HospitalInspections.org

Based on staff interview and balance sheet review, the facility failed to have an effective utilization review plan implemented and to ensure an overall budget was in effect on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/30/19 at 9:30 a.m., the Administrator confirmed the document submitted " ...Inc 11 Balance Sheet As of December 31, 2018" was the hospital's three (3) year budget plan.

Review of the facility's " ...,Inc II Balance Sheet As of December 31, 2018" revealed another company's name on the balance sheet. Further review revealed the dates and data on the balance sheet were for January 2018 through December 2018.

Cross Refer to A-0652 for the facility's failure to ensure an effective utilization review (UR) plan providing review of services furnished was implemented.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, personnel file review, and policy and procedure review, the facility failed to be in compliance with State and Local Laws on maintaining complete personnel files. Fifteen (15) out of 15 personnel files reviewed were incomplete.

Findings Include:

During an interview on 5/29/19 at 1:30 p.m. with Director of Nursing and Human Resource Director, personnel records were requested for review and revealed the following:

Review of RN Employee #1's personnel file revealed no documented evidence of job description or yearly in-service training.

Review of Director of Nursing's personnel file revealed no documented evidence of current nursing license, background check, job description, CPR certification or yearly in-service training.

Review of Pharmacy #1's personnel file revealed no documented evidence of application, background check, orientation, chest X-ray for positive TB skin test, or yearly in-service training.

Review of Administrator's personnel file revealed no documented evidence of application, job description, or yearly in-service training.

Review of RN Employee #2's personnel file revealed no documented evidence of job description, CPR certification, or yearly in-service training.

Review of Certified Nurse Aide (CNA) Employee #1's personnel file revealed no documented evidence of current license, job description, CPR certification or required yearly in-service training.

Review of Certified Nurse Aide (CNA) Employee #2's personnel file revealed no documented evidence of current license, job description, CPR certification or required yearly in-service training.

Review of Certified Nurse Aide (CNA) Employee #3's personnel file revealed no documented evidence of current license, job description CPR certification or required yearly in-service training.

Review of Activities Staff Employee #1's personnel file revealed no documented evidence of job description or yearly in-service training.

Review of Medical Records Employee #1's personnel file revealed no documented evidence of job description or yearly in-service training.

Review of Director of Support's personnel file revealed no documented evidence of job description or yearly in-service training.

Review of Social Services Employee #1's personnel file revealed no documented evidence of job description, orientation, CPR certification or yearly in-service training.

Review of Dietary Department Staff Employee #1's personnel file revealed no documented evidence of job description, or yearly in-service training.

Review of Housekeeping/Maintenance Staff Employee #1 personnel file revealed no documented evidence of orientation, job description or yearly in-service training.

Review of Pharmacy Staff Employee #2 personnel file revealed no documented evidence of job description or yearly in-service training.

Based on review of the Governing Body Board Minutes, the governing body failed to ensure quarterly meetings were held for the period reviewed 1/25/18 through 5/15/19; to ensure an effective utilization review plan was implemented; to ensure an overall budget was in effect; to ensure the medical staff held quarterly meetings; to ensure the facility maintained complete and accurate open and closed medical records for every patient; to ensure the contracted laboratory (lab) was a certified laboratory; to ensure the dishes and utensils used to prepare patient meals from 5/24/19 breakfast meal through the lunch time meal on 5/28/19 were properly sanitized; to ensure an effective utilization review (UR) plan providing review of services furnished was implemented; to ensure the overall hospital environment was maintained to ensure the safety and well-being of patients; to ensure the hospital tracks the reason for hospital readmissions, evaluate results and makes changes to the discharge planning process when identified; to ensure all professional staff license were verified and current; to ensure an effective utilization review (UR) plan providing review of services furnished was implemented; to ensure the senior care unit had occupational therapy services available; and to ensure a director of respiratory services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly was either full-time or part-time and on staff.

Findings Include:

During an interview on 5/30/19 at 2:30 p.m., the Administrator confirmed the following governing body meeting dates: 1/25/18, 3/22/18, 4/2/18, 2/27/19 and 5/15/19.

Review of the "Governing Body" meeting minutes from 1/25/18 through 5/15/19 revealed no documented evidence that quarterly medical staff meetings were held in the third or fourth quarter of 2018.

