospital did not have an active Utilization Review program but was marked for reporting on 4/9/2013.
2.) Environment of Care reported number data only. No effectiveness of safety, processes of care, or outcomes documented. The facility has 9 patient falls.
3.) Seclusion and restraints had one chemical restraint reported with no further data.
4.) Respiratory Services and Laboratory Services are not represented in the facility's QAPI process.

An interview with staff #5 and #6 on 5/30/2013 at 3:00 PM, confirmed that the facility did not have a active Utilization Review Committee. Respiratory Services and Laboratory Services were not included in the QAPI process.

Based on review of Quality Assurance /Performance Improvement (QAPI) reports and interviews the Governing Board (GB) failed to oversee the clear expectations for safety processes and education through the QAPI process.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (b.) The board shall require and receive summary reports, at least quarterly, of the findings of quality assessment activities, including significant patient care problems, and of the implementation of appropriate actions to solve the problems and the results of the actions. (c.) The board shall undertake, and shall require its members to participate in, educational activities regarding the approach and methods of continuous quality improvement.

During a review of the QAPI reports on 5/30/13 the April 2013 meeting minutes, revealed number data was reported on 9 patient falls in the month of March 2013. The "Action/Status" review stated, " Patients on fall precautions will be given a bell, which we'll be using as an alert system. Will reinforce with Intake more aggressive screening on the front end for fall hazards and seizure risk, then actively indicate on form. Staff #12 will do an in-service on filling our incident reports correctly." No further staff, nursing involvement, or education documented on falls and prevention.

An Interview was conducted on 5/30/13 with staff # 6 regarding QAPI process regarding falls. Staff #6 reported that they are looking at falls and informing the staff on fall procedures. Staff #6 confirmed that there was no further implementation written in the
QAPI plan and no further processes implemented.

Based on interviews and document review the Governing Body (GB) failed to ensure the Quality Assessment Performance Improvement (QAPI) program documented quality improvement projects that demonstrated measurable improvements, conducted projects, reasons for conducted projects, and the measurable progress achieved on these projects.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

No data was found for Respiratory Services, Laboratory Services ,or Utilization Review.

On 5/30/13 a record review of the QAPI plan and QAPI meeting for 4/9/2013 was reviewed. The "2013 HQC" reporting schedule had the departments below marked to participate in the QAPI process.

1.) The hospital did not have an active Utilization Review program but was marked for reporting on 4/9/2013.
2.) Environment of Care reported number data only. No effectiveness of safety, processes of care, or outcomes documented. The facility has 9 patient falls in March 2013.
3.) Seclusion and restraints had one chemical restraint reported with no further data.
4.) Respiratory Services and Laboratory Services are not represented in the facility's QAPI process.

An interview with staff #5 and #6 on 5/30/2013 at 3:00 PM, confirmed that the facility did not have a active Utilization Review Committee. Respiratory Services and Laboratory Services were not included in the QAPI process. Staff #6 was unable to provide documentation of conducted projects with measurable outcomes.

Based on interviews and document review the Governing Body (GB) failed to ensure the Quality Assessment Performance Improvement (QAPI) program included all departments within the scope of services provided over a 12 month period.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

No data was found for Respiratory Services, Laboratory Services ,or Utilization Review.

An interview with staff #5 and #6 on 5/30/2013 at 3:00 PM, confirmed that the facility did not have a active Utilization Review Committee. Respiratory Services and Laboratory Services were not included in the QAPI process.

Based on review of Quality Assurance /Performance Improvement (QAPI) reports and interviews the Governing Board (GB) failed to oversee the clear expectations for safety, and that all improvement actions are evaluated.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (b.) The board shall require and receive summary reports, at least quarterly, of the findings of quality assessment activities, including significant patient care problems, and of the implementation of appropriate actions to solve the problems and the results of the actions. (c.) The board shall undertake, and shall require its members to participate in, educational activities regarding the approach and methods of continuous quality improvement.

During a review of the QAPI reports on 5/30/13 the April 2013 meeting minutes, revealed number data was reported on 9 patient falls in the month of March 2013. The "Action/Status" review stated, " Patients on fall precautions will be given a bell, which we'll be using as an alert system. Will reinforce with Intake more aggressive screening on the front end for fall hazards and seizure risk, then actively indicate on form. Staff #12 will do an in-service on filling our incident reports correctly." No further staff, nursing involvement, or education documented on falls and prevention.

