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Based on the number and nature of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Governing Body. Specifically, the governing body allowed the facility, identified as Hospital A, to comingle space and services with a separately certified hospital, Hospital B, in a manner that did not permit either hospital to comply with all applicable conditions of participation.

The failures resulted in the co-mingling of patient services, physical space, and personnel with Hospital B, creating confusion for patients and visitors for both the facility and Hospital B. Additionally, the failures resulted in opportunities that affect health outcomes, patient safety, and quality of care being overlooked by the quality department and governing body and resulted in an increased risk of negative patient outcomes.

Cross-reference:

A-0083 - Standard: The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. The governing body failed to ensure contracted services were provided in a manner which allowed the hospital to comply with applicable conditions of participation and standards of care. These failures resulted in opportunities that affect health outcomes, patient safety, and quality of care being overlooked and resulted in an increased risk of negative patient outcomes. Further, the failures did not permit the hospital to comply with all applicable conditions of participation and standards for the contracted services.

A-0093 - Standard: If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. The facility relied on a separately certified hospital (Hospital B) to provide services for emergencies. Further, the facility failed to provide initial treatment needed by persons with emergency conditions and failed to arrange necessary transport to an appropriate facility. These failures potentially contributed to delays in the provision of emergency medical treatment and poor patient outcomes.

Findings:

Based on observations, interviews and document reviews, the governing body did not maintain separate hospital space and services in a manner that permitted the facility to comply with all applicable conditions of participation.

The failure resulted in the comingling of patient services, physical space, and personnel with a separately certified facility, Hospital B, creating confusion for patients and visitors for both the facility and Hospital B.

1. The facility comingled space with a separately certified hospital (Hospital B).

a) Review of the facility's first floor level floor plan revealed Hospital A's space (the facility) was surrounded by Hospital B's outpatient Transitional Care Clinic, outpatient Wound Care Clinic, and Medical Records Department.

b) An interview was conducted with the Plant Services Coordinator (PSC #18) on 03/17/16 at 8:10 a.m. PSC #18 stated the facility owned hospital space that was surrounded by Hospital B's space on the first floor of the facility.

c) On 03/17/16 at 8:15 a.m., a tour of the medical records department and pharmacy was conducted with PSC #18 and the Regulatory Manager (Manager #17). Observation revealed the surveyors passed Hospital A's pharmacy and Hospital B's outpatient wound care clinic while proceeding to the medical records department, which processed medical records for both the facility and Hospital B. Observation of the sign on the door of the medical records department revealed both the facility's name and Hospital B's name directly above the words "Medical Records," along with the operating hours of 8:00 a.m. to 4:00 p.m.

An interview was conducted with Manager #17 during the tour. S/he stated patients of both the facility, Hospital A, and of Hospital B could come downstairs to the medical records department that serviced both the facilities and request medical records from whichever facility they had received services from.

d) During the same tour, observation revealed walking through a corridor that contained the facility's inpatient pharmacy in order to get to Hospital B's outpatient Transitional Care Clinic and outpatient Intravenous (IV) Infusion Center.

e) According to the floor plan provided by PSC #18 on 03/17/16 at 8:18 a.m., the "CT" room was a part of the facility's space.

An interview was conducted during the tour on 03/17/16 at 8:33 a.m. with Hospital B's (Registered Nurse, RN Q) while s/he was restocking items in the CT room used for the outpatient Transitional Care Clinic. S/he stated the CT room was used to see Hospital B's Transitional Care Clinic patients.

f) Further observation during the same tour revealed the outside entrance of Hospital B's outpatient Transitional Care Clinic had signage on the automatic sliding doors that read "Transitional Care Clinic" (for Hospital B) and Hospital A "East Entrance." Upon entering the automatic sliding doors Patient Access Representative (Representative P) stated s/he was responsible for registering patients for the outpatient Transitional Care Clinic from the facility and Hospital B, but only Hospital A patients on Wednesday from 8:00 a.m. to 11:00 a.m., on a first come, first serve basis. Representative P stated s/he registered patients for Hospital B's Transitional Care Clinic at all other times.

g) Observation during the tour revealed signage for Hospital A's Patient Bill of Rights placed above a seating area for patients who were registering for Hospital B's Transitional Care Clinic.