Review of the facility's "Governing Board Bylaws", page 9, review date of 1/2/19, revealed: " ...Article IV - 4.1 Meetings - Regular meeting of the Governing Body may be held as necessary, but no less than quarterly ...".

Cross Refer to A-0008 for the Governing Body's failure to ensure an effective utilization review plan was implemented and to ensure an overall budget was in effect.

Cross Refer to A-0353 for the Governing Body's failure to ensure the medical staff held quarterly meetings.

Cross Refer to A-0431 for the Governing Body's failure to ensure the facility maintained complete and accurate open and closed medical records for every patient.

Cross Refer to A-0582 for the Governing Body's failure to ensure the contracted laboratory (lab) was a certified laboratory.
Cross Refer to A-0618 for the Governing Body's failure to ensure the dishes and utensils used to prepare patient meals from 5/24/19 breakfast meal through the lunch time meal on 5/28/19 were properly sanitized.

Cross Refer to A-0652 for the Governing Body's failure to ensure an effective utilization review (UR) plan providing review of services furnished was implemented.

Cross Refer to A-0700 for the Governing Body's failure to ensure the overall hospital environment was maintained to ensure the safety and well-being of patients.

Cross Refer to A-0843 for the Governing Body's failure to ensure the hospital tracks the reason for hospital readmissions, evaluate results and makes changes to the discharge planning process when identified

Cross Refer to A-1110 for the Governing Body's failure to ensure all professional staff license were verified and current.

Cross Refer to A-1111 for the Governing Body's failure to ensure an effective utilization review (UR) plan providing review of services furnished was implemented.

Cross Refer to A-1121 for the Governing Body's failure to ensure the senior care unit had occupational therapy services available.

Cross Refer to A-1151 for the Governing Body's failure to ensure a director of respiratory services who is a Doctor of Medicine or Osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly was either full-time or part-time and on staff.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on document review, staff interview, and policy and procedure review, the facility failed to maintain and demonstrate an effective, ongoing, hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program involving all hospital departments and services focusing on indicators related to improved health outcomes; and failed to ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital depart; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors; and failed to maintain and demonstrate evidence of its QAPI program for review by CMS on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/28/19 at 1:00 p.m., and each survey day thereafter, with Administrator and Director of Nursing related to Quality Assessment and Performance Improvement (QAPI) Program, policies and projects records were requested. Review of the facility's "Quality Assurance Performance/Improvement Plan" revealed no revision of the QAPI plan since August 17, 2011. Review of QAPI documentation also revealed no documented evidence of measurable quality indicators, no data collection, no measurable progress or outcomes and no documented facility QAPI projects.

Review on 5/29/19 and 5/30/19 of Facility's Quality Assurance/Performance Improvement Plan confirmed department heads will be responsible for collecting and analyzing data and reporting any trends, actions and recommendations to the Patient Care Committee or EOC quarterly. Review on 5/30/19, of one (1) documented Patient Care Agenda/Report dated January 10, 2019, confirmed no documented quality measures noted for 2019 and no new policies and procedures developed. Report also revealed Performance Improvement (PI) projects for "2018 pending until 1st quarter meeting." Report also confirmed A & D Unit open with difficulty filling beds with focus on community relations as well as exploring need for New Community Educator. Report confirmed three (3) patient falls with two (2) injuries for fourth quarter 2018. Dashboard Report revealed discrepancy in number of fall. Dashboard Report documented no falls for fourth quarter 2018 and no fall program implemented for same period.

Based on document review, staff interview, and policy and procedure review, the facility failed to ensure a Quality Assessment and Performance Improvement (QAPI) program implemented, ongoing and facility-wide with measurable indicators on three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0263/482.21 for the facility's failure to maintain and demonstrate an effective, ongoing hospital-wide data driven Quality Assessment and Performance Improvement (QAPI) program involving all hospital departments and services focusing on indicators related to improved health outcomes.

Based on document review and staff interview, the facility failed to ensure Performance Improvement activities track medical errors and adverse patient events, analyze causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Findings Include:

Cross Refer to A-0263/482.21 for facility's failure to provide evidence aimed at performance improvement implementation of actions, measuring success and tracking performance to ensure that improvements are sustained.