An Interview was conducted on 5/30/13 with staff # 6 regarding QAPI process regarding falls. Staff #6 reported that they are looking at falls and informing the staff on fall procedures. Staff #6 confirmed that there was no further implementation written in the QAPI plan and no further processes implemented.

Based on review of Quality Assurance /Performance Improvement (QAPI) reports and interviews the Governing Board (GB) failed to oversee the clear expectations for safety processes and education through the QAPI process.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (b.) The board shall require and receive summary reports, at least quarterly, of the findings of quality assessment activities, including significant patient care problems, and of the implementation of appropriate actions to solve the problems and the results of the actions. (c.) The board shall undertake, and shall require its members to participate in, educational activities regarding the approach and methods of continuous quality improvement.

During a review of the QAPI reports on 5/30/13 the April 2013 meeting minutes, revealed number data was reported on 9 patient falls in the month of March 2013. The "Action/Status" review stated, "Patients on fall precautions will be given a bell, which we'll be using as an alert system. Will reinforce with Intake more aggressive screening on the front end for fall hazards and seizure risk, then actively indicate on form. Staff #12 will do an in-service on filling our incident reports correctly." No further staff, nursing involvement, or education documented on falls and prevention.

An Interview was conducted on 5/30/13 with staff # 6 regarding QAPI process regarding falls. Staff #6 reported that they are looking at falls and informing the staff on fall procedures. Staff #6 confirmed that there was no further implementation written in the QAPI plan and no further processes implemented.

Based upon record review and interview, the Director of Nursing Services failed to ensure there was a nurse staffing plan to determine adequate nurse staffing to meet the needs of the patients.

Review of nursing policies and procedures revealed there was no nurse staffing plan. There was one policy #NS 3.2 titled "Acuity System" that revealed a description of the chain of command for nursing staff members and that staffing is determined by the nursing unit census, unique patient care requirements, changes in the census and the geographic location of the adult units. The policy also indicated the Youth Care Services and the adult units would be staffed with a minimum of 2 staff members, at least one of these being an RN. Patients requiring One-to-One, seclusion or restraints would be provided a separate nursing staff member. Patients requiring constant observation level would be observed within the planned staffing level.

During an interview with the Director of Nursing Services on 5/29/13 at 2:30 pm in the classroom, a staff grid was presented that indicated how many nursing staff and mental health technicians were needed on each unit based upon numbers for numbers. The Director of Nursing Services reported that the staffing grid was all the staffing plan that was available. The Director of Nursing also reported there was nothing in writing that determined staffing based on the number of patients, characteristics of the patients emotional, mental, and medical needs, the expertise of the nursing staff, nursing staff continuity and cohesion, and the amount of time required by the nursing staff for administrative activities.

An attempt was made to review nurse staffing by comparing the number of patients to the number of staff that actually worked on a shift. The nurse staffing schedules did not account for acuity of the patients, the special precautions, the medical needs of patients. The staffing schedules reflected the basic minimal staffing for the number of patients on a unit so the schedules appeared to have adequate numbers. Due to no staffing plan, there was not a mechanism in place to determine when additional staff were needed to meet the needs of the patients and ensure patient safety.

Based on document review and interview the facility failed to provide policies and procedure to ensure the safety of the patients /staff and failed to integrate the contracted Radiology services into its Quality Assessment and Process Improvement (QAPI) program for 8 of 8 months reviewed.

On 5/30/2012 at 11:00 AM in the conference room the QAPI meeting minutes were reviewed from October, November, December of 2012 and January, February, March April and May of 2013. No data was found for the Radiology Department. No discussion was documented regarding the provision of this services.

On 5/30/2013 both staff #5 and #6 confirmed the Radiology Department had not participated in the QAPI program.


The facility failed to provide policies for the radiological services provided to ensure the safety of the patients and staff.

Refer to A0535

Based on observation and interview the facility failed to provide policies for the radiological services provided to ensure the safety of the patients and staff.

On 5/30/2013 at 11:00 AM in the conference room the contracted services for the facility were reviewed and revealed the Radiology services were contracted. No policies were identified for this contracted service.