Based on observations, interviews and document reviews, the governing body failed to ensure contracted services were provided in a manner which allowed the hospital to comply with applicable conditions of participation and standards of care.

These failures resulted in opportunities that affect health outcomes, patient safety, and quality of care being overlooked and resulted in an increased risk of negative patient outcomes. Further, the failures did not permit the hospital to comply with all applicable conditions of participation and standards for the contracted services.

Findings:

1. The governing body failed to ensure contracted services and departments were monitored and included as part of an ongoing Quality Assessment and Performance Improvement (QAPI) program.

a) The Director of Quality (DQ #10) was interviewed on 03/15/16 at 4:30 p.m. DQ #10 provided copies of the Board of Directors Meeting records for meetings held on 01/19/16, and 09/15/15. Review of the Board of Directors Meeting records from the meetings showed no evidence of discussion or approval of data, collection frequency, or details for quality monitoring and indicators for contracted services the hospital received from outside parties. Further, the documents did not show improvement actions were recommended or evaluated for contracted services.

b) During the same interview, DQ #10 provided a copy of the facility's contracted services, of which, more than 40 services related to the clinical care of patients. DQ #10 stated the facility's quality department did not monitor the majority of the contracted services that provided clinical care in the facility. (Cross Reference A-0308).

The interview with DQ #10 revealed the following examples of contracts which were not being monitored included:

1) Anesthesia Specialists - provided anesthesia services to facility patients.
2) Colorado Imagining Associates - provided radiology services to facility patients.
3) Foothills Urology - provided urology services to facility patients.
4) Metropolitan Pathologists - provided pathology services to facility patients.
5) Mile High Multilingual Services - provided interpreter services to facility patients.
6) Emergency services - provided by a separately certified hospital.
7) Intravenous therapy - provided by a separately certified hospital.
8) Laboratory service - provided for patient clinical care.
9) Medical imaging services - provided for patient clinical care.

2. The governing body failed to ensure contracted services permitted the hospital to comply with all applicable conditions of participation. As example:

a) The facility contracted out the grievance process, which included the intake, investigation, resolution and response to the patient or family member to a separately certified hospital. (Cross Reference A-0115).

b) The facility relied on nursing services and emergency services from a separately certified hospital while the employees were working concurrently at the other hospital. (Cross Reference A-0385).

c) The facility contracted out their medical records department to a separately certified hospital. (Cross Reference A-0431).

Based on observation, interviews, and document review the facility (identified as Hospital A) relied on a separately certified hospital (Hospital B) to provide services for emergencies. Further, Hospital A failed to provide the initial treatment needed by persons with emergency conditions and failed to arrange necessary transport to an appropriate facility.

These failures potentially contributed to delays in the provision of emergency medical treatment and poor patient outcomes.

FINDINGS

POLICY

According to Code Blue policy, Flight for Life staff is to respond to Code Blues unless concurrently responding to a neonatal emergency at Hospital B. Designated staff on the Hospital B/Hospital A Campus will respond to a Code Blue through an overhead page.

According to, Rapid Response policy a Registered Nurse (RN) from the [Rapid Response] Team completed the documentation. Non-Patient Rapid Response Team Activation, the Rapid Response Team (RRT) responders will place a downtime number band on the individual, located in the RRT supply bag. Registration at Hospital B is called to activate the downtime number. An RRT responder will notify Hospital B Charge RN of transport to Hospital B for further care. An RRT RN responder transports the patient to Hospital B.

1. The facility failed to provide appropriate staff to respond to emergencies and relied on staff from a separately certified hospital (Hospital B) to respond and assist with emergent events.

a) Review of Rapid Response Team Records revealed 4 of 5 records when the House Supervisor (Registered Nurse, RN) working at Hospital B responded to and assisted with rapid responses at Hospital A.

