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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the attending psychiatrist and social services participated in patient treatment planning for one of one applicable medical record reviewed (MR15).

Findings include:

Review on September 15, 2021, of the facility's "Treatment Planning" policy, effective December 18, 2021, revealed "Policy: The attending psychiatrist will lead the treatment team in developing each patient's treatment plan based on a thorough assessment of the patient's biological, psychological, psychosocial, environmental, self care, educational and aftercare planning needs. A Master Treatment Plan will be completed by the multidisciplinary treatment team within 72 hours of admission and approved by the attending psychiatrist. Those involved in the treatment planning process include the patient, physician, registered nurse, social worker or therapist, and all other clinical staff involved in the patients care ..."

Review on September 15, 2021, of the facility's "Behavior Health Goals and Intervention Sheet for Risk of Violence" last reviewed May 2021, revealed "...Interventions: Physician or other Authorized Provider: Assess/adjust medication efficacy during each visit and/or as needed. Monitor and educate regarding precautions, risks, benefits, and side effects of medications, during each visit. Obtain informed consent for psychoactive medication, prior to initiating each medication. Signature Discipline Date Time ..."

Review on September 15, 2021, of the facility's "Behavioral Health Treatment Plan Update Form B" last reviewed May 2021, revealed "...Signatures of Treatment Team Present Psychiatrist Date/Time, Social Services Date/Time, AT/RT/OT/PT Date/Time, Nurse Date/Time and Other Date/Time."

Review of MR15 on September 15, 2021, revealed this patient was admitted to the facility on April 6, 2021 and continued to be an inpatient at the time of the medical record review.

Review on September 15, 2021, of MR15's Behavior Health Goals and Intervention Sheet for Risk of Violence dated April 15, 2021, revealed no documentation the physician or authorized provider completed, signed and dated the Intervention section on the Behavior Health Goals and Intervention Sheet for Risk of Violence.

Interview with EMP3 on September 15, 2021, at the time of review confirmed MR15 was admitted to the facility on April 6, 2021 and continued to be an inpatient at the time of the medical record review. EMP3 confirmed MR15's Behavior Health Goals and Intervention Sheet for Risk of Violence dated April 15, 2021, contained no documentation the physician or authorized provider completed, signed, and dated the Intervention section of this sheet.

Review on September 15, 2021, of MR15's Behavioral Health Treatment Plan Update Form B dated June 2, 9, 16 and 22, 2021, revealed no documentation the psychiatrist and social services were present for this patient's Treatment Team meetings on these dates. There was no signature on the Behavioral Health Treatment Plan Update Form B documenting the psychiatrist and social services were in attendance and participated in MR15's Treatment Team meetings on these dates.

Interview with EMP1 and EMP3 on September 15, 2021, at the time of review confirmed MR15's Behavioral Health Treatment Plan Update Form B dated June 2, 9, 16 and 22, 2021, contained no documentation the psychiatrist and social services were present for this patient's Treatment Team meeting on these dates. EMP1 and EMP3 confirmed there was no signature on the Behavioral Health Treatment Plan Update Form B documenting the psychiatrist and social services were in attendance and participated in MR15's Treatment Team meetings on these dates.

Review on September 15, 2021, of MR15's Behavioral Health Treatment Plan Update Form B dated August 30, 2021 and September 13, 2021, revealed no documentation the psychiatrist was present for this patient's Treatment Team meeting on these dates. There was no signature on the Behavioral Health Treatment Plan Update Form B documenting the psychiatrist was in attendance and participated in MR15's Treatment Team meetings on these dates.

Interview with EMP1 and EMP3 on September 15, 2021, at the time of review confirmed MR15's Behavioral Health Treatment Plan Update Form B dated August 30, 2021 and September 13, 2021, revealed no documentation the psychiatrist was present for this patient's Treatment Team meetings on these dates. EMP3 confirmed there was no signature on the Behavioral Health Treatment Plan Update Form B documenting the psychiatrist was in attendance and participated in MR15's Treatment Team meetings on these dates.

Based on review of facility documents, medical records (MR), observation, and staff interview (EMP), it was determined the facility failed to ensure personal care items were properly secured and the facility failed to follow its established admission COVID policy for three of three applicable medical records reviewed (MR10, MR14 and MR15).

Findings include:

Review on September 14, 2021, of the facility's "Patient's Bill of Rights and Responsibilities" policy, last reviewed October 2020 revealed "Patient Bill of Rights and Responsibilities ... Your Rights ... As our patient, you have the right to safe, respectful, and dignified care at all times. ..."

Review on September 14, 2021, of EMP4's "Annual Personal Disclosure" dated July 17, 2020, revealed "... Performance Evaluation Competency 2019 - 2020 ... Standards for Community Care Service Excellence ... 8. Safety Awareness Ensures an accident-free environment. Establishes, promotes and monitors a proactive approach to enhance hospital and patient safety. ... Position Description Nurse Manager ... General Duties ... 4. Manage the therapeutic milieu by providing structure and maintaining a safe environment ..."

Review on September 14, 2021, of the facility's "Infection Control in Behavioral Health Settings" policy, effective January 3, 2021, revealed "Background: Patients residing in behavioral health facilities have unique characteristics that differentiate them from patients in acute medical/surgical facilities. ... Procedure ... II. General Principles of Infection Control A. Standard Precautions: ... 1. Standard precautions will be utilized for the care of all patients. ... 10. Emesis basins will be used for storage of patient toothbrushes/toothpaste (toothbrushes need a vinyl cover.) Wash basins will be used to store larger items, such as shampoo. ... "

Review on September 15, 2021, of the facility's "COVID-19 Response Plan" revised January 3, 2021, revealed "I. Purpose: The purpose of this policy is to provide a plan for early detection and response to a potential patient with coronavirus COVID-19 and includes considerations for staff/visitors. II. Policy: It is the policy of First Hospital that patients with a possible diagnosis of COVID-19 will not be admitted or allowed to visit within the facility. Due to the primary focus of First Hospital as a behavioral health hospital, infectious patients and/or suspected cases should not enter the communal environment existing within the facility. ... IV. Procedure: Complete the screener questions for any admission: 1. Do you have a fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, now loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea Yes No if Yes = Notify Nurse Manger or Nurse Supervisor 2. Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory confirmed COVID-19 or with anyone who has any symptoms. Yes No if Yes = Notify Nurse Manger or Nurse Supervisor 3. Have you been isolating or quarantining because you may have been exposed to a person with COVID or are worried that you may be sick with COVID-19 Yes No if Yes = Notify Nurse Manger or Nurse Supervisor 4. Referring agency has confirmed the patient has been 24 hours without the use of fever-reducing or other symptom - altering medications (e.g. cough suppressants)? Yes No if Yes = Notify Nurse Manger or Nurse Supervisor Please Note: If the origin of the fever is known and/or the patient has respiratory symptoms deemed unlikely to be COVID-10 by the referring agency, the patient must be 24 hours without the use of fever-reducing or other symptoms - altering medications (e.g. cough suppressants) before the case can be re-evaluated for admission. ..."

1. Observation tour of patient unit Adult 3 on September 14, 2021, revealed an unopened bottle of hand lotion and an unopened bottle of liquid soap in the shower in the restraint room shower.