On 5/30/2013 at 11:15 staff #6 was asked about policies for radiology services. Staff #6 indicated there were not any policies because the service was provided by contract. Radiology services were not provided from within the hospital.

Based on interview, observation, and document review the facility failed to meet this condition of participation. The facility failed to provide policies and procedure (P&P) to ensure the safety of the patients /staff and failed to integrate the contracted Laboratory services into its Quality Assessment and Process Improvement (QAPI) program for 8 of 8 months reviewed.

On 5/29/2012 at 10:00 AM on the adult treatment unit, staff #10 was interviewed regarding the laboratory (Lab) services. She explained the service was not provided by the nurses but was provided by an outside lab service. Staff #10 was asked if there were policies and procedures. She provided a notebook with information about the lab service and one (1) document, titled "Nursing Services Policy and Procedure; Critical Test Results Reporting", was located in the front of the notebook. There were no other P&P's identified. Staff #10 was asked if there were any lab policies for the lab services and she stated "no, not that I'm was aware of".

On 5/30/2012 at 11:00 AM in the conference room the QAPI meeting minutes were reviewed from October, November, December of 2012 and January, February, March April and May of 2013. No data was found for the Laboratory Department. No discussion or review was documented regarding the provision of this services.

On 5/30/2013 both staff #5 and #6 confirmed the following; no P&P's were established for the lab service and the Lab Department had not participated in the QAPI program.

Based on document review and interviews the facility failed to have a Utilization Review (UR) Plan or Committee for review of services furnished by the facility by members of the medical staff.


Refer to Federal Tags A-653, A-654, A-655, A-656, A-658.

Based on document review and interviews the facility failed to have a Utilization Review (UR) Committee.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

Review of the facility Medical Staff Bylaws on 5/30/13, revealed in "Article 2 Responsibilities 2.2.1 to account to the Board for the patient care processes and outcomes rendered by all Members, Residents,Interns, and Allied Health Professionals authorized to practice in the facility through the following means: (d) a utilization review/case management program to allocate medical and health services based upon clinical determinations of individual treatment needs."

During an interview on 5/30/13 at 9:05 AM, staff #3 confirmed that the facility did not have a designated utilization review committee. Staff #3 stated, "We only have accounts receivable meetings. I have not been involved in a UR committee." Staff #5 confirmed that UR issues were discussed in the morning flash meetings but there was not a organized UR committee, meetings, physician director, or minutes.

Based on document review and interview the facility failed to have a organized Utilization Review (UR) plan, committee, minutes that include dates, delineation of the responsibilities, members in attendance, extended stay reviews with approval or disapproval noted in a status report of any actions taken.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

Review of the facility Medical Staff Bylaws on 5/30/13, revealed in "Article 2 Responsibilities 2.2.1 to account to the Board for the patient care processes and outcomes rendered by all Members, Residents,Interns, and Allied Health Professionals authorized to practice in the facility through the following means: (d) a utilization review/case management program to allocate medical and health services based upon clinical determinations of individual treatment needs."

During an interview on 5/30/13 at 9:05 AM, staff #3 confirmed that the facility did not have a designated utilization review committee. Staff #3 stated, "We only have accounts receivable meetings. I have not been involved in a UR committee." Staff #5 confirmed that UR issues were discussed in the morning flash meetings but there was not a organized UR committee, meetings, physician director, or minutes.

The facility failed to have a organized Utilization Review (UR) plan, committee, minutes that include dates, delineation of the responsibilities, members in attendance, extended stay reviews with approval or disapproval noted in a status report of any actions taken.

Review of the facility Medical Staff Bylaws on 5/30/13, revealed in "Article 2 Responsibilities 2.2.1 to account to the Board for the patient care processes and outcomes rendered by all Members, Residents,Interns, and Allied Health Professionals authorized to practice in the facility through the following means: (d) a utilization review/case management program to allocate medical and health services based upon clinical determinations of individual treatment needs."

During an interview on 5/30/13 at 9:05 AM, staff #3 confirmed that the facility did not have a designated utilization review committee. Staff #3 stated, "We only have accounts receivable meetings. I have not been involved in a UR committee." Staff #5 confirmed that UR issues were discussed in the morning flash meetings but there was not a organized UR committee, meetings, physician director, or minutes.