Additionally, 3 of 5 records showed an additional RN from Hospital B responded to and assisted with rapid responses at Hospital A; and 2 of 5 records when critical care RNs from Hospital B responded to and assisted with rapid responses at Hospital A. As example,

- On 08/03/15, at 3:17 p.m., RN F responded to and assisted with a rapid response in Hospital A while working at Hospital B. Also, noted on the record, a House Supervisor for Hospital B responded and assisted while working at Hospital B, no name was provided.

- On 08/30/15, at 6:57 a.m., RN Administrator G and RN H responded and assisted with a Code Blue called at Hospital A while working at Hospital B.

- On 11/06/15, at 4:39 p.m., RN Administrator G responded and assisted with a patient having symptoms of a stroke at Hospital A while working at Hospital B. Also, noted on record as responding and assisting was a Critical Care RN from Hospital B, no name provided.

-On 02/08/16, at 6:20 p.m., RN H responded and assisted with a rapid response in Hospital A while working for Hospital B.

b) An interview with the Clinical Lead (RN #2) was conducted on 03/15/16, at 12:29 p.m. S/he stated a Flight for Life RN, a House Supervisor, and a Critical Care RN from Hospital B were notified and trained to respond to rapid responses and code blues at Hospital A. RN #2 went on to say the emergency alerts were paged overhead at both Hospital A and Hospital B and the response team from Hospital B was notified via page for emergencies at Hospital A.

c) An interview with Hospital B's RN A on 03/21/16 at 1:33 p.m., and a separate interview with Hospital B's RN B on 03/22/16, at 1:00 p.m., revealed that part of Hospital B's orientation included how to respond to Hospital A's emergencies and how to be a resource RN for Hospital A. Hospital A did not provide an orientation for RN A or RN B.

Further, RN A and RN B stated the employee badge issued at Hospital B provided him/her access to both Hospital A and Hospital B. Both RNs reported they did not report time spent at Hospital A and were never trained to do so. Any services provided for Hospital A or Hospital B were documented together on Hospital B's Resource Nurse Daily Log.

d) On 03/22/16 at 2:10 p.m., Hospital B's Critical Care RN D revealed the charge RNs of Hospital B responded to rapid responses and code blues called at Hospital A. S/he stated Hospital B's initial code responder training included responding to Hospital A's codes. RN D stated s/he was not oriented at Hospital A; however, orientation of Hospital B included a tour of Hospital A. S/he further stated a rapid response kit containing emergency drugs from Hospital B would be taken and could be used at rapid responses at Hospital A.

e) On 03/22/16 at 10:00 a.m., an interview with Hospital B's Administrative Manager (RN E) was conducted. S/he stated emergency alerts for Hospital A were announced over the speaker system at Hospital B as well as an alert that came over RN E's pager, provided by Hospital B.

S/he further stated part of Hospital B's training was to acknowledge that Hospital A would need Hospital B's services during emergent events. RN E did not keep track of time s/he provided services at Hospital A while concurrently working at Hospital B.

f) On 03/15/16, at 3:30 p.m., an interview with Emergency Telephone Operator (ETO) #9 revealed s/he was contacted via phone when Hospital A needed an emergency response. ETO #9 was provided slides of instructions to follow for each emergent situation at both Hospital A and Hospital B.

ETO #9 provided the 12 emergent situations and the instructions s/he had been provided for Hospital A. Eleven out of 12 slides instructed ETO #9 to contact staff working at Hospital B and have them respond in the event of an emergency within Hospital A.

The list of Hospital B's staff, who were to respond to patient emergencies in Hospital A, included Hospital B's Administrative RN, Hospital B's Code BLUE group, Hospital B's notification group, Hospital B's Code RED group, and Hospital B's Rapid Response Team.

g) During an interview on 03/21/16 at 9:15 a.m., Vice President of Patient Care Services (VP) #1 stated Flight for Life RNs employed and working at Hospital B responded to rapid responses and code blues within Hospital A. S/he further stated rapid responses and code blues for Hospital A were called overhead at both Hospital A and Hospital B.