Interview with EMP4 on September 14, 2021, at the time of the observation revealed facility staff routinely keep unopened bottles of hand lotion and liquid soap in the shower.

Interview with EMP1, EMP2, EMP3 and EMP5 on September 14, 2021, at approximately 1:00 p.m. revealed unopened bottles of hand lotion and liquid soap are not to be kept in any of the patient showers on any of the patient units because it could potentially compromise the safety of the mental health patient.

2. Review of MR10 on September 15, 2021, revealed this patient was admitted to the facility on July 7, 2021. MR10's Coronavirus Screening form did not contain answers to the facility's pre-admission screening questions. There was documentation indicting "See Attached". There was no documentation in MR10 indicating the facility screened this patient for COVID-19 and determined MR10 was safe for admission.

Interview with EMP3 on September 15, 2021, at approximately 10:00 a.m. confirmed MR10 was admitted to the facility on July 7, 2021; this patient's Coronavirus Screening form did not contain answers to any to the facility's required pre-admission screening questions and the documentation indicting "See Attached". EMP3 reviewed the information attachment to MR10's Coronavirus Screening form. EMP3 revealed the information does not meet the symptom screening criteria to determine a possible diagnosis of COVID-19.

Review of MR14 on September 15, 2021, revealed this patient was admitted to the facility on August 29, 2021. MR14's Coronavirus Screening form did not contain answers to the facility's pre-admission screening questions. Further review revealed documentation indicting "See Attached". There was no documentation in MR14 indicating the facility screened this patient for COVID-19 and determined MR14 was safe for admission.

Interview with EMP3 on September 15, 2021, at approximately 10:00 a.m. confirmed MR14 was admitted to the facility on August 29, 2021; this patient's Coronavirus Screening form did not contain answers to any to the facility's required pre-admission screening questions and the documentation indicting "See Attached". EMP3 reviewed the information attachment to MR14's Coronavirus Screening form. EMP3 revealed the information did not meet the symptom screening criteria to determine a possible diagnosis of COVID-19.

Review of MR15 on September 15, 2021, revealed this patient was admitted to the facility on April 5, 2021. MR15's Coronavirus Screening form did not contain answers to the facility's pre-admission screening questions. Further review revealed documentation this patient had COVID, was quarantined in the ER, and was cleared to come to the facility on April 5, 2021. There was no documentation in MR15 indicating the facility screened this patient for COVID-19 and determined MR15 was safe for admission.

Interview with EMP3 on September 15, 2021, at approximately 10:00 a.m. confirmed MR15 was admitted to the facility on April 5, 2021; MR15's Coronavirus Screening form did not contain answers to any to the facility's pre-admission screening questions and the documentation this patient had COVID, was quarantined in the ER, and was cleared to come to the facility on April 5, 2021. EMP3 confirmed the information did not meet the symptom screening criteria to determine a possible diagnosis of COVID-19.

Based on the systemic non-compliance and the effect on patient outcome, the facility failed to substantially comply with this Condition.

482.22(a)(1) Tag A-0340
Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure Allied Health Professional candidates applying for appointment or reappointment to the medical staff indicated the clinical privileges the candidate was requesting for one of 14 credential files reviewed (CF2); the facility failed to ensure the medical staff approved candidates applying for appointment or reappointment to the medical staff clinical privileges for five of five Allied Health Professional credential files reviewed (CF2, CF7, CF8, CF9, and CF12); the facility failed to ensure the medical staff approved the candidates applying for appointment or reappointment to the medical staff clinical privileges for four of four physician credential files reviewed (CF10, CF11, CF13 and CF14); and the facility failed to ensure the medical staff reviewed and completed the criteria for appointment or reappointment of Allied Health Professionals for two of four credential files reviewed (CF2 and CF7).

482.22(a)(2) Tag A-0341
Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure a Physician Assistant (CF3) had a current Drug Enforcement Administration (DEA) registration number.

482.22(c) Tag A-0353
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the suspension process was followed for patient medical records that were not completed within 30 days following discharge.

Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure Allied Health Professional candidates applying for appointment or reappointment to the medical staff indicated the clinical privileges the candidate was requesting for one of 14 credential files reviewed (CF2); the facility failed to ensure the medical staff approved candidates applying for appointment or reappointment to the medical staff clinical privileges for five of five Allied Health Professional credential files reviewed (CF2, CF7, CF8, CF9, and CF12); the facility failed to ensure the medical staff approved the candidates applying for appointment or reappointment to the medical staff clinical privileges for four of four physician credential files reviewed (CF10, CF11, CF13 and CF14); and the facility failed to ensure the medical staff reviewed and completed the criteria for appointment or reappointment of Allied Health Professionals for two of four credential files reviewed (CF2 and CF7).

Findings include:

Review on September 13, 2021, of the facility's "Medical Staff Bylaws" last approved January 2021, revealed "... Article II Purpose & Responsiblities ... 2.2 Responsibilities The responsibilities of the Medical Staff include: ... 2.2(b)(2) Define and implement credentialing procedures, including a mechanism for appointment and reappointment and the delineation of clinical privileges and assurance that all individuals with clinical privileges provide services within the scope of individual clinical privileges granted. ... 6.3 Processing the Application. 6.3(a) Request for Application A practitioner wishing to be considered for Medical Staff appointment or reappointment and clinical privileges may obtain an application form therefore by submitting his/her written request for a application form to the CEO or his/her designee. ... 6.3(d) Submission of Application & Verification of Information Upon completion of the application form and attachment of all required information, the Applicant shall submit the form to the CEO or his/her designee. The application shall be returned to the practitioner and shall not be processed further if one (1) or more of the following applies ... (8) Application Incomplete. The applicant has failed to provide any information required by these bylaws or requested on the application, has provided false or misleading information on the application, or has failed to execute an acknowledgment, agreement or release required by these bylaws or included in the application. ... 6.3(e) Description of Initial Clinical Privileges Medical Staff appointments or reappointments shall not confer any clinical privileges or rights to practice in the hospital. Each practitioner who is appointed to the Medical Staff of the hospital shall be entitled to exercise only those clinical privileges specifically granted by the Board. The clinical privileges recommended to the Board shall be based upon the applicant's education, training, experience, past performance, demonstrated competence and judgement, references and other relevant information. The applicant shall have the burden of establishing his/her qualifications for, and competency to exercise the clinical privileges he/she requests. 6.3(f) Medical Executive Committee Action ... Determination will be made as to whether the applicant has established and met all of the necessary qualifications for the category of Medical Staff membership and clinical privileges requested. ... The MSEC shall then forward to the Board a written report on the prescribed form concerning staff recommendations and, if appointment is recommended, staff category and clinical privileges to be granted ..."

