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

Tag 0273: the hospital's failure to monitor the effectiveness of the safety of services and quality of care provided related to patients who were admitted to inpatient units when the hospital was at capacity as required by the hospital policy on Overcapacity and

Tag 0321: failed to have a hospital quality plan individualized from the system quality plan that takes into account the hospital's unique circumstances and significant differences in patient populations and services offered for the hospital as evidenced by there not being a focus on psychiatric services and outpatient services identified in the approved quality plan.

The cumulative impact of this failure has a potential risk to health and safety of the patients by not having an fictive plan to evaluate the care and services of the Psychiatric Hospital when the hospital admits high risk behavioral health patients to include children from the age of 6 to adults.

Based on a review of medical records, census documents, interviews and tour, it was determined the hospital failed to monitor the effectiveness of the safety of services and quality of care provided related to patients who were admitted to inpatient units when the hospital was at capacity as required by the hospital policy on Overcapacity.

Findings include:

The surveyor observed on tour on 04/29/2021 there were patients in the Child and Adolescent Observation outpatient unit who were being held there due to there not being inpatient beds at the hospital nor at other hospitals in the valley. The patients were all seen in the Intake Department of the hospital.

The surveyor reviewed the inpatient census documented provided and the census indicated patients were admitted to the hospital as overcapacity. These patients were admitted to the outpatient child and adolescent unit, inpatient child and adolescent unit, adult inpatient (AP3), and adult inpatient (AP5).

The surveyor toured the areas and observed the areas the patient's were placed in when admitted as an overcapacity patient. The location of these rooms were on the units and in rooms that were used as small group rooms or previously used as offices. A tour on 05/05.2021 revealed the room on the Child and Adolescent unit was bare except from some patient clothing items and a platform bed with a mattress on top of the platform. This room was currently occupied by a inpatient and the inpatient had been in the room for three days.

The surveyor identified the hospital has a policy on overcapacity and it outlines the procedures to be completed by hospital personnel and medical staff as well as the definition of an emergency condition.

The policy revealed all admissions were to have an Emergency Placement Assessment completed in intake and the form was to be scanned to the patient's record and a form provided to Employee #6..

The policy revealed the Quality Department will evaluate each occurrence of exceeding licensed capacity, including any actions taken for resolving occurrences of exceeding licensed capacity.

The surveyor reviewed five patients who were designated as over capacity patients admitted on the following dates: 04/15/2021 patient admitted to the Child and Adolescent unit, 04/19/2021 patient admitted to Child and Adolescent unit, 04/28/2021 patient admitted to Adult Psychiatric 3 unit, 05/02/2021 patient admitted to the Child and Adolescent unit, and 04/19/2021 patient admitted to the Child and Adolescent unit.

The survey asked Employee #1 and Employee #6 to provide documentation that the Emergency Placement forms were completed and what quality review had been completed related to these cases as required by the procedure within the policy.

Employee #6 was able to provide 2 of the 5 Emergency Placement Assessment forms to the surveyor. Employee #6 stated the other forms had not been completed. There was no documented evidence of the forms scanned into the medical record of the patients. There was no other identified process in place that would trigger a review of patients in overcapacity for data collection, analysis and action as appropriate.

The Governing Body minutes of March 18, 2021 revealed an old business topic of overcapacity. The discussion related to if the current process met the requirement for evaluation. The action plan was to have a separate meeting to discuss. Employee #6 stated there had not been a follow up meeting as of 05/05/2021 and there was not one scheduled at this time.

Employee #6 confirmed there was no process in place to monitor the overcapacity documentation to ensure the process as identified in the policy and procedure was followed.

Based on review of the Governing Board's hospital approved quality plan, meeting minutes, and interviews, it was determined that the approved unified multi-system hospital plan failed to take into account the hospital's unique circumstances and significant differences in patient populations and services offered for the hospital as evidenced by there not being a focus on psychiatric services and outpatient services identified in the approved quality plan.