2. The facility did not provide initial treatment needed by persons with emergency conditions and failed to arrange necessary transport to an appropriate facility.

a) On 03/15/16 at 2:10 p.m., a Non-Patient Rapid Response was observed at Hospital A's main entrance. As Concierge #12 assisted the individual to a wheelchair Physician #20 asked the individual if s/he had been stabbed. The individual was observed to be guarding his/her stomach with multiple layers of clothing on stating s/he was in pain. The individual stated s/he had been jumped the night before not stabbed, to which Physician #20 replied ok. Concierge #12 then wheeled the individual to Hospital B's emergency department.

VP #1 approached surveyors stating this scenario happened occasionally since Hospital A was at the front of the campus. VP #1 further stated when people came in off the street for services the rule was to call a rapid response.

b) Upon request for the witnessed rapid response record, on 03/15/16 at 2:45 p.m., VP #1 stated the report was being completed by Nurse Manager #3. Manager #3 was not present during the rapid response. An incomplete rapid response team record for the individual seeking emergency services was provided on 03/15/16 at 3:15 p.m.

The Rapid Response Team Record had no signature of the staff member recording the events and also omitted the presence of Concierge #12 who transferred the individual to Hospital B's emergency department. Upon request for the individual's medical record on 03/16/16, at 2:02 p.m., Regulatory Manager #17 stated that Hospital A did not have a medical record for the individual seeking emergency services.

c) On 03/17/16, at 10:10 a.m., an interview with Nurse Manager #3 was conducted. Manager #3 confirmed s/he completed the Rapid Response Record for the individual seeking emergency services, but did not sign the document. Manager #3 further confirmed s/he was not present at the Rapid Response.

d) On 03/16/16 at 11:30 a.m., an interview with Concierge #12 was conducted. Concierge #12 confirmed s/he transported the individual named in the non-patient rapid response to Hospital B's emergency department. Concierge #12 further stated individuals seeking emergency services from outside the facility would approach his/her desk and if the individual denied chest pain s/he would instruct them to leave Hospital A and provide instructions to Hospital B's emergency department.

e) On 03/21/16 at 9:15 a.m., VP #1 was interviewed. VP # 1 stated s/he did not feel the non-patient rapid response witnessed on 03/15/16 at 2:10 p.m. followed Hospital A's policy. VP #1 further stated a RN needed to transport the individual, and it was his/her expectation the rapid response report be done in real time. VP # 1 went on to say a debriefing was done for the event; however, no documentation of the debriefing was completed and policy was not discussed at the debriefing.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.13, PATIENT'S RIGHTS, was out of compliance.

A-0119 - Standard: The hospital's governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The governing body relied on a separately certified hospital, Hospital B, to intake, investigate, resolve, and respond to patient complaints and grievances. Further, Hospital B served as a liaison between patients and families, and the facility. The failure created the potential for patient complaints and grievances to go unresolved by facility staff and allowed for potential deviation from the process approved by the governing body for complaint and grievance investigation and resolution. The failure also created the potential for unauthorized staff from Hospital B to gain knowledge of patient complaint and grievance information at the facility.

Based on interviews and document review, the facility relied on a separately certified hospital, Hospital B, to intake, investigate, resolve, and respond to patient complaints and grievances in 3 of 3 grievances reviewed (Patients #11, #12, and #13). Further, Hospital B served as a liaison between patient, families, and the facility, Hospital A.

The failure created the potential for patient complaints and grievances to go unresolved by facility staff and allowed for potential deviation from the process approved by the facility's governing body for complaint and grievance investigation and resolution. The failure also created the potential for unauthorized staff from Hospital B to gain knowledge of patient complaint and grievance information at the facility.

Findings:

POLICY

According to the policy, Patient Complaint/Grievance Mechanism Plan, the Patient Relations Coordinator (PRC) has responsibility to coordinate and manage the complaint and grievance process at the Hospital. The PRC serves as a liaison between the patient/family and the facility, and provides objective mediation and collaboration between the patient, family members, administration, staff, and physicians to meet the state requirements for a complaint/grievance mechanism for patients/families. The PRC communicates with patients/families to resolve the stated issues or concerns and collaborates with staff and physicians to coordinate, investigate, and resolve patient/family complaints or grievances. Complete documentation on the investigation and maintain an electronic log/database of complaints/grievances that were received from the Customer Service phone line, that involved the PRC, and for all hospital identified grievances. The PRC maintains records of all the complaints/grievances submitted to the PRC, including hard copies and/or electronic copies of initial grievance letters, on-going correspondences, and final response letters. The PRC schedules meetings and maintains the minutes of the Grievance Committee, submits reports to the hospital's QAPI, and provides the Board of Trustees with a complaint/grievances status report on a regular basis.