Review on September 13, 2021, of the facility's "Allied Health Professional Medical Staff Clinical Privileges Family Communication and Education" form, no review date, revealed "A. Privileges Provision of Family Communication and Education at First Hospital. Observation - Chart Review - Supervision; Documentation of Family Communication and Education in the Medical Record. Chart Review and Participation Treatment Planning Meeting when indicated Observation. ..." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 13, 2021, for the facility's "Allied Health Professional Medical Staff Clinical Privileges Individual Therapy" form, no review date, revealed "A. Privileges Provision of Individual Therapy at First Hospital. Observation - Chart Review - Supervision; Documentation of Individual Therapy in the Medical Record. Chart Review and Participation Treatment Planning Meeting when indicated Observation." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 13, 2021, for the facility's "Allied Health Professional Medical Staff Clinical Privileges Assessment and Diagnosis of Psychiatric Disorders" form, no review date, revealed "A. Privileges Provision of Assessment and Diagnosis of Psychiatric Disorders at First Hospital. Observation - Chart Review - Supervision; Documentation of Assessment and Diagnosis of Psychiatric Disorders in the Medical Record. Chart Review and Participation Treatment Planning Meeting when indicated Observation - Supervision." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns on the form to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 13, 2021, for the facility's "Allied Health Professional Medical Staff Clinical Privileges Medication Use For Treatment of Psychiatric Disorders" form, no review date, revealed "A. Privileges Prescribing of medication of psychiatric disorders at First Hospital. Observation - Chart Review; documentation of medication use for treatment of psychiatric disorders in the medical record. Chart Review." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 13, 2021, for the facility's "Allied Health Professional Medical Staff Clinical Privileges Detoxification From Drugs" form, no review date, revealed "A. Privileges Documentation of detoxification from drugs in the medical record. Chart Review; Participation in treatment planning meetings when indicated. Observation - Supervision." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date."

Review on September 13, 2021, for the facility's "Allied Health Professional Medical Staff Clinical Privileges Detoxification From Alcohol" form, no review date, revealed "A. Privileges Documentation of detoxification from alcohol in the medical record. Chart Review; Participation in treatment planning meetings when indicated. Observation - Supervision." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 14, 2021, for the facility's "Medical Staff Clinical Privileges Family Practice" form, last revised February 24, 2015, revealed "A. Privileges History and Physical - including Chief Complaint, history of Presenting illness, Present History, Review of Systems, Physical Exam, Impression, Plan, Diagnosis. Observation - Chart Review. Assessment, diagnosis, treatment, and management of uncomplicated medical problems using non-invasive treatment that meet the philosophy and scope of treatment of First Hospital. Chart Review. Physician Orders to treat the patient's medical problems. Chart review. Charting privileges. Chart review." There were columns labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 14, 2021, for the facility's "Medical Staff Clinical Privileges Physical Medicine and Rehabilitation" form, last revised February 24, 2015, revealed "A. Privileges Physical medicine and rehabilitation Consultation at First Hospital. Observation - Chart Review. Assessment, diagnosis, non-invasive treatment, and management of physical medicine and rehabilitation problems that meet the philosophy and scope of treatment at First Hospital. Chart Review. Physician's Orders to treat the patient's physical medicine and rehabilitation problems. Chart Review. Charting privileges. Chart Review." There were columns on the form labeled population: Child, Adolescent and Adult; please select using a check mark. There were columns to be completed by Medical Staff Services: Granted. Not Granted, Granted with Supervision and Competency with Supervisor Signature and Date.

Review on September 14, 2021, for the facility's Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol revealed "...B. Criteria Candidate must have graduated from an accredited Allied Health Professional Program, posses an active Pennsylvania Allied Health Professional's License, and a current National Commission on Certification of Allied Health Professionals Certificate. Candidate must possess a Primary Allied Health Professional Supervisor Registration Number and Primary/Substitute Allied Health Professional Supervisor Agreement (as required by Section 13e of the Pennsylvania Medical Practice Act of 112 of 1985). Unless a recent graduate, candidate must have documented experience within the past two (2) years and posses documented related continuing education. Candidate must possess satisfactory peer and supervisory references from past and present facilities in which he/she had/has worked and/or maintained privileges indicating competence. Areas reviewed included the Six General Competencies, Performance Improvement, Medical Records, and Risk Management. Candidate has been oriented to the facility through review of Medical Staff Bylaws, Rules and Regulations, Ethics Policy, and has completed the Physician Orientation program. Candidate's peer and supervisory references reflected that his/her physical and mental health status did not interfere with job performance." There were three columns on the form indicating Yes, No, and N/A.

1. Review of CF2 on September 13, 2021, revealed the Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated November 18, 2020. There was no documentation indicating the specific privileges and patient population CF2 requested for consideration by the Medical Staff Executive Committee (MSEC) for appointment to the medical staff.

Interview with EMP8 on September 13, 2021, at approximately 2:00 p.m. confirmed CF2's Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated November 18, 2020. EMP8 confirmed there was no documentation indicating the specific privileges and patient population CF2 requested for consideration by MSEC for appointment to the medical staff

2. Review of CF2 on September 13, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated November 18, 2020. There was no documentation by the medical staff indicating the specific privileges and patient population CF2 was approved for by the MSEC for appointment to the medical staff.

Review of CF7 on September 13, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated October 17, 2020. There was no documentation by the medical staff indicating the specific privileges and patient population CF7 was approved for by the MSEC of appointment to the medical staff.

Review of CF8 on September 13, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated October 3, 2020. There was no documentation by the medical staff indicating the specific privileges and patient population CF8 was approved for by the MSEC of appointment to the medical staff.

Review of CF9 on September 14, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated February 12, 2020. There was no documentation by the medical staff indicating the specific privileges and patient population CF9 was approved for by the MSEC of appointment to the medical staff.

Review of CF12 on September 14, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated January 15, 2020. There was no documentation by the medical staff indicating the specific privileges and patient population CF12 was approved for by the MSEC of appointment to the medical staff.

Interview with EMP8 on September 14, 2021, at approximately 10;15 a.m. confirmed CF2, CF7, CF8, CF9, and CF12's Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol did not contain documentation by the medical staff indicating the specific privileges and patient population these Allied Health Professional candidates were approved for by the MSEC of appointment to the medical staff.

3. Review of CF10 on September 14, 2021, revealed Medical Staff Clinical Privilege list for Family Practice dated January 8, 2019. There was no documentation by the medical staff indicating the specific privileges and patient population CF10 was approved for by the MSEC of appointment to the medical staff.

Review of CF11 on September 14, 2021, revealed Medical Staff Clinical Privilege list for Physical Medicine and Rehabilitation dated January 16, 2020. There was no documentation by the medical staff indicating the specific privileges and patient population CF11 was approved for by the MSEC of appointment to the medical staff.

Interview with EMP8 on September 14, 2021, at approximately 10:15 a.m. confirmed CF11's Medical Staff Clinical Privilege list for Physical Medicine and Rehabilitation did not contain documentation by the medical staff indicating the specific privileges and patient population CF11 was approved for by the MSEC of appointment to the medical staff.

Review of CF13 on September 14, 2021, revealed Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated January 15, 2020. There was no documentation by the medical staff indicating the specific privileges and population CF13 was approved for by the MSEC of appointment to the medical staff.

Interview with EMP8 on September 14, 2021, at approximately 1015 a.m. confirmed CF13's Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol did not contain documentation by the medical staff indicating the specific privileges and patient population CF13 was approved for by the MSEC of appointment to the medical staff.

Review of CF14 on September 14, 2021, revealed Medical Staff Clinical Privilege list for Family Practice dated December 6, 2019. There was no documentation by the medical staff indicating the specific privileges and patient population CF14 was approved for by the MSEC of appointment to the medical staff.