Findings Include:

The Quality Plan for St. Luke's Medical Center was requested on the day of initiation of the complaint validation, April 29, 2021. The plan revealed on the title says Steward health Care System, LLC Quality and Patient Safety Plan Effective for Calendar Year 2020 - 2021. Updated July 2020. The plan outlines in the document the major components of the Steward health Care System Hosptial Division quality and patient safety plan. The plan begins with the Steward Vision and then transitions to the Structure and Accountability for the Steward health Care: Hospital quality and Safety Information Flow.

In the flow there is flow chart that had the Hospital Board of Directors at the top with two way communication with the Medical Executive Committee and the Quality Committee of the Board of Directors. Then feeding into the Medical Executive and the Quality Committee of the Board of Directors is the Medical Staff, Clinical Operational Committees and Hospital Administration.

The plan identifies the Board of Directors as the overall reasonability and accountability for the quality of patient care including the safety of patient, staff and visitors and the appropriate utilization of resources as well as the credentialing of the medical staff as established by the Medical Staff Bylaws.

The plan endorses the PDSA process. Pan, Do, Study, and Act. There are two Appendix. Appendix A documented the committees that would be included in the quality plan and Appendix B documented the Steward Health Care Quality and Safety Indicators.

The Appendix B document represented 44 indicators that according to the plan that may be employed routinely or episodically as appropriate. The 44 indicators do not address outpatient services specifically.

There was no specific document that addressed how St. Luke's Behavioral Hospital's Quality Plan is individualized focusing on the population of behavioral health, which is the only patient population served as well as a focus on the child and adolescent patient population.

The surveyor reviewed the quality documents being implemented at the hospital Quality Committee and to the Board of Directors. There are some specific indicators, however these indicators are not reflected in a plan.

Employee #6 provided the Hospital Quality Committee documentation for January, February and March 2021. The minutes reflected some reports with some action plans documented. Employee #6 provided the Governing Board's meeting minutes for November 2020, February 2021, and March 2021. The November 2020 minutes revealed Quality for the third quarter of 2020 was reported by Employee #6. The Board unanimously approved the quarterly reports as presented.

The surveyor interviewed Employee #6 on 05/05/2021. During this interview, Employee #6 confirmed the plan reviewed by the surveyor was the plan approved by the Governing Board.

Based on documentation review and interview, it was determined the hospital failed to require medical record maintained by a psychiatric hospital contained the degree and intensity of the treatment provided to the patients as evidenced by:

Tag 1632: the hospital's failure to require one of two licensed and credential nurse practitioners complete a history and physical for 6 of 6 patients admitted to the observation stabilization unit on the dates of 04/23/2021 through 04/27/2021 within 24 hours as required by the hospital's Medical Staff Rules and Regulations.

Tag 1642: the hospital's failure to require there were written care plans with goals that described the achievement timeline or revision of the plan as the patient's stay progressed as required by the hospital policy and procedure for the Outpatient Crisis Observation Stabilization Unit (OSCA) for 5 of 6 medical records reviewed that described goals and interventions for the individuals admitted to the area.

Tag 1645: the hospital's failure to require treatment and rehabilitation progress notes indicated how the activities and interventions related to the patient's goals and the patient's response to the interventions, as evidenced by the electronic documentation separated the goals, interventions, and patient responses in different areas of the record which did not allow a tracking of progress or lack of progress or confirmation of individualization of the plan based on the patient's needs and progress through the coarse of the plan.

The cumulative effect of this has the potential risk of the coordination and systematic treatment of the patient with a documentation process that allows all staff to know the status of the patient, patient's response to interventions, and how this relates to the goals identified by the professional team to include the patient and family.

Based on medical record reviews, Medical Staff Bylaws Rules and Regulations review, interview and observations, it was determined the hospital failed to require one of two licensed and credential nurse practitioners complete a history and physical for 6 of 6 patients admitted to the observation stabilization unit on the dates of 04/23/2021 through 04/27/2021 within 24 hours as required by the hospital's Medical Staff Rules and Regulations.