1. The facility relied on a separately certified hospital, Hospital B, to intake, investigate, resolve, and respond to patient complaints and grievances in 3 of 3 grievances reviewed (Patients #11, #12, and #13).

a) Document review of Patient #13's grievance, dated 06/01/15, revealed the Vice President of Patient Care (VP #1) delegated the intake, investigation, resolution, and patient response to a Hospital B employee (PRC M). PRC M also met with Patient #13 in person in the Administration area of Hospital B on 06/01/15 when the patient stopped by to discuss his/her concerns about the facility. According to the document, PRC M referred to managers and staff at Hospital B (Risk Manager J and Patient Safety Specialist K) for review of the grievance. PRC M marked the complaint as "resolved" in the electronic grievance tracking system on 06/08/15 and mailed a letter to Patient #13 based on VP #1's summary of the grievance resolution on 06/19/15.

b) Document review of Patient #11's grievance, dated 09/04/15, revealed PRC M entered the complaint into the electronic grievance tracking system along with the location comment, "not sure which room patient was in during this hospitalization" on 09/04/15. According to the document, Hospital B's PRC M referred to managers and staff at Hospital B (Risk Manager J and Patient Safety Specialist K) for review of the grievance. After the investigation was complete, PRC M called Patient #11 with the resolution of the grievance. PRC M marked the complaint as "resolved" in the electronic grievance tracking system on 09/03/15 and mailed a letter to Patient #11 summarizing the grievance resolution on 09/04/15.

c) Document review of Patient #12's grievance, dated 06/09/15, revealed Hospital B's PRC M entered the complaint into the electronic grievance tracking system on 06/10/15. According to the document, PRC M referred to managers and staff at Hospital B (Risk Manager J and Patient Safety Specialist K) for review of the grievance. After the investigation was complete, PRC M mailed a letter to the patient summarizing the grievance resolution and marked the complaint as "resolved" in the electronic grievance tracking system on 06/16/15.

d) A tour of the facility was conducted on 03/16/16 at 3:30 p.m. After requesting to meet with the facility Patient Relations Coordinator (PRC), the survey team was led outside of the facility's space into the hospital space called "Administration" of the separately certified Hospital B.

e) An interview was conducted with Hospital B's PRC N on 03/16/16 at 3:35 p.m. PRC N stated his/her job title was Patient Relations Coordinator, but s/he was employed by Hospital B. S/he stated Hospital B's Grievance Department processed the facility's (Hospital A) grievances and complaints. PRC N stated the facility notified him/her at Hospital B of complaints and grievances and s/he would follow-up with the patient for resolution.

This resulted in the grievance process beginning with the employee of Hospital B who was also responsible for routing the grievance to the facility's administration, staff, and physicians to coordinate, investigate, and resolve patient and family grievances. S/he maintained records of all of Hospital A's complaints and grievances submitted to him/her including hard copies and/or electronic copies of initial grievance letters, on-going correspondences, notes of meetings with facility staff, and final grievance resolution and response letters sent to patient's and families.

During the same interview, PRC N provided the surveyor's with two business cards: one for the facility, and another for Hospital B, both with the job title Patient Relations Coordinator and both with the same telephone contact number. PRC N's voicemail at the telephone number on the business cards revealed that voicemail messages could be left by both the facility's patients and Hospital B's patients.

Based on the nature of standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.21, QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM, was out of compliance.

A-0308 - Standard: The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement). The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. The governing body failed to ensure all departments and services of the hospital, including clinical care provided under contracted or arranged services, were monitored by the quality program. The failure resulted in opportunities that affect health outcomes, patient safety, and quality of care being overlooked by the quality department and governing body and resulted in an increased risk of negative patient outcomes.