Interview with EMP8 on September 14, 2021, at approximately 10:15 a.m. confirmed CF14 Medical Staff Clinical Privilege list for Family Practice did not contain documentation by the medical staff indicating the specific privileges and population CF14 was approved for by the MSEC of appointment to the medical staff.

4. Review of CF2 on September 14, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated November 18, 2020. There was no documentation the medical staff reviewed and determined CF2's candidate criteria met approval for appointment or reappointment to the medical staff.

Review of CF7 on September 14, 2021, revealed Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated October 17, 2020. There was no documentation the medical staff reviewed and determined CF7's candidate criteria met approval for appointment or reappointment to the medical staff.

Interview with EMP8 on September 14, 2021, at approximately 11:30 a.m. confirmed CF2 and CF7's Allied Health Professional Medical Staff Clinical Privilege lists for Family Communication and Education, Individual Therapy, Assessment and Diagnosis of Psychiatric disorders, Medication Use For Treatment of Psychiatric Disorders, Detoxification Form Drugs and Detoxification From Alcohol dated contained no documentation the medical staff reviewed and determined CF2 and CF7's candidate criteria met approval for appointment or reappointment to the medical staff.

Cross reference
482.22(a)(2) Medical Staff Credentialing

Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure a Physician Assistant (CF3) had a current Drug Enforcement Administration (DEA) registration number.

Findings include:

Review on September 13, 2021, of the facility's "Medical Staff Bylaws" last approved January 2021, revealed "...Article VI Procedures for Appointment & Reappointment 6.1 General Procedures The Medical Staff through its designated committees and departments shall investigate and consider each application for appointment or reappointment to the staff and each request for modification of staff membership status and shall adopt and transmit recommendations thereon to the Board which shall be the final authority on granting, extending, terminating or reducing Medical Staff privileges. The Board shall be responsible for the final decision as to Medical Staff appointments. A separate, confidential record shall be maintained for each individual requesting Medical Staff membership or clinical privileges. 6.2 Content of Application for All Initial Appointment Each application for appointment to the Medical Staff shall be in writing, submitted on the prescribed form approved by the Board, and signed by the applicant. A copy of all active state licenses, current DEA registration / controlled substance certificate (for all practitioners except pathologists), a signed Medicare penalty statement and a certificate of insurance must be submitted with the application. No application fee or Medical Staff dues shall be assessed. Applicants shall supply the Hospital with all information requested on the application. ... 6.4 Reappointment Process ... 6.4(b) Content of Reapplication Form The Reapplication Form shall include, at a minimum, updated information regarding the following: ... (7) (iv) Drug Enforcement Agency (DEA) number / controlled substance license ..."

Review of CF3 on September 13, 2021, revealed this Physician Assistant (Pa-C) was a member of the facility's medical staff with active clinical privileges. CF3's DEA registration number expired February 28, 2015.

Interview with EMP3 on September 13, 2021, at approximately 1:45 p.m. revealed the purpose of a DEA registration number was for ordering controlled substance medications to patients.

Interview with EMP3 and EMP8 on September 14, 2021, at approximately 1:45 p.m. confirmed CF3 was a member of the facility's medical staff with active clinical privileges and CF3's DEA registration number expired February 28, 2015.

Review on September 13, 2021, of CF3's file revealed documentation dated February 9, 2015, indicating CF3 will not be renewing the DEA registration number because the cost was $731.00; CF3 was only working per diem (as needed), and the facility would not reimburse CF3 for the cost of the DEA. Further review revealed documentation that CF3 discussed the DEA renewal with CF5. CF5 indicated CF3's DEA was not necessary to renew.

Interview with EMP3 and EMP8 on September 14, 2021, at approximately 1:45 p.m. confirmed the documentation dated February 9, 2015, indicating CF3 will not be renewing the DEA registration number because the cost was $731.00; CF3 was only working per diem; the facility would not reimburse CF3 for the cost of the DEA; the documentation that CF3 discussed the DEA renewal with CF5 and CF5 indicated CF3's DEA was not necessary to renew.

Interview with EMP5 on September 14, 2021, at approximately 2:00 p.m. and with EMP1 on September 15, 2021, at approximately 10:30 a.m. revealed CF3 saw patients in the facility from February 28, 2015 and most likely prescribed controlled substance medications to patients without a current DEA registration number.

Cross reference
482.22(a)(1) Medical Staff Periodic Appraisals

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the suspension process was followed for patient medical records that were not completed within 30 days following discharge.

Findings include:

Review on September 14, 2021, of the facility, "Medical Staff Bylaws First Hospital" dated February 2021, revealed "...2.1 Purpose The purposes of the Medical Staff are: ... 2.1(g) To promulgate, maintain, and enforce bylaws and rules and regulations for the proper functioning of the medical staff; ... 2.2 Responsibilities The responsibilities of the Medical Staff include: ... 2.2(b) Accounting for the quality, appropriateness and cost effectiveness of patient care rendered by all practitioners and AHPs authorized to practice in the Hospital, by taking action to: ... (6) Initiate and pursue corrective action with respect to practitioners and AHP's, when warranted; (7) Develop, administer, and enforce these bylaws, the rules and regulations of the staff and other hospital policies related to medical care; ... 2.2 (d) Participating and cooperating in implementation of the policies of federal and state regulatory agencies, including the requirements of the Data Bank; and ... 3.3 Basic Responsibilities of Staff Membership Each member of the medical staff shall: ... 3.3(f) Adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the Hospital; ...5.5 Responsibilities Each AHP shall: ...5.5 Responsibilities Each AHP shall ... 5.5(b) Abide by the Medical Staff Bylaws and other lawful standards, policies and Rules and Regulations of the medical staff ... 8.4 Automatic Suspension ... 8.4(c) Medical Records (1) Automatic suspension of a practioner's or AHP's [AHP - Allied Health Professional] privileges shall be imposed for failure to complete medical records as required by the Medical Staff Bylaws and Rules and Regulations. ..."

Review on September 14, 2021, of facility, "Rules and Regulations Of The Medical Staff First Hospital," reviewed January 2021, revealed "1. Purpose of Rules and Regulations The purpose of the Rules and Regulations of the Medical Staff of First Hospital Wyoming Valley and Choices (referred to as "Hospital") is to further clarify the standards of professional practice and medical record documentation which govern the Medical Staff. A. The Medical Staff abides by all policies and procedures of the facility. ... XI. Delinquent Medical Records Patient Medical records are required to be completed within thirty (30) days of discharge. The Health Information Management Department will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty-first (21st) day for any incomplete medical records, the letter will include a warning that the record (s) will be delinquent at thirty days and the physicians privileges will be suspended if any records become delinquent. (a.) Suspension. A chart which is not completed within thirty (30) days of discharge will trigger suspension of the responsible physician's privileges. When a staff member is notified of suspension, the staff member may not provide any hands-on patient care, whether inpatient or outpatient. Any admissions scheduled thereafter shall be postponed until all delinquent records are completed. New admissions or the scheduling of procedures are not permitted. Consultations are not permitted. The suspended physician may not admit under a partner's or other Attending Physician's name. Any exception must be approved by the Chief of Staff and the CEO. (b) The suspended staff member is obligated to provide to the hospital CEO and the Chief of Staff the name of another physician who will take over the care of his/her hospitalized patients, consultations and any other services that physician provides. (c) All hospital departments shall be notified of suspension to enable the enforcement of the suspension. (d) Any physician who remains on suspension for seven (7) calendar days or longer will be referred to the MEC for further action. ..."