Based on staff interview and documentation review there is no Infection Control data being gathered, analyzed or reviewed by the facility to identify or address potential problems related to infection control.

Findings Include:

Staff interview with the Infection Control Officer/Director of Nursing, on 5/29/19 from 02:45p.m. to 3:15 p.m. revealed no infection control data being gathered. When request infection control data being gathered she stated, "I put the Infection Control Manual in there, it's all in there."

Documentation Review of the hospital Infection Control Plan, page 4 reference #1017, effective 06/01/07, revised May 2011, revealed, ".... a risk analysis is performed by the Infection Control Department to identify behaviors and characteristics of the demography of patients being served by a healthcare facility's ability to serve that particular population."

"INFECTION CONTROL FUNCTION: ..."The Infection Control Practitioner will also maintain a close working relationship with the staff for quality assessment and improvement and patient relations functions, and will interface through all departments to achieve goals and objectives of the hospital Infection Control Program."

Page 5, reference #1017, effective 06/01/07, revised May 2011. "ACTIVITIES: Infection control activities include the following: Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management: Antibiotics-resistant organisms, HAI TB, other communicable diseases, employee health trends, Continuously collecting and/or screening data to identify isolated incidents or potential infection outbreaks. "

No data collection information was received or noted in the Infection Control Manual.

Exit conference on 5/30/19 at 6:30 p.m. identified areas of concern and no additional data was received for review.

Based on document review and interview, the facility failed to document quality improvement projects being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Findings Include:

Cross Refer to A-0263/482.21 for facility's failure to provide documented evidence of quality improvement projects being conducted, the reason for conducting projects, and measurable progress achieved on projects.

Based on staff interview and Medical Staff Bylaws review, the medical staff failed to ensure at least quarterly meetings were held for the period reviewed 1/18/18 through 4/18/19.

Findings Include:

During an interview on 5/30/19 at 9:33 a.m., the Administrator confirmed the following medical staff meeting dates: 1/18/18, 4/26/18, 5/6/18, 1/30/19 and 4/18/19.

Review of the "Medical Staff" meeting minutes from 1/18/18 through 4/18/19 revealed no documented evidence that quarterly medical staff meetings were held in the third or further quarter of 2018.

Review of the facility's "Medical Staff Bylaws", page 12, review date of 1/2/19, revealed: " ...Article II ...3.3 Medical Executive Committee (MEC) ...(C) Meetings - The MEC will meet quarterly ...".

Based on staff interview, open and closed medical record review, the facility failed to ensure a complete and accurate medical record was maintained in six (6) out of 20 medical records reviewed; Patient #3, #4, #6, #11, #12 and #13.

Findings Include:

During an interview on 5/29/19 at 10:58 a.m., the Medical Records Clerk confirmed the last acute care patient admission was on 9/20/18. Surveyor requested a copy of the delinquent medical record report, the consultants quarterly medical record review documentation and policy and procedures for the departmental functions. No documentation was submitted for review.

Medical record review for Patient #3, #4, #6 and #13 revealed no documented evidence of a discharge plan.

Medical record review for Patient #11 revealed the "Voluntary Admission Consent Form" had no documented evidence of a physician signature or date signed and the "Initial Treatment Plan/Nursing Standards of Patient Care" was incomplete.

Medical record review for Patient #12 revealed the "Voluntary Admission Consent Form" had no documented evidence of a physician signature or date physician signed.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

A-0489/482. - Conditions of Participation: Pharmaceutical Services

Based on document review, staff interview, observation, and policy and procedure review, the facility failed to ensure the pharmacy services were implemented according to facility policy and procedure on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/28/19 at 4:00 p.m., the Director of Nursing confirmed that in absence of Pharmacist #1 she was unable to provide documented pharmacy medication logs (medications removed from the pharmacy by nursing staff). Surveyor requested policy and procedure on after hours removal of medications from the pharmacy. No documentation submitted for review.

Observation of the pharmacy on 5/28/19 at 4:30 p.m. revealed three (3) vials of Haloperidol 1 mg/1 ml, expired 03/2019. Surveyor requested policy pharmacy policy and procedure on expired medications. No documentation submitted for review.

Observation of the pharmacy medication room (door labeled biohazard) on 5/29/19 at 2:00 p.m., revealed 13 boxes of medications containing stock formulary medication, patient specific medications, and controlled substances (narcotics) too many to count were stored on shelves and/or floor.

