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Based on staff interview, the facility continued to fail to indicate that an annual review of patient care policies had occurred since the original validation survey of 6/6/11 to 6/8/11.

Findings:
1. at 10:00 AM on 11/7/11, interview with staff member NA indicated:
a. all patient care policies are being entered into the computer system "Image Now--Policy Manager"
b. the process of transferring all policies from the previous format to the new format/system is taking longer than anticipated
c. the medical directors of each area, such as: Radiology, Med/Surg, Critical Care, etc. are to review and sign off (electronically) on each policy for their specific area once the policies are entered in the system
d. the patient care committee meets monthly and includes the physician who is the Chief of Staff and the physician who is the Performance Improvement practitioner
e. since the validation survey process of June 2011, the patient care committee still has not approved the patient care policies and procedures
f. the patient care committee has not developed a policy related to how the annual review/approval of patient care policies will be addressed in the future



29550

Based on document review and interview, the facility failed to review its policies/procedures at least annually by a group of professional personnel that included at least one doctor of medicine (MD) or osteopathy (DO).

Findings:

1. Review of the committee minutes considered by the facility to be the professional group for 2010 and 2011 failed to indicate a review of all facility policies/procedures was performed on an annual basis and failed to indicate an MD or DO was present for the meetings as a committee member.

2. Review of the patient care policy/procedures failed to indicate an annual review by the professional group.

3. During an interview on 06-08-11 at 0950 hours with employee #AD 19, the employee indicated they could not recall the last time an annual review had been performed by the professional group, and no MD/DO was a member of the committee or participated in an annual review of all policies/procedures with the group.

4. During an interview on 06-08-11 at 1028 hours, employee #AD 3 confirmed the committee does not perform a full annual review of its policies/procedures.

Based on document review and staff interview, the facility continued to fail to list all services on the list of contracts.

Findings:
1. at 11:00 AM on 11/7/11, review of the updated PI (performance improvement) Plan indicated that "Monitoring of all providers for clinical engineering services" would be performed

2. Review of the minutes of the 9/28/11 Governing Board meeting at 11:50 AM on 11/7/11 indicated: the PI Plan was approved at the 9/28/11 Board Meeting (information was presented at the 8/24/11 meeting, but a vote was not taken for approval of the updated PI Plan until the 9/18/11 meeting)

3. at 12:30 PM on 11/7/11, review of the most current contract listing, of those entities providing services to the facility, indicated fire alarm and smoke detection and sprinkler checks and fire extinguishers continued to be absent from the listing

4. interview with staff member NB at 12:00 PM on 11/7/11 indicated:
a. the contractual list provided to the surveyor is the most current
b. the current contract listing still is missing two companies who provide services to the facility: fire alarms and smoke detectors and sprinkler checks and fire extinguishers
c. fire alarms and smoke detectors and sprinkler checks and fire extinguishers should have been added to the contract listing



29550

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

Findings:

1. Review of the document Contract Spreadsheet listed 24 providers for clinical engineering services for the facility.

2. Review of the facility document Contract Spreadsheet failed to include current service provider agreements for 6 services (biohazardous waste management, fire systems maintenance, fire extinguisher maintenance, generator preventive maintenance, pest control services and after-hours radiology interpretation) and listed agreements with 5 providers no longer providing services (biohazardous waste management, biomed equipment preventive maintenance, generator preventive maintenance, magnetic resonance service and speech pathology service).

3. During an interview on 06-06-11 at 1500, employee #AD1 confirmed the list of contracts had not been maintained.

Based on patient medical record review, and staff interview, the facility continued to fail to ensure that all members of the multidisciplinary committee participated in the creation of a comprehensive care plan, and in attending the weekly team/committee conferences for 6 of 7 patients (pts. N11, N12, N13, N15, N16 and N17).

Findings:
1. at 12:40 PM on 11/7/11, review of swing bed patient medical records for patients N11 through N17 indicated:
a. pt. N11 was admitted on 10/2/11, had an IDT (interdisciplinary) case conference meeting on 10/4/11, was discharged on 10/7/11 and had an electronic signature, approving the care plan and conference meeting information, by the physician on 10/10/11
b. pt. N12 was admitted on 9/28/11, had an IDT case conference meeting on 10/4/11, was discharged on 10/7/11 and had authentication by the provider that was not dated, making in impossible to determine whether this was signed prior to the discharge date
c. pt. N13 was admitted on 9/30/11, had an IDT case conference meeting on 10/4/11, was discharged on 10/7/11 and had an electronic signature, approving the care plan and conference meeting information, by the physician on 10/10/11
d. pt. N15 was admitted on 10/1/11, had an IDT case conference meeting on 10/4/11, was discharged on 10/7/11 and had an electronic signature, approving the care plan and conference meeting information, by the physician on 10/10/11
e. pt. N16 was admitted on 10/23/11, had an IDT case conference meeting on 10/25/11, was discharged on 10/7/11 and had physician authentication dated 11/7/11
f. pt. N17 was admitted on 10/22/11, had an IDT case conference meeting on 10/25/11, was discharged on 10/28/11 and had physician authentication dated 11/1/11

2. interview with staff member NH at 12:50 PM on 11/7/11 indicated:
a. the physicians do not attend the case conference meetings
b. interaction with the physicians is occurring, but is not indicated by lack of documentation, in the medical record
c. physicians are not on the floor on a daily basis to review and authenticate case conference notes
d. patients N11, N13, N15, and N17 had authentication by physicians, on the case conference meeting notes, after the patients had been discharged making it impossible to determine that there was input by the physicians to the patients' swing bed care plans
e. pt. N12 had authentication by the provider that was not dated, making it impossible to determine whether this was signed prior to the discharge date
f. pt. N16 had an IDT case conference meeting on 10/25/11, was discharged on 10/7/11 and had physician authentication dated 11/7/11, which was after the patient was discharged