Review on September 14, 2021, of the facility's medical record deficiency report dated September 8, 2021, revealed a total of 189 delinquent medical records. This report revealed the following practitioners had delinquent medical records:
OTH1-5 delinquent medical records
OTH2-18 delinquent medical records
OTH3-96 delinquent medical records
OTH4-20 delinquent medical records
OTH5-1 delinquent medical record
OTH6-4 delinquent medical records
OTH7-28 delinquent medical records
OTH8-11 delinquent medical records
OTH9-2 delinquent medical records
OTH10-4 delinquent medical records

Interview on September 14, 2021, at approximately 11:10 A.M. with EMP6, confirmed the facility's medical record deficiency report dated September 8, 2021, revealed a total of 189 delinquent medical records. EMP6 confirmed OTH1 had 5 delinquent medical records, OTH2 had 18 delinquent medical records, OTH3 had 96 delinquent medical records, OTH4 had 20 delinquent medical records, OTH5 had 1 delinquent medical record, OTH6 had 4 delinquent medical records, OTH7 had 28 delinquent medical records, OTH8 had 11 delinquent medical records, OTH9 had 2 delinquent medical records, OTH10 had 4 delinquent medical records. EMP6 confirmed the facility did not follow their policy for delinquent medical records. The practitioners and AHP's have not been suspended as per the Bylaws and the Rules and Regulations of the Medical Staff and were admitting patients to the facility.

Review on September 14, 2021, of the, "First Hospital Medical Executive Committee meeting minutes" dated February 18, 2021, revealed, " ...5.1.6 HIM Delinquency Rate Discussion: The HIM Director presented the results of her audit on medical record deficiencies through the Health Information Management Report. Recommendations/Actions: Implementation of action outlined in report. ...Action needed for the following: HIM needs to implement weekly Letter Process so that providers know weekly what records are in need of their completion HIM needs to communicate to Administration/Leadership a list of those Physicians/PAs who have Delinquent Medical Records with the totals A timeline needs to be identified for implementing the Suspension process so that we are following the Rules and Regulations of the Medical Staff Medical Record Analysis by HIM Staff of Non-Physician/PA providers needs to be moved out of HIM Enforcement of Medical Records only leaving the HIM Department for Patient Care or Regulatory Audits/Surveys needs to be implemented ..."

Interview on September 14, 2021, at approximately 11:35 A.M. with EMP6, revealed EMP6 started working for the facility in January 2021 and notified administration immediately of the medical records deficiencies, notified the Regional Director at the corporate office and presented the HIM Report at the February 18, 2021 Medical Executive Committee meeting as well as the action that needed to take place.

Cross Reference
482.24(c)(4)(viii) Content Of Record-Final Diagnosis

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to monitor a patient's vital signs and neurological needs were met following a fall for one of one medical record reviewed (MR8) and the facility failed to measure and monitor a patient's hematoma following a fall for one of one medical record reviewed (MR8).

Findings include:

A request was made of EMP3 and EMP7 on September 15, 2021, for the facility policy, procedure, guideline, or protocol for staff follow regarding monitoring a patient's vital signs and completing neurological checks on a patient following a fall. No facility policy, procedure, guideline, or protocol was provided.

Interview with EMP3 and EMP7 on September 15, 2021, at approximately 9:50 a.m. revealed the facility did not have a policy, procedure, guideline, or protocol for staff follow regarding monitoring a patient's vital signs and completing neurological checks on a patient following a fall. EMP7 revealed monitoring a patient's vital signs and completing neurological checks on a patient after a fall was the physician's determination and not a nursing judgment.

A request was made of EMP3 and EMP7 on September 15, 2021, for the facility policy, procedure, guideline, or protocol for staff follow regarding measuring and monitoring a patient's hematoma following a fall. No policy, procedure, guideline, or protocol was provided.

Interview with EMP3 and EMP7 on September 15, 2021, at approximately 9:50 a.m. revealed the facility did not have a policy, procedure, guideline, or protocol for staff follow regarding measuring and monitoring a patient's hematoma following a fall. EMP7 revealed measuring and monitoring a patient's hematoma following a fall was the physician's determination and not a nursing judgment.

Review on September 13, 2021, of the facility's "Nursing Assessments and Reassessments" policy, last reviewed October 2020, revealed "Policy: The Registered Nurse will complete Nursing assessments and reassessments during the admission assessment process and throughout the patient's hospitalization as outlined in specific policies and protocols. Aspects of these assessments and reassessments which may be delegated are identified within specific policy. Purpose: 1. To assure that Nursing assessments and reassessments are completed as frequently as necessary considering the complexity and dynamics of the patient's clinical course. ... 3. Nursing reassessments are completed by a Registered Nurse (components may be delegated to other competent Nursing staff as outlined in specific Nursing Policies) throughout the patient's hospital stay and are documented in the patient record in the progress notes and/or on nursing forms. ... b. Reassessments are completed prior to, during, and following specific events or procedures including, but not limited to, the following: ... Post fall ..."

1. Review on September 13, 2021, of MR8 revealed nursing documentation dated July 21, 2021 at 12:21 p.m. the patient threw self to the floor, striking the left side of the head.

There was no documentation nursing staff assessed MR8's level of consciousness after throwing self to floor and striking the left side of the head.

There was no documentation nursing staff monitored MR8's vital signs and neurologic status (level of consciousness, pupil size and reactivity, equality of hand grip strength and tiredness) for potential changes following throwing self to floor and striking the left side of the head.

Interview with EMP3 on September 13, 2021, at the time of the review confirmed nursing documentation for MR8 dated July 21, 2021 at 12:21 p.m. indicating this patient threw self to the floor, striking the left side of the head and had bleeding noted from the eyebrow. EMP3 confirmed there was no documentation nursing staff assessed MR8's level of consciousness, and there was no documentation nursing staff monitored MR8's vital signs and neurologic status for potential changes following throwing self to floor and striking the left side of the head.

2. Review on September 13, 2021, of MR8 revealed nursing documentation dated July 21, 2021 at 12:21 p.m. that this patient threw self to the floor, striking the left side of the head and a small hematoma was starting to form. There was no documentation nursing staff measured and monitored MR8's hematoma (a pool or collection of blood trapped outside a blood vessel caused by an accident or trauma) following throwing self to floor and striking the left side of the head.

Interview with EMP3 on September 13, 2021, at the time of the review confirmed nursing documentation for MR8 dated July 21, 2021 at 12:21 p.m. revealed this patient threw self to the floor, striking the left side of the head and a small hematoma was starting to form. EMP3 confirmed there was no documentation nursing staff measured and monitored MR8's hematoma following throwing self to floor and striking the left side of the head.

Review of MR8 on September 13, 2021, revealed nursing documentation dated July 24, 2021, at 9:59 a.m. indicating this patient was observed lying in bed, color dusky, no respirations were noted, no pulse was palpated, CPR (cardiopulmonary resuscitation) was started and MR8 was transferred to a local hospital.