During an interview on 5/29/19 at 3:00 p.m., Pharmacist #1 confirmed he was not aware of the written pharmacy policy and procedures. Surveyor requested pharmacy policy and procedures. No documentation was submitted for review.

During an interview on 5/29/19 at 3:00 p.m. Pharmacist #1, Nursing Staff #1, and the Director of Nursing all confirmed no controlled substance medications had been ordered in the past several months.

During an interview on 5/29/19 at 3:15 p.m. Pharmacist #1 confirmed that four (4) other staff members (Director of Nursing, Charge Nurse Desk, Pharmacy Staff #1 and Pharmacist #2) have keys to Pharmacy.

Interview with Pharmacy Staff #1 on 5/30/19 at 10:00 a.m., confirmed no pharmacy key was issued to her.

During an interview on 5/30/19 at 11:30 a.m. Nursing Staff #1 confirmed the pharmacy key is a master key that unlocks multiple doors in the hospital. She further confirmed that she hands off the pharmacy keys to the Nurse Aides to open the Nurse Aide supply closet.

Observation of the Pharmacy Medication Room (labeled biohazard) on 5/30/19 at 4:30 p.m. revealed a box containing narcotics to be destroyed remained on the floor. Surveyor observed Pharmacist #1 count the contents of the box containing the following narcotics:
1. Clonazepam 1 mg - #22 - 4/12/19
2. Lorazepam 1 mg - #19 - 4/15/19
3. Clonazepam 1 mg- #5 - 2/22/19
4. Clonazepam 0.5 mg - #5 - 2/22/19
5. Clonazepam 0.5 mg - #5 - 2/22/19
6. Clonazepam 0.5 mg #19 - 3/8/19
7. Clonazepam 1 mg - #25 - 3/26/19

During an interview on 5/30/19 at 4:45 p.m. Pharmacist #1 confirmed he plans to waste medication about every six (6) months.

Review of the facility's "Pharmacy Policy Drug Procurement Inventory Control 3201", policy revision date January 2, 2019, revealed: "Responsibility for control of medications within this hospital rests with the Pharmacy Department. Policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the hospital ... .....The Pharmacy Department is locked at all times. Access is limited to pharmacists and Pharmacy Department Personnel under the direct supervision of a Pharmacist". Further review revealed the hospital's policies and procedures do not address how to prevent unauthorized personnel from gaining access to locked areas where drugs and biologicals are stored.

During exit conference on 5/30/19 at 6:30 p.m., survey findings were discussed and no further documentation was submitted for review.

Based on staff interview, review of pharmacy and therapeutic committee minutes, review of pharmacy medication logs and policy and procedure review, the facility failed to ensure the pharmacy or drug storage area is maintained and secured according to pharmacy policies and procedures and that pharmacist #1 developed, supervised, and coordinated all activities of pharmacy on three (3) of three (3) days of survey.

Findings Include:

Cross Refer A-0489/482.25 for facility's failure to ensure the pharmacy drug storage area was secure.

Cross Refer A-0489/482.25 for the pharmacist's failure to coordinate all activities of pharmacy.

Based on staff interview and contract review, the facility failed to ensure the contracted laboratory (lab) was a certified laboratory on three (3) of three (3) days of survey.

Findings Include:

5/29/19 at 10:50 a.m. - Entrance conference was stopped to tour patient care areas due to problems with air conditioning.

During an interview on 5/28/19 at 10:50 a.m., the Human Resources Director confirmed the Lab area was shutdown. She confirmed they (hospital) send their lab to another contracted hospital. She confirmed the lab area had been shut down since 2014.

During an interview on 5/30/19 at 9:30 a.m., the Administrator confirmed the facility contracts their laboratory services with another hospital. Surveyor requested a copy of the Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver for the contracted hospital, current lab contract and facility policy and procedure. No documented evidence of a current CLIA certificate for the contracted hospital or facility policy and procedure was submitted for review.