Based on document review and interviews the facility failed to have a organized Utilization Review (UR) plan, committee, minutes that include dates, delineation of the responsibilities, members in attendance, extended stay reviews with approval or disapproval noted in a status report of any actions taken.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

Review of the facility Medical Staff Bylaws on 5/30/13, revealed in "Article 2 Responsibilities 2.2.1 to account to the Board for the patient care processes and outcomes rendered by all Members, Residents,Interns, and Allied Health Professionals authorized to practice in the facility through the following means: (d) a utilization review/case management program to allocate medical and health services based upon clinical determinations of individual treatment needs."

During an interview on 5/30/13 at 9:05 AM, staff #3 confirmed that the facility did not have a designated utilization review committee. Staff #3 stated, "We only have accounts receivable meetings. I have not been involved in a UR committee." Staff #5 confirmed that UR issues were discussed in the morning flash meetings but there was not a organized UR committee, meetings, or minutes.Staff #5 reported that there is no documentation of outlier reviews.

Based on document review and intervirews the facility failed to have a organized Utilization Review (UR) plan, committee, minutes that include dates, delineation of the responsibilities, members in attendance, extended stay reviews with approval or disapproval noted in a status report of any actions taken.

Review of the facilities Board of Governing Bylaws on 5/30/13, revealed in article XIII, "1. Board Responsibilities: (a.) The Board shall review and evaluate activities of the Medical Staff and other professional staffs in the Facility on a continuing basis to assess, preserve and continuously improve the quality and efficiency of patient care in the Facility. The Board shall further, within the reasonable capabilities of the Facility, make effort to provide the administrative assistance necessary to support the implementation and evaluation of Quality Assessment/Improvement activities, including use of medications, medical record review, pharmacy and therapeutics functions, infection control, utilization review, risk management, safety management, and all other departmental and facility-wide monitoring and evaluation activities."

Review of the facility Medical Staff Bylaws on 5/30/13, revealed in "Article 2 Responsibilities 2.2.1 to account to the Board for the patient care processes and outcomes rendered by all Members, Residents,Interns, and Allied Health Professionals authorized to practice in the facility through the following means: (d) a utilization review/case management program to allocate medical and health services based upon clinical determinations of individual treatment needs."

During an interview on 5/30/13 at 9:05 AM, staff #3 confirmed that the facility did not have a designated utilization review committee. Staff #3 stated, " We only have accounts receivable meetings. I have not been involved in a UR committee." Staff #5 confirmed that UR issues were discussed in the morning flash meetings but there was not a organized UR committee, meetings, physician director, or minutes.

Based on observation and interview the facility failed to meet this condition of participation. The facility failed to provide and ensure a sanitary environment based on 3 of 3 areas, the kitchen, patient seclusion room and gymnasium (gym) and failed to provide an active program for the prevention of communicable diseases.

On 5/29/2013 at 8:30 AM while touring the dietary department the following observations were made.
a. A stand up mixer in the kitchen was observed with brokenandmissing paint, exposing the bare metal, on both arms and at the base of the stand. The broken paint surface did not protect from bacteria and sanitation after cleaning could not be insured.
b.. The walk in vegetable cooler, located in the kitchen, was observed with standing water on the floor from condensation. Rubber mats were placed in the walk way to keep staff out of the water and avoid slipping. Vegetables were stored on metal shelving above the wet floor.

On 5/29/2013 at 8:30 the Dietary Services Director DSD) confirmed the floor standing mixer was missing paint and sanitation could not be insured. During the same tour the DSD confirmed the walk-in vegetable cooler had been collecting condensation and at one time the electrical outlets had been at risk

On 5/28/2013 at 9:00 AM, during a tour of the adult units, the following observation was made.
a. The seclusion room was observed with a substance dried in the window screen. The metal window sill was visibly rusted.
On 5/28/2013 at 9:00 Am staff #11 confirmed the dried substance in the window screen and also confirmed the metal window frame was rusty.

On 5/28/2013 10:30 AMA during a tour of the adolescent unit the seclusion room the following observations were made.
a. What appeared to be spaghetti and a red substance was dried on the seclusion room bed. The Director of Nurses (DON) confirmed the seclusion room had been used over the previous weekend.
b.. The room identified as the " Quiet room " was observed with lint balls on the floor.