Findings include:

The St. Luke ' s Behavioral health Center Medical Staff Rules and Regulations document revealed: ' .. Admission Policies ... 6. Admission by On-Call Physician: The admitting or "on-call: physician may transfer care to another physician, but the admitting physician is responsible for the patient ' s care until responsibility is assumed by the accepting physician .... '

The St. Luke ' s Behavioral Health Center Medical Staff Rules and Regulations document revealed: "... A medical history and physical examination (H&P) must be performed and documented by a Physician, Oral Surgeon, or other qualified licensed individual (as identified\ in applicable Medical Staff or Hospital Policies), no more than thirty (30) days before or twenty-four (24) hours after admission or registration ...."

Interview with Employee #1 conducted on April 30, 2021 confirmed that for the Observation Crisis Stabilization unit the Psychiatric Consult document is the required provider documentation and represents the history and physical of this outpatient department of the hospital and is required to be completed within 24 hours of the patients admission to the Observation Stabilization Unit.

Patient #1
Patient #1's medical record revealed the patient was admitted to the Observations Crisis Stabilization Unit (OSCA) on 04/25/2021 as a transfer from an acute hospital. The on-call provider (Provider #1 documented an order on 04/25/2021 at 23:26 the patient was to be admitted. Generic orders were documented i.e. diet, nurse routine, vital signs. On 04/26/2021 Patient #1 was ordered by Provider #1 to be admitted as an inpatient.

Provider # 2 documented on 04/28/2021 at 0652 the first Psychiatric consultation related to Patient #1. This was three days after the patient was admitted to the OSCA unit and two days after the patient was ordered to be admitted to the inpatient within first documented Psychiatric Consultation was documented.

Patient #2
Patient #2's medical record revealed the patient was admitted to the Observations Crisis Stabilization Unit (OSCA) on 04/25/2021 as a transfer from an acute hospital. The on-call provider (Provider #1) documented an order on 04/25/2021 at 23:26 the patient was to be admitted. Generic orders were documented i.e. diet, nurse routine, vital signs. On 04/26/2021 Patient #1 was ordered by Provider #1 to be admitted as an inpatient. Patient #2's medical record revealed there was no documented Psychiatric Consult documented on the medical record at the time of the review of the record on 04/29/2021. This was three and 1/2 days after the admission to the unit.

Patient #3
Patient #3's medical record revealed the patient was admitted to the Observations Crisis Stabilization Unit (OSCA) on 04/25/2021 at 1600 as a transfer from an acute hospital. The on-call provider (Provider #1) documented an order on 04/25/2021 at 15:35 the patient was to be admitted to the OSCA unit. Generic orders were documented i.e. diet, nurse routine, vital signs. On 04/26/2021 Patient #3 was ordered by Provider #1 to be discharged. There was no documented evidence of a Psychiatric Consult on the Medical Record by Provider #1 or any other provider as of the closed record review on 04/29/2021.

Patient #4
Patient #4's medical record revealed the patient was admitted by Provider #1 to the OSCA unit on 04/25/2021 at 18:22. There is no documented evidence in the medical record of a Psychiatry Consultation until 04/28/2021 and Physician #2 completed the document at 0656 on the 28th of April. This was three days after the patient's admission and 2 days after the patient was order to go to inpatient status on 04/26/2021 at 14:30.

Patient #5
Patient #5's medical record revealed the patient was admitted to the OSCA unit on 04/24/2021 at 0047. Provider #2 documented the admission order and the generic orders for. diet, nurse routine, and vital signs. Provider #1 assumed care of the patient in the morning and ordered the patient to be inpatient when bed available at 18:38. The record revealed no evidence of a Psychiatric Consultation until 04/27/2021 when Provider #1 documented a draft report at 18:44. This was 3 days after admission and 3 days after the patient was determined to require admission to the acute care unit.

Patient #6
Patient #6's medical record revealed the patient was admitted to the OSCA on 04/23/2021. The on-call provider (Provider #2 documented an order on 04/24/2021 at 00:25 for admission to the OSCA unit. Generic orders were documented i.e. diet, nurse routine, vital signs were documented by Physician #2. Based on interview with Employee #1 and confirmed by Employee #6, Provider #1 assumed care of the patient that am since Provider #1 was the on call physician at that time. The surveyor and Employee #1 reviewed the medical record and found that there was no documented Psychiatry Consultation, which is the History and Physical for the hosptial documented until 04/28/2021 when Physician #2 documented after realizing there had not been any provider documentation since the patient admission to the hospital. This was four days after admission and four days after the patient was determined to need inpatient acute care.