Interview with EMP7 on September 15, 2021, at approximately 10;00 a.m. confirmed MR8's nursing documentation dated July 24, 2021, at 9:59 a.m. indicating this patient was observed lying in bed, color dusky, no respirations were noted, no pulse was palpated, CPR was started and MR8 was transferred to a local hospital

Cross reference
482.24(c)(4)(vi) Content Of Record: Orders, notes, reports

Based on the systemic non-compliance and the effect on patient outcome, the facility failed to substantially comply with this Condition.

482.24(c) Tag A-0449
Based on review of facility documents, a medical record, and staff interview (EMP), it was determined the facility failed to ensure a physician completed a late entry to a medical record as per facility policy for one of one applicable medical records reviewed (MR1).
482.24(c)(1) Tag A-0450
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a psychiatric assessment was completed within 24 hours of the admission of a patient for two of two applicable medical records reviewed (MR1and MR8); failed to ensure all patients were seen by a psychiatrist a minimum of four (4) days per week with no more than two (2) days between contacts for two of three applicable medical records reviewed (MR1 and MR3); and failed to ensure all physician assistant (PA) notes were signed by a supervising psychiatrist within 72 hours for two of three applicable medical records reviewed (MR1 and MR3).

482.24(c)(2) Tag A-0454
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the physician authenticated telephone orders within twenty four (24) hours as per facility policy for five of 15 medical records reviewed (MR2, MR3, MR4, MR9 and MR11).

482.24(c)(4)(vi) Tag A-0467
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to notify a physician regarding a patient fall for one of one medical record reviewed (MR8); the facility failed to document a patient's level of consciousness following a fall for one of one medical record reviewed (MR8); the facility failed to measure and monitor a patient's hematoma following a fall for one of one medical record reviewed (MR8); the facility failed to monitor a patient's vital signs and neurology checks for potential changes following a fall for one of one medical record reviewed (MR8); and the facility failed to complete a re-weight for one of one medical record reviewed (MR8).

482.24(c)(4)(viii) Tag A-0469
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure patient medical records were completed within 30 days following discharge.

Based on review of facility documents, a medical record, and staff interview (EMP), it was determined the facility failed to ensure a physician completed a late entry to a medical record for one of one applicable medical records reviewed (MR1).

Findings include:

Review on September 15, 2021, of the facility policy "Legal Health Record," reviewed April 2020, revealed "Purpose: The purpose of this policy is to identify and ensure the integrity of the Legal Health Record for the business and legal objectives of the facility. Scope: This policy applies to all information and documents generated or received by the facility that may be used to make decisions about, and provide health care services to an individual. ... Late Entry means documentation that is entered after the point of care. Legal Health Record (LHR) means the declared record of healthcare services provided to an individual by the facility. ... The LHR contains information, maintained to any medium that was collected and relied upon to provide healthcare services to, and document the healthcare status of, an individual. The term includes records of care provided in any setting used by healthcare professionals while providing patient care services, reviewing patient data, or documenting observations, actions, or instructions. ... If a late entry to the legal health record is necessary, the entry should be documented as close to chronological sequence as possible using "Late Entry, date, time" and indicate the date/time being referenced when the documentation should have been recorded. ..."

Review on September 13, 2021, of MR1 revealed a psychiatric progress note dated August 30, 2021, with current status filled out. Further review revealed current problems, Assessment, Miscellaneous, Plan/Thought Processes, Barriers to Discharge, and Disposition not documented. No physician signature, date, or time was noted.

Interview on September 13, 2021, with EMP2 and EMP3, at approximately 11:30 A.M. confirmed MR1 had a psychiatric progress note dated August 30, 2021, with current status filled out. EMP2 and EMP3 confirmed current problems, Assessment, Miscellaneous, Plan/Thought Processes, Barriers to Discharge, and Disposition were not documented. EMP2 and EMP3 confirmed no physician signature, date, or time was noted.

Review on September 14, 2021, of MR1 revealed OTH2 completed the psychiatric progress note dated August 30, 2021, completing the Assessment, Miscellaneous, Plan/Thought Processes, Barriers to Discharge, and Disposition. OTH2 signed and dated this progress note September 14, 2021.

Interview on September 14, 2021, with EMP1 and EMP3 confirmed OTH2 completed the psychiatric progress note dated August 30, 2021 to include Assessment, Miscellaneous, Plan/Thought Processes, Barriers to Discharge, and Disposition. EMP1 and EMP3 confirmed OTH2 signed and dated the progress note September 14, 2021. EMP1 and EMP3 confirmed OTH2 did not follow the facility policy for a late entry to a medical record.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a psychiatric assessment was completed within 24 hours of the admission of a patient for two of two applicable medical records reviewed (MR1and MR8); failed to ensure all patients were seen by a psychiatrist a minimum of four (4) days per week with no more than two (2) days between contacts for two of three applicable medical records reviewed (MR1 and MR3); and failed to ensure all physician assistant (PA) notes were signed by a supervising psychiatrist within 72 hours for two of three applicable medical records reviewed (MR1 and MR3).

Findings include:

Review on September 13, 2021, of the facility's "Medical Staff Bylaws" last approved January 2021, revealed "... Article II Purpose & Responsiblities ... 2.2 Responsibilities The responsibilities of the Medical Staff include: ... 2.2(b)(5) Develop an organizational structure that provides continuous monitoring of patient care practices and appropriate supervision of AHP's [Allied Health Professional] ..."

Review on September 13, 2021, of the facility's "Rules and Regulations Of The Medical Staff First Hospital," reviewed January 2021, revealed "I. Purpose of Rules and Regulations The purpose of the Rules and Regulations of the Medical Staff of First Hospital Wyoming Valley and Choices (referred to as "Hospital") is to further clarify the standards of professional practice and medical record documentation which govern the Medical Staff. A. The Medical Staff abides by all policies and procedures of the facility. ... III. Admissions ... E. Within twenty-four (24) hours of admission of a patient, the admitting, on-call or assigned Medical Staff physician will dictate a Psychiatric Assessment ... IV. Treatment A. All patients will be seen by a psychiatrist a minimum of four (4) days per week with no more than two (2) days between contacts. ... all PA notes and orders will be signed by a supervising psychiatrist within 72 hours. A PA with appropriate privileges may round on patients as a supplement to, but not in lieu of, the rounding requirements of the attending licensed independent practitioner. ... J. The Attending Physician must sign/co-sign the following medical record documents: ... 3. Progress Notes (handwritten/typed) ... VII. Documentation in the Medical Record ... C. The Medical Staff will be responsible for the quality of the medical record for each patient in the Hospital. ... F. The Attending Physician is responsible to maintain at least five (5) adequate progress notes each week on each of his/her patients unless special arrangements are made with the Medical Director. ... H. A complete Psychiatric Assessment will be dictated within 24 hours of admission to First Hospital Wyoming Valley. ..."

1. Review on September 13, 2021, of MR1 revealed an admission date of August 20, 2021. The patient's psychiatric evaluation was dated August 22, 2021, at 12:33 P.M. and completed by OTH1.

Interview on September 13, 2021, with EMP2 at approximately 10:30 A.M. revealed MR1 was admitted to the facility on August 20, 2021. EMP2 confirmed the patient's psychiatric evaluation was dated August 22, 2021, at 12:33 P.M. and was completed by OTH1. EMP2 confirmed the psychiatric assessment was not completed within 24 hours of admission for MR1.