On 5/30/2013 at 1:30 PM, during a tour of the gym the following observations were made.
a. A working water fountain, built into the wall, was observed with visible stains and residue on the metal surface and debris in the drain.
b. A pad lock on a door was observed broken. The door connected a small room directly to the gym. This small room had heavy cob webs, a heavy layer of dark gray dust and lint, there was a blue mat on the floor and an orange cone on the floor. The sink and toilet had been removed and the piping for both was protruding from the wall. The floor had a partially covered open drain area.
c. The gym floor was observed to be carpeted in its entirety. There was visible debris (small pieces of paper, crumpled wrappers) observed around the floor and five (5) areas of the base board was missing cove base.
d. The gym contained, an interior low roof over the storage area. This area was observed with heavy dust and debris (dirt, Frisbee, gym ball, cob webs) easily visible from the floor.
h. The air conditioner vents in the gym ceiling were missing two of the three vent port covers and visible dirt was observed on the ceiling.

On 5/30/2013 at 1:00 PM during the tour of the gym, staff #11 was asked how frequently the carpet in the gym was vacuumed. His reply was "twice a week". When staff #11 was asked how often were patients in the gym. He replied every day.

On 5/30/2013 at 1:00 PM during a tour of the building staff member #15 was questioned about the number of housekeepers, staffed to meet the needs of the building, staff and patients. He replied 2 (two) were staffed. He continued to explain one staff member worked Sunday through Thursday and another staff member worked Monday through Friday and they both worked 4 hours Saturday. Staff #15 confirmed 2 housekeepers cared for all the housekeeping needs of the 50 bed psychiatric facility. Two staff were responsible for sanitation of patients, staff and general housekeeping of the building to include vacuuming the carpet in the gym as well as wiping down walls, water fountains, window sills and collecting all the soiled linen on a daily basis.

On 5/30/2013 at 3:00 PM in the conference room the medical records (MR) for the following patients (Pt) (Pt # 1, 3, 4, 5, 6, 7, 9, 10) were reviewed for influenza vaccination administration or influenza declination forms. Pt #6 was admitted 12/03/12. No evidence of influenza administration or a declination form was found in Pt #6 MR.

On 5/30/2013 staff #6 and #10 was interviewed regarding whether the nursing staff offered flue vaccinations. Staff #6 indicated the influenza vaccine was offered only to those persons over 65 years of age or to children under 6 years of age. When staff #6 was asked if he was aware of the requirement that all patients must be given the opportunity for influenza vaccine during the influenza season, he stated "I didn't know that". Staff #10, the infection control nurse confirmed influenza vaccines were not offered to all patient during the influenza season but only to those over 65. Patients under 6 year of age were not admitted to the facility.

The facility had no policy or procedure to screen, or offer the influenza vaccine to either patients or staff during the influenza season.

Based upon record review and interview, the facility failed to ensure policies and procedures were developed for the provision of outpatient services. The facility also failed to ensure outpatient services were integrated into its QAPI (Quality Assurance Performance Improvement) program.

Review of policy and procedure manuals revealed no policies for the provision of outpatient services and how they are integrated into inpatient services. Review of a document provided by administration titled "Glen Oaks Hospital - Plan of Services" revealed a Partial Hospitalization Program was provided as a "continuum of care when a patient no longer needs inpatient treatment, but continues to need intensive treatment on a daily basis." No policies were provided for the Partial Hospitalization Program. The "Plan of Services" document made no mention of other outpatient services.

An interview with the Administrator on May 29, 2013 at 11:00 am in the classroom. The Administrator reported the facility had an Chemical Dependency Outpatient Program, an Intensive Outpatient Program for Chemical Dependency, and the Partial Hospitalization Program. The Administrator confirmed the services were not organized as an Outpatient Service.

Review of QAPI meeting minutes since January, 2013 to present revealed outpatient services had not reported to the quality commitee during this time frame.

An interview was conducted with Staff #43 on 5/30/13 at 3:30 pm in the classroom. Staff #43 reported that he turns in data to his supervisor for quality reporting but he was unaware of what happens to the data then. Staff #43 reported the data he turns in is primarily related to patient surveys of the services received.