The surveyor conducted interviews with Employee #1, Employee #2, and Employee #6 on 04/29/2021 throughout the day of 04/29/2021 and Employee #1 present at the record review and visualized the same documentation as described above for Patient 1 through 6. All of these individuals confirmed that a documented licensed provider credentialed to admit patient to the unit was required to conduct and document a Psychiatric Consult within 24 hours of admission to the OSCA unit.

Based on medical record review, interviews, and observation, it was determined the hospital failed to require there were written care plans with goals that described the achievement timeline or revision of the plan as the patient's stay progressed as required by the hospital policy and procedure for the Outpatient Crisis Observation Stabilization Unit (OSCA) for 5 of 6 medical records reviewed that described goals and interventions for the individuals admitted to the area.

Findings include:

Hospital policy for Admission Assessment - OSCA dated 03/21/2021 under Procedure A. 10. "... Complete OSCA Care Plan - treatment plan for observation.

Employee #1, Employee #3, and Employee #2 revealed during interviews conducted on April 29, 2021 the OSCA unit was the unit where adolescents and kids ages from 6 to 17 were admitted for evaluation for inpatient admission. This unit is part of the inpatient certified hospital.

Employee #2 confirmed on 04/29/2021 the form titled OSCA Care Plan was the Treatment Plan required in the policy and procedures. There was no documented procedure for the use of the OSCA Care Plan

Patient #1
Patient #1 was admitted to the OSCA unit on 04/25/2021. The reason for admission was an attempt to harm self. The OSCA Care Plan revealed a goal for "Coping" with no interventions to address this goal. The goal according to the documentation was identified by the patient in the patient's own words.

The provider ordered the patient to be admitted to the inpatient program on 04/26/2021 and there was no update to the plan. The patient remained in the OSCA unit until 04/28/2021. There is documented evidence ongoing evaluation of the plan during the extended stay in the OSCA unit from the time of the initial plan on 04/26/2021 through the patient's transfer on 04/28/2021.

Patient #2
Patient #2 was admitted to the OSCA unit on 04/25/2021 from the intake unit. The reason for admission was substance abuse and the patient had frequent episodes of running away from home. The OSCA Care Plan revealed in the patient's own works "no goal". There was no documented evidence of goals by the hospital personnel. The plan documented the patient receiving a coping skills packet, group, and 1:1. There was no documented evidence of determined goals or achievement timelines for the time from 04/25/2021 through the transfer of the patient to an inpatient status and moved out of the OSCA unit on 04/26/2021.

Patient #4
Patient #4 was admitted to the OSCA unit on 04/25/2021 with a presenting issue of suicidal ideations. The OSCA Care Plan revealed the patient had no goals and there was no documentation on the plan by the OSCA personnel of any goals with achievement days or interventions related to the patient's stay at the hospital. The provider ordered the patient to be admitted to inpatient on 04/26/2021. The patient remained in the OSCA unit until 04/28/2021 when the patient was transferred. There was no documented evidence of additions to the patient's care plan for 3 days. There was no evidence of treatment modalities that were provided during this three day stay at the hospital.

Patient #5
Patient #5 was admitted to the OSCA unit on 04/23/2021 with a presenting issue of aggression and extremely impulsive behavior. The OSCA Care Plan revealed the patient described the goal of "not break into people's houses". There was no documentation of goals identified for the patient by the OSCA personnel in collaboration with the patient and other team members. There was a note under the interventions which revealed the following: "... observation, coping skills packet, group, ...."

The provider ordered this patient for inpatient services on 04/25/2021. The patient remained on the OSCA unit until the evening of 04/28/2021 with no documentation of goals or interventions to address the presenting concerns.

Patient #6
Patient #6 was admitted to the OSCA unit on 04/23/2021 with a presenting issue of anger, additions, depression and anxiety. The OSCA Care Plan revealed the patient's goal of "manage my anger better". There was no documentation of goals identified for the patient by the OSCA personnel in collaboration with the patient and other team members. There was a note under the interventions which revealed the following: "... observation, coping skills packet, group, ...."