Review of the facility's "Service Agreement" for laboratory services dated 1/5/10 revealed: "This service Agreement ...shall become effective 1/5/10 ...and is between the facility and the contracted hospital. Background: ...facility is of the opinion that ...contracted hospital has the necessary qualifications, experience and abilities to provide services to the customer ...". No documented evidence of a current CLIA certificate for the contracted hospital was submitted for review.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on observation and staff interview, the facility failed to ensure the dishes and utensils used to prepare patient meals from 5/24/19 breakfast meal through the lunch time meal on 5/28/19 were properly sanitized on one (1) of three (3) days of survey.

Findings Include:

Observation of the dietary department on 5/28/19 at 2:40 p.m. revealed the kitchen dishwasher had been out of order since 5/24/19 and the three (3) compartment sink was being used to sanitize the dishes.

During an interview on 5/28/19 at 2:40 p.m., the Dietary Director confirmed the dishwasher had been broken since this past Friday, 5/24/19 and the kitchen had been using the three (3) compartment sink to clean and sanitize the dishes. She confirmed the cleaning solutions and sanitizer in the three (3) compartment sink were automatic. Surveyor requested to review the documentation on the three (3) compartment sink since Friday 5/24/19. She confirmed the Dietary Department Cook #1 said he forgot to record the result of the sanitizer. When asked Dietary Department Cook #1 if he had recorded the sanitizer solution results, he confirmed he had forgot to record the results. Surveyor requested a copy of the facility policy on three (3) compartment sink, a copy of the manufacturer guidelines on how to verify the three (3) compartment sink sanitizer was ready for use and documentation on the three (3) compartment sink since 5/24/19. No documentation was submitted for review.

During Exit Conference on 5/20/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview and policy and procedure review, the facility failed to ensure an effective utilization review (UR) plan providing review of services furnished was implemented on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/28/19 at 2:10 p.m., the Director of Nursing (DON) confirmed she was responsible for the UR services. She said she does (performs) it (UR) but does not document it (UR).

Review of the facility's "Clinical Standards for Utilization Management" policy, reviewed on 1/2/19, revealed: "Purpose: The utilization management plan's objective is to provide both quality patient care and effective utilization of available health facilities and services ...It provides for timely review of the medical necessity for admission, continued stays and services rendered ...The utilization management program applies to all patients regardless of payment source ...Concurrent Review: ...Within one (1) working day of admission, the Utilization Review must screen the medical record of patients identified for review to determine medical necessity and appropriateness of admission ...".

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on observation and staff interview, the facility failed to ensure the overall hospital environment was maintained to ensure the safety and well-being of patients on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/28/19 at 11:05 a.m. the Human Resources Director confirmed rooms #114 through #117 were used for acute care patients. Further observation revealed theses rooms had closed doors that were secured with a black strap like a zip tie. She confirmed rooms #118-#130 had not been in use since 2014. She confirmed the acute care floor was shut down at this time and not in use.

Observation of the acute care floor on 5/29/19 from 3:55 p.m. through 4:15 p.m. revealed:
Room #114 had no bed and the oxygen was not operable.
Room #115 had five (5) boxes of Halloween supplies stored in the room and loose wire hanging from ceiling over the patient bed that was still attached to the TV and the oxygen was not operable.
Room #116 had an out of order bathroom, the sink leaking on the hot water side, a hole in the wall to the right of the sink and the oxygen was not operable.
Room #117 had multiple holes in the walls and the oxygen was not operable.
Crash cart was not stocked with supplies.
Patient bathroom was not operable. There was a sign on the bathtub that read "Stopped up drain".

During an interview on 5/29/19 at 4:17 p.m., the Administrator confirmed the oxygen in the acute care rooms was not operable. She confirmed the facility would have to use oxygen concentrators in the acute care rooms. Surveyor requested a copy of the facility policy and procedure on upkeep of the physical environment. No documentation was submitted for review.

Observation of the senior care floor on 5/30/19 from 10:50 a.m. through 11:40 a.m. revealed:
Room #101 had broken surfaces on the edges of the bedside table and loose ceiling tile in the bathroom.
Room #102 had four (4) small holes in the wall over sink area and a broken toilet paper holder in the bathroom.
Room #103 had four (4) small holes is the wall over the sink area, a broken toilet paper holder in the bathroom, small holes in the wall by the patient closet.
Room #106 had scuff marks on the wall by the sink and peeling paint on the closet door.
Room #107 had scuff marks on all four (4) walls and a broken wall surface on left side of the air conditioner.
Room #108 had scuff marks on all four (4) walls, peeling paint on the wall by the window and four (4) small holes in the wall over the sink area.
Room #110 had a broken toilet paper holder in the bathroom, four (4) small holes in the wall over the sink area and the air conditioner was not working.
The dayroom had a broken toilet paper holder in the bathroom, no sink was in the bathroom, a broken wall surface and peeling paint on the wall to the right of the bathroom.