Based on interview and document review the facility failed to

A. provide an organized Respiratory Services department, failed to provide a director for the Respiratory Services department, failed to provide Policies and Procedure for the Respiratory Services department, failed to provide trained staff to deliver the Respiratory Services and failed to demonstrate the integration of the Respiratory Service into the Quality Assessment Process Improvement for the facility.
Refer to A1152

B. demonstrate an organized respiratory services department for 8 of 8 months identified. (October, November and December of 2012 and January, February, March April and May of 2013.
Refer to A1153

C. ensure a designated Director of the Respiratory services department of 8 of 8 months.
Refer to A1160

Based on document review and interview the facility failed to demonstrate an organized respiratory services department for 8 of 8 months identified. (October, November and December of 2012 and January, February, March April and May of 2013.

On 5/28/2013 at 10:00 AM in the conference room the Medical Staff meeting minutes were reviewed and revealed no mention of Respiratory services to be provided with in the facility. There was no scope of services outlined, no designation of training or staff to provide Respiratory services and no Respiratory Service Director appointment.

On 5/29/2012 at 10:00 AM staff #10 was interviewed, in the adult treatment unit, nurses station, regarding respiratory services. Staff #10 was asked who provided respiratory services when they were needed. She replied "the nurses" Staff #10 was asked to explain the scope of service she replied, "The nurses do nebulizers, apply oxygen and do EKG's (electrocardiograms). Staff #10 was asked if the nurses received training prior to performing an EKG. She replied "I think it's on the annual competency, but it's really simple. There is a diagram that shows you where to put the leads and then you just turn on the switch. The Doctor looks at it when he makes his rounds".

On 5/29/2013 at 10:20 AM staff #36 was stopped in the adult treatment unit hallway and asked if she ever provided Respiratory care. Staff #36 stated "Yes". When asked what respiratory services she provided, she replied "Oxygen when needed, occasionally a nebulizer". When asked if she ever received a physician's order for EKG she replied "yes". Staff #36 was asked if she received formal training on conducting an EKG or if it was simply on the job training from another nurse. She replied "I don't recalled any annual training for EKG's, I learned by watching another nurse". She indicated she had worked at the hospital "more than 10 years".

On 5/30/2013 at 10:00 AM in the conference room an attempt was made to review the Policies and Procedures (P&P) for the provision of Respiratory services. None were found.

On 5/30/2013 at 3:00 PM in the conference room staff #6 confirmed there were no P&P for Respiratory services.

On 5/30/2013 at 3:30 PM in the conference room the education record for staff #4, #27, and #36 were reviewed. No documentation of education for the provision of EKG or other Respiratory services was identified. There were no annual competencies that included respiratory care and the operation of an EKG machine.

Based on record review and interview the facility failed to ensure a designated Director of the Respiratory services department of 8/8 months.

On 5/28/2013 at 10:00 AM in the conference room the Medical Staff meeting minutes were reviewed and revealed no mention of Respiratory services to be provided within the facility. There was no scope of services outlined, no designation of training or staff to provide Respiratory services and no Respiratory Service Director appointment.

On 5/30/2013 at 3:00 PM in the conference room staff #6 confirmed there were no Director for Respiratory services.

Based on interview and document review the facility failed to provide policies and procedure to ensure the safety of the patients and failed to document education and training of staff who provided Respiratory services.

On 5/29/2012 at 10:00 AM staff #10 was interviewed, at the adult treatment unit nurses station, regarding respiratory services. Staff #10 was asked who provided respiratory services when they were needed. She replied "the nurses" Staff #10 was asked to explain the scope of service she replied, "The nurses do nebulizers, apply oxygen and do EKG's (electrocardiograms). Staff #10 was asked if the nurses received training prior to performing an EKG. She replied "I think it's on the annual competency, but tit's really simple. There is a diagram that shows you where to put the leads and then you just turn on the switch. The Doctor looks at it when he makes his rounds". Staff #10 was asked if there were Policies and Procedures for Respiratory services, She replied "Not that I know of".


On 5/30/2013 at 10:00 AM in the conference room an attempt was made to review the Policies and Procedures (P&P) for the provision of Respiratory services. None were found.

On 5/30/2013 at 3:00 PM in the conference room staff #6 confirmed there were no P&P for Respiratory services.

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