Review of MR8 on September 13, 2021, revealed this patient was admitted to the facility on July 3, 2021 and transferred to a higher level of care on July 24, 2021. There was no documentation OTH3 completed a psychiatric evaluation on MR8 within 24-hours of admission or at any time during MR8's admission.

Interview with EMP2 and EMP3 on September 13, 2021 at approximately 2:00 p.m. confirmed MR8 was admitted to the facility on July 3, 2021; transferred to a higher level of care on July 24, 2021, and there was no documentation OTH3 completed a psychiatric evaluation on MR8 within 24-hours of admission or at any time during MR8's admission.

2. Review on September 14, 2021, of MR1 revealed a psychiatric progress note from a physician assistant on August 26, 2021, August 27, 2021 that was signed August 28, 2021, and August 29, 2021.

Interview on September 14, 2021, with EMP1 and EMP3, at approximately 11:30 A.M. confirmed MR1 had a psychiatric progress note from a physician assistant on August 26, 2021, August 27, 2021 that was signed August 28, 2021, and August 29, 2021. EMP1 and EMP3 confirmed there were more than 2 days between the psychiatrist's visits.

Review on September 14, 2021, of MR3 revealed a psychiatric progress note from a physician assistant on August 14, 2021 and August 15, 2021 and a psychiatric progress note from a nurse practitioner on August 16, 2021.

Interview on September 14, 2021, with EMP3, at approximately 1:00 P.M. confirmed MR3 had a psychiatric progress note from a physician assistant on August 14, 2021 and August 15, 2201 and a psychiatric progress note from a nurse practitioner on August 16, 2021. EMP3 confirmed there were more than 2 days between the psychiatrist's visits.

3. Review on September 14, 2021, of MR1 revealed psychiatric progress notes dated August 11, 2021, August 12, 2021, and August 26, 2021 from a physician assistant. The psychiatric progress notes were not signed off by a supervising psychiatrist within 72 hours.

Interview on September 14, 2021, with EMP1 and EMP3 confirmed MR had psychiatric progress notes dated August 11, 2021, August 12, 2021, and August 26, 2021 from a physician assistant, and the notes were not signed off by a supervising psychiatrist within 72 hours.

Review on September 14, 2021, of MR3 revealed a psychiatric progress notes from physician assistants dated August 14, 2021, August 15, 2021, August 21, 2021, August 22, 2021, August 28, 2021, and August 29, 2021. The psychiatric progress notes were not signed off by a supervising physician within 72 hours.

Interview on September 14, 2021, with EMP3 confirmed MR3 had psychiatric progress notes from physician assistants dated August 14, 2021, August 15, 2021, August 21, 2021, August 22, 2021, August 28, 2021, and August 29, 2021, and the notes were not signed off by a supervising physician within 72 hours.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the physician authenticated telephone orders within twenty four (24) hours for five of 15 medical records reviewed (MR2, MR3, MR4, MR9 and MR11).

Findings include:

Review on September 14, 2021, of the facility's "Rules And Regulations Of The Medical Staff First Hospital" reviewed January 2021, revealed "I. Purpose of Rules and Regulations The purpose of the Rules and Regulations of the Medical Staff of First Hospital Wyoming Valley and Choices (referred to as "Hospital" ) is to further clarify the standards of professional practices and medical record documentation which govern the Medical Staff. A. The Medical Staff abides by all policies and procedures of the facility. ... IV. Treatment ... J. The Attending Physician must sign/co-sign the following medical record documents: ... 5. Physician Orders -Verbal or Telephone orders must be signed, dated, and timed within twenty-four (24) hours ... VIII. Physician Orders A. ...Verbal physician orders will be authenticated within twenty-four (24) hours by the physician's co-signature, date, and time of the signature. ..."

Review on September 14, 2021, of the facility policy, "Telephone Orders" reviewed October 2020, revealed "Safety is the overriding principle in accepting telephone orders. Telephone orders have a higher potential for errors as these orders can be misheard, misinterpreted and/or mis-transcribed. Telephone orders are to be used infrequently and never for the convenience of the physicians. Policy 1. Verbal and telephone orders may be accepted by a registered nurse or LPN [licensed practical nurse] for emergencies and when it is impossible or impractical for the physician to write them. Procedure ...3. The order must be authenticated as per Medical Staff bylaws."

Review on September 14, 2021, of MR2 revealed a verbal telephone order from the physician on September 5, 2021, at 6:14 P.M. for Ativan (a medication used for anxiety) 2 milligrams (mg) po (by mouth) stat (immediately) for agitation. Physician authentication was completed September 7, 2021, at 12:10 P.M.

Interview on September 14, 2021, with EMP3 confirmed MR2 had a verbal telephone order from the physician on September 5, 2021, at 6:14 P.M. for Ativan 2mg po stat for agitation. EMP3 confirmed physician authentication was completed September 7, 2021, at 12:10 P.M. EMP3 confirmed facility policy was not followed.

Review on September 14, 2021, of MR2 revealed a verbal telephone order from the physician on August 21, 2021, at 6:10 P.M. for Zyprexa Zydis (anti-psychotic medication) 10mg po stat for agitation. Physician authentication was completed August 23, 2021, at 12:40 P.M.

Interview on September 14, 2021, with EMP3 confirmed MR2 had a verbal telephone order from the physician on August 21, 2021, at 6:10 P.M. for Zyprexa Zydis 10mg po stat for agitation. EMP3 confirmed physician authentication was completed August 23, 2021, at 12:40 P.M. EMP3 confirmed facility policy was not followed.

Review on September 14, 2021, of MR3, revealed a verbal telephone order from the physician on August 30, 2021, at 8:55 P.M. for Zyprexa Zydis 5mg po every (q) six(6) hours prn (as needed) for anxiety/agitation. Physician authentication was completed September 10, 2021, at 9:19 A.M.

Interview on September 14, 2021, with EMP3 confirmed MR3 had a verbal telephone order from the physician on August 30, 2021, at 8:55 P.M. for Zyprexa Zydis 5mg po q 6 hours prn for anxiety/agitation. EMP3 confirmed physician authentication was completed September 10, 2021, at 9:19 A.M. EMP3 confirmed facility policy was not followed.

Review on September 14, 2021, of MR4, revealed a verbal telephone order from the physician on September 1, 2021, at 9:58 A.M. for Tylenol (medication used to treat mild to moderate pain) 325mg one tab q 6 hours prn pain. Physician authentication was completed September 10, 2021, at 1:35 P.M.

Interview on September 14, 2021, with EMP3 confirmed MR4 had a verbal telephone order from the physician on September 1, 2021, at 9:58 A.M. for Tylenol 325mg q 6 hours prn pain. EMP3 confirmed physician authentication was completed September 10, 2021, at 1:35 P.M. EMP3 confirmed facility policy was not followed.

Review of MR9 on September 15, 2021, revealed a verbal telephone order from this patient's physician dated August 5, 2021, at 8:45 A.M. for Haldol (an antipsychotic medication used to treat schizophrenia) 5 mg po now. Physician authentication was
completed on August 9, 2021.

Interview with EMP3 on September 15, 2021, at the time of review, confirmed MR9's verbal telephone order from this patient's physician dated August 5, 2021, at 8:45 A.M. for Haldol 5 mg po now, and the physician authentication of this order was completed on August 9, 2021.