During an interview on 5/30/19 at 11:40 a.m., RN#1 confirmed no call lights were operable in any of the senior care patient rooms and maintenance is aware. She also confirmed Room #110 was not being used for patient care at this time.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on documentation review and staff interview, the facility failed to have an active program in place for the prevention, control and investigation of infections and communicable diseases on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/29/19 from 2:45 to 3:15 p.m., the Infection Control Officer/Director of Nursing confirmed she did not have an updated list of communicable diseases and no information on how to report on required reportable diseases. When asked how the hospital complied with the reportable disease requirements, she stated, "I'm not sure" and "I have only been doing this job since October 2018 and was not aware I was supposed to keep up with that." Surveyor requested a copy of the facility policy and procedure. No documentation was submitted for review. No additional data received.

Review of the facility's "Infection Control Plan", reference #1017, page 2 of 9, effective 06/01/07, revised May 2011, revealed: "PURPOSE: The Infection Control Program at this hospital incorporates the following in a continuing cycle: ....Reporting: Provision of information to external agencies as required by state and federal law and regulation ...".

During Exit Conference on 5/30/19 at 6:30 p.m., the survey findings were discussed and no further documentation was submitted for review.

Based on staff interview and documentation review, the facility failed to ensure respiratory fit testing.

Findings Include:

Staff interview the Infection Control Officer/ Director of Nursing on 5/29/19 2:45 p.m. to 3:15 p.m., revealed when asked if they have fit tested respiratory mask she stated "not that I am aware of" that the hospital does not have respiratory mask that are fit tested.

Documentation review of the hospital policy titled "Infection Control Plan", Reference #2011, page 3 of 8, effective 6/2007 and revised May 2011 revealed underneath section titles:
"-Airborne transmission:
...In addition, special respiratory protection with NIOSH approved N-95 masks must be used to prevent transmission ....".

"PERSONAL PROTECTIVE EQUIPMENT:", continued under page 4, reference #2011, effective 06/07, revised May 2011.
"Particulate Respirators: Respiratory protection through the use of a NIOSH approved N95 dust/mist respirator is an OSHA requirement for all HCW to protect them against M. Tuberculosis. N-95 respirators are used in caring for patients with SARS, Varicella zoster(chicken pox) small pox and measles. Respirators should be used when caring for all patients in AII Isolation.
Respirators must be test fitted for each HCW using the most recent fit-testing protocol as issued by OSHA. It is presently required to fit-test all HCW's who care for AII patients at the time of hire and annually thereafter."

No further data received.

Based on staff interview, medical record review and policy and procedure review, the facility failed to ensure the discharge planning process applied to all patients in four (4) of 20 medical records reviewed; Patient #3, #4, #6 and #13.

Findings Include:

During an interview on 5/28/19 at 2:30 p.m. with the Director of Nursing (DON) and Administrator, both were asked for the documentation on how the facility reviews their discharge planning process and readmissions. No documentation was submitted for review.

Medical record review for Patient #3, #4, #6 and #13 revealed no documented evidence that a discharge plan was initiated, ongoing and finalized prior to each patient discharge.

Review of the facility's "Continuing Care Plan" policy, reviewed on 1/2/19, revealed: "1.0 Purpose - Discharge from the hospital is a transition point for most patients ...This is where solid discharge planning can play such a vital role. 2.0 Policy - Planning the patient's discharge may involve addressing several issues ...Thus it is apparent that each patient needs assistance in preparing for discharge while the patient is still in the hospital. In fact, due to the enormity of the task, planning needs to begin at the time of admission ...As the patient progresses through treatment their needs will come into sharper focus and specific plans may then begin to take shape ...Each patient should leave the hospital with a written plan for continuing care ...It is the responsibility of the Therapist/Social Worker and Community Educators to ensure that discharge planning and follow through occurs. It is the responsibility of the Program Director to establish a mechanism to assess if continuing care is provided".