The provider ordered the patient for inpatient services on 04/24/2021. The patient remained on the OSCA unit until mid-day on 04/28/2021. There was no documented evidence of adjusted to the care plan or interventions to address the presenting concerns.

The surveyor observed a group activity on 04/30/2021 at 0945 in the OSCA area. During this group activity there were individual goals identified with the assistance of the Behavioral Health Technician (BHT) and the goals were documented on the white board for each of the patients to see. The BHT was asked what happens once they document these goals and the BHT responded each patient is continually reminded to use the identified coping skills to achieve the goals. This activity is not documented in the medical record.

Interview with Employee #2 on 04/29/2021 revealed there are several workbooks that are age specific that are utilized during the OSCA stay. There is no documentation of this activity in the medical records reviewed on 04/29/2021 and 04/30/2021. Employee #2 stated these go home with the patients and are not maintained in the medical record.

The surveyor interviewed Employee #5 and Employee #6 on 04/30/2021 and each confirmed the BHTs actions are not documented in the medical record. The BHT is only allowed to document the vital signs and the every 15 minute safety checks.

Based on observation, medical record review, and interviews, it was determined the hospital's treatment and rehabilitation progress notes failed to indicate how the activities and interventions related to the patient's goals and the patient's response to the interventions, as evidenced by the electronic documentation separated the goals, interventions, and patient responses in different areas of the record which did not allow a tracking of progress or lack of progress or confirmation of individualization of the plan based on the patient's needs and progress through the coarse of the plan. This was observed in the records of Patients # 10, 13, 15, 16, 17 and 8.

Findings include:

The surveyor reviewed the hospital policy and procedure for Inpatient Treatment Planning last revised on 10/13/2020. The policy stated all patients admitted to St. Luke' Behavioral Health will receive a plan for care, treatment, and services that is individualized to meet the patient's unique needs through interdisciplinary treatment plan process. The plan is maintained and revised based on the patient's response.

The procedure for the treatment policy revealed that upon admission to the inpatient unit, the initial/preliminary individualized treatment plan is initiated by the admitting registered nurse within eight hours and formulated on the basis of the input from the admitting intake/provider's assessment, nursing assessment, patient/family/ case manager input.

In review of multiple medical records, the surveyor identified there were three areas in the electronic record where goals, interventions, and patient responses could be found. In review of the inpatient records with Employee #1 and some were reviewed with Employee #6 and #11 the surveyor and the employees had difficulty in tracking the patient's progress of the goal and how the interventions would be applicable to the individual patients.

The surveyor was guided through the medical record with the assistance of Employee #1. Treatment plans for Patient's #15, 16, and 17 failed to have documented evidence the identified goals had interventions, and noted progress to the interventions identified in the patient's medical records.

Detail of Patient #8's medical record provided as an example of the failure of documentation of interventions, how the interventions relate to the goals, patient's progress to the goals and the patients response to the activities.

Patient #8's record revealed on March 21, Vocational Training, on March 22, 2021 the notes indicated the patient was provided with the GED information. There was no documented evidence of follow up as to if the patient was pursing the GED or determined this was not to be part of the treatment plan for the patient.

The record documentation included the need for academic coping skills with value clarification. There was no documenation of the patient's response to this plan or when the plan was implemented.

The documentation on March 29 the record indicated the patient participated in the team challenges and development of listening skills. There was no documentation as to how the patient participated and/or if the participation was appropriate.

On April 1 the record indicated there was a focus on reading and writing skills. There was no documentation as to the patient's response to this activity and how this activity related to the goals.

At the time of discharge there was no closure to the goals or summary of the patient's success or non success to the treatment plan interventions.

Interview with Employee #11 who implements the treatment plans for both the children and the adults reviewed the records and confirmed there was not documentation of the patient's response only documentation of the activity that was provided. The notes indicated the patient progressing, however there was no documentation as to what progressing meant and if the plan was adequate or needed to be adjusted based on the patient's responses.