Review of MR11 on September 15, 2021, revealed a verbal telephone order from this patient's physician dated August 31, 2021, at 3:30 P.M. for Zyprexa Zydis 10 mg po now. There was no documentation the physician authenticated this order.

Interview with EMP3 on September 15, 2021, at the time of review, confirmed MR11's verbal telephone order from this patient's physician dated August 31, 2021, at 3:30 P.M. for Zyprexa Zydis 10 mg po now, and there was no documentation the physician authenticated this order.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to notify a physician regarding a patient fall for one of one medical record reviewed (MR8); the facility failed to document a patient's level of consciousness following a fall for one of one medical record reviewed (MR8); the facility failed to measure and monitor a patient's hematoma following a fall for one of one medical record reviewed (MR8); the facility failed to monitor a patient's vital signs and neurologic checks for potential changes following a fall for one of one medical record reviewed (MR8); and the facility failed to complete a re-weight for one of one medical record reviewed (MR8).

Findings include:

Review on September 13, 2021, of the facility's "Fall Safety Measures" policy, last revised December 2020, revealed "Policy: In order to ensure that optimal safety of patients is maintained during hospitalization, fall safety measures will be utilized for patients identified as a fall risk. Purpose: ... 3. To promote patient safety. ... Response Post Fall Notify physician, nurse manager of [sic] supervisor, and patient family ..."

Review on September 13, 2021, of the facility's "Nursing Assessments and Reassessments" policy, last reviewed October 2020, revealed "... Purpose: 1. To assess that Nursing assessments and reassessments are completed as frequently as necessary considering the complexity and dynamics of the patient's clinical course. ... 3. ... b. Reassessments are completed prior to, during, and following specific events or procedures including, but not limited to, the following: ... Post fall ..."

A request was made of EMP2, EMP3 and EMP7 on September 13, 2021, for a facility policy, procedure, guideline, or protocol for staff follow regarding reweighing a patient when there was a discrepancy between the previous weight and the new weight. No facility policy, procedure, guideline, or protocol was provided.

Interview with EMP3 on September 13, 2021, at 2:30 p.m. revealed the facility does not have a facility policy, procedure, guideline, or protocol for staff follow regarding reweighing a patient when there was a discrepancy between the previous weight and the new weight.

1. Review of MR8 on September 13, 2021, revealed nursing documentation dated July 21, 2021 at 12:21 p.m. that this patient threw self to the floor, striking the left side of the head and had bleeding noted from the eyebrow area and a small hematoma was starting to form.

There was no documentation nursing staff notified MR8's physician regarding this patient throwing self to the floor and striking the left side of the head.

There was no documentation nursing staff assessed MR8's level of consciousness after throwing self to the floor and striking the left side of the head.

There was no documentation nursing staff measured and monitored MR8's hematoma (a pool or collection of blood trapped outside a blood vessel caused by an accident or trauma) following throwing self to the floor and striking the left side of the head.

There was no documentation nursing staff monitored MR8's neurologic status (level of consciousness, pupil size and reactivity, equality of hand grip strength and tiredness) for potential changes following throwing self to the floor and striking the left side of the head.

Interview with EMP3 on September 13, 2021, at the time of review confirmed nursing staff did not document notification of MR8's physician regarding this patient's fall; nursing staff did not document MR8's level of consciousness following a fall; nursing staff did not measure and monitor MR8's hematoma following a fall and nursing staff did not monitor MR8's vital signs and neurologic checks for potential changes following a fall.

2. Review of MR8 on September 13, 2021, revealed nursing staff documented an admission weight of 257 pounds on July 3, 2021 and 232.8 pounds on July 5, 2021. There was no documentation nursing staff completed a reweight on MR8 to determine the accuracy of the weight obtained on July 5, 2021.

Interview with EMP3 on September 13, 2021, at 2:30 p.m. confirmed nursing staff documented an admission weight of 257 pounds on July 3, 2021 and 232.8 pounds on July 5, 2021, for MR8, and there was no documentation nursing staff completed a reweight on MR8 to determine the accuracy of MR8's weight on July 5, 2021

Cross reference
482.23(b) Staffing And Delivery of Care

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure patient medical records were completed within 30 days following discharge.

Findings include:

Review on September 14, 2021, of the facility's "Rules and Regulations Of The Medical Staff First Hospital," reviewed January 2021, revealed "I. Purpose of Rules and Regulations The purpose of the Rules and Regulations of the Medical Staff of First Hospital Wyoming Valley and Choices (referred to as "Hospital ") is to further clarify the standards of professional practice and medical record documentation which govern the Medical Staff. A. The Medical Staff abides by all policies and procedures of the facility. ... XI. Delinquent Medical Records Patient Medical records are required to be completed within thirty (30) days of discharge. The Health Information Management Department will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty-first (21st) day for any incomplete medical records, the letter will include a warning that the record (s) will be delinquent at thirty days and the physicians privileges will be suspended if any records become delinquent. (a.) Suspension. A chart which is not completed within thirty (30) days of discharge will trigger suspension of the responsible physician's privileges. When a staff member is notified of suspension, the staff member may not provide any hands-on patient care, whether inpatient or outpatient. Any admissions scheduled thereafter shall be postponed until all delinquent records are completed. New admissions or the scheduling of procedures are not permitted. Consultations are not permitted. The suspended physician may not admit under a partner's or other Attending Physician's name. Any exception must be approved by the Chief of Staff and the CEO. (b) The suspended staff member is obligated to provide to the hospital CEO and the Chief of Staff the name of another physician who will take over the care of his/her hospitalized patients, consultations and any other services that physician provides. (c) All hospital departments shall be notified of suspension to enable the enforcement of the suspension. (d) Any physician who remains on suspension for seven (7) calendar days or longer will be referred to the MEC for further action. ..."

Review on September 14, 2021, of the facility's medical record deficiency report dated September 8, 2021, revealed a total of 189 delinquent medical records. This report revealed the following practitioners had delinquent medical records:
OTH1-5 delinquent medical records
OTH2-18 delinquent medical records
OTH3-96 delinquent medical records
OTH4-20 delinquent medical records
OTH5-1 delinquent medical record
OTH6-4 delinquent medical records
OTH7-28 delinquent medical records
OTH8-11 delinquent medical records
OTH9-2 delinquent medical records
OTH10-4 delinquent medical records

Interview on September 14, 2021, at approximately 11:10 A.M. with EMP6, confirmed the facility's medical record deficiency report dated September 8, 2021, revealed a total of 189 delinquent medical records. EMP6 confirmed OTH1 had 5 delinquent medical records, OTH2 had 18 delinquent medical records, OTH3 had 96 delinquent medical records, OTH4 had 20 delinquent medical records, OTH5 had 1 delinquent medical record, OTH6 had 4 delinquent medical records, OTH7 had 28 delinquent medical records, OTH8 had 11 delinquent medical records, OTH9 had 2 delinquent medical records, OTH10 had 4 delinquent medical records. EMP6 confirmed the facility did not follow their policy for delinquent medical records and the practitioners have not been suspended as per the Rules and Regulations of the Medical Staff.

Cross reference:
482.22(c) Medical Staff Bylaws