During Exit Conference interview on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, the facility failed to ensure the hospital tracks the reason for hospital readmissions, evaluate results and makes changes to the discharge planning process when identified on three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0799 for the facility's failure to ensure the discharge planning process was tracked, evaluated and changes were implemented on hospital readmissions.

Based on organ procurement contract review, policy review, lack of Tissue Donation Report, and staff interview, the facility failed to ensure specific organ, tissue, and eye procurement requirements are met.

Findings Include:

Interview with Director of Nursing on 5/28/19 at 1:00 p.m. confirmed no knowledge of organ procurement policy and/or contract.

On 5/30/19, review of Facility "Organ and Tissue Donation" Policy #1011 effective 02/01/07 confirmed unmet specific requirements as evidenced by no definition of "imminent death".

Review on 5/30/19 of the written agreement with Mississippi Organ Recovery Agency (MORA) confirmed it had expired. Effective date of agreement was March 11, 2014, and term of agreement was annual review, not to exceed a period of five (5) years, until terminated either by MORA or the Hospital upon sixty (60) days prior written notice. No documented evidence of annual review.

Surveyor requested MORA activity for the past 12 months and no documentation was submitted for review.

Review of personnel records and staff interview on 5/30/19 confirmed no documented evidence of training of all patient care staff on donation issues in cooperation the MORA, including the consent process, importance of using discretion and sensitivity when approaching families; role of designated requestor; transplantation and donation, quality improvement activities, and role of the organ procurement organization.

Based on staff interview and policy and procedure review, the facility failed to ensure the definition of imminent death was included in the Organ Procurement policy.

Findings Include:

Cross Refer to A-0884/482.45 for facility's failure to address the definition of imminent death.

Based on review of staff interview and contract review, the facility failed to ensure an Organ Procurement Organization (OPO) contract was in place on three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0884/482.45 for facility's failure to ensure a current agreement with an OPO was in place.

Based on review of policies, QAPI, training records, and contracts, the facility failed to show documented evidence of working cooperatively with the designated Organ Procurement Organization (OPO) in educating staff on donation issues on three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0884/482.45 for facility's failure to show documented evidence of working cooperatively with the designated OPO in educating staff on donation issues.

Based on personnel record review, the facility failed to ensure all professional staff license were verified and current on three (3) of three (3) days of survey.

Findings Include:

Personnel file review for the DON revealed no documented evidence of a current nursing license.

Based on staff interview and policy and procedure review, the facility failed to ensure an effective utilization review (UR) plan providing review of services furnished was implemented on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/28/19 at 2:10 p.m., the Director of Nursing (DON) confirmed she was responsible for the UR services. She said she does (performs) it (UR) but does not document it (UR).

Review of the facility's "Clinical Standards for Utilization Management" policy, reviewed on 1/2/19, revealed: "Purpose: The utilization management plan's objective is to provide both quality patient care and effective utilization of available health facilities and services ...It provides for timely review of the medical necessity for admission, continued stays and services rendered ...The utilization management program applies to all patients regardless of payment source ...Concurrent Review: ...Within one (1) working day of admission, the Utilization Review must screen the medical record of patients identified for review to determine medical necessity and appropriateness of admission ...".

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, the facility failed to ensure the senior care unit had occupational therapy services available on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/28/19 at 2:15 p.m., the DON confirmed the facility does not have an Occupational Therapist employed or contracted.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, contract review and review of the facility's physician roster, the facility failed to ensure a director of respiratory services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly was either full-time or part-time and on staff on three (3) of three (3) days of survey.

Findings Include:

During an interview on 5/29/19 at 3:25 p.m., the Administrator confirmed the facility provides the following respiratory services: breathing treatments, nebulizer and oxygen according to physician orders. She confirmed the facility does not have a physician director of respiratory services. She stated, "Respiratory Services are contracted."

Review of the facility's contracts revealed a contract with "Southern Respiratory service dated 06/07/07 with a one (1) year auto-renewal.

Review of the facility's "Physician Roster" list revealed no documented evidence of a Physician with respiratory credentials listed as on staff.

During Exit Conference on 5/30/19 at 6:30 p.m. survey findings were discussed, and no further documentation was submitted for review.