Based on interview and record review, the facility's governing body failed to ensure all departments and services of the hospital, including clinical care provided under contracted or arranged services, were monitored by the facility's quality program.

The failure resulted in opportunities that affect health outcomes, patient safety, and quality of care being overlooked by the quality department and governing body and resulted in an increased risk of negative patient outcomes.

Findings:

POLICY

According to the document, Organizational Performance Improvement & Patient Safety Plan FY 2016, objectives of the quality management program were to identify and prioritize high risk, high volume, or problem prone areas processes for improvement. Process improvement activities were focused on problem prone areas related to the care and services provided within each department or unit. The program was to develop and implement necessary actions when problems or opportunities for improvement in care and/or service were identified, and measure and evaluate the results of actions taken to assure that the desired result had been achieved and sustained. The quality program was to refer identified improvement opportunities that affected major processes/systems of care/services that were cross departmental or cross-disciplinary to the chief executive officer. The program needed to assure the provision of a safe environment through systematic measurement and evaluation of accidents, injuries, and safety hazards.

1. The facility's governing body failed to ensure the quality department monitored all departments and services and demonstrated evidence of an ongoing Quality Assessment and Performance Improvement (QAPI) program that included all contracted services.

a) The Director of Quality (DQ #10) was interviewed on 03/15/16 at 4:30 p.m. DQ #10 provided copies of the Board of Directors Meeting records for meetings held on 01/19/16, and 09/15/15. Review of the Board of Directors Meeting records from the meetings showed no evidence of discussion or approval of data, collection frequency, or details for quality monitoring and indicators for contracted services the hospital received from outside parties. Further, the documents did not show improvement actions were recommended or evaluated for contracted services.

b) During the same interview, DQ #10 provided a copy of the facility's contracted services, of which, more than 40 services related to the clinical care of patients. DQ #10 stated the facility's quality department did not monitor the majority of the contracted services that provided clinical care in the facility.

The interview with DQ #10 revealed the following examples of clinical contracts which were not being monitored included:

1) Anesthesia Specialists - provided anesthesia services to facility patients.
2) Colorado Imagining Associates - provided radiology services to facility patients.
3) Foothills Urology - provided urology services to facility patients.
4) Metropolitan Pathologists - provided pathology services to facility patients.
5) Mile High Multilingual Services - provided interpreter services to facility patients.

DQ #10 stated the facility received contracted and arranged services from another facility, Hospital B, which were also not routinely monitored. Specifically, DQ #10 stated the quality department did not monitor or have a Quality Assessment Performance Improvement (QAPI) project for the contracted service that provided remote cardiac monitoring for patients in the facility.

The interview with DQ #10 also revealed the following examples of clinical contracts provided by Hospital B that were not being monitored included:

1) Emergency services - provided for patient clinical care.
2) Intravenous therapy - provided for patient clinical care.
3) Laboratory service - provided for patient clinical care.
4) Medical imaging services - provided for patient clinical care.

The facility's quality management program was unable to identify and prioritize high risk, high volume, or problem prone clinical areas for improvement related to contracted services due to a lack of quality monitoring of all contracted and arranged services provided to patients in the facility.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES was out of compliance.

A-0393 - Standard: The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under §488.54(c)of this chapter. The facility failed to provide 24 hour nursing services. Further the facility relied on a separately certified hospital to provide nursing services for patients with difficult intravenous (IV) access. This failure created the potential for an individual seeking medical service to not be able to receive services while the hospital was closed, potential leading to poor individual outcomes. Further, this failure created the potential for patient care to be delayed.

Based on interviews and document reviews, the facility (Hospital A) failed to provide 24 hour nursing services. Further, Hospital A relied on a separately certified hospital (Hospital B) to provide nursing services for patients with difficult intravenous (IV) access.

This failure created the potential for an individual seeking medical service to not be able to receive services while the hospital was closed, potentially leading to poor individual outcomes. Further, this failure created the potential for patient care to be delayed.

1. The facility did not have a registered nurse on duty for service 24 hours a day.

a) During an interview with Clinical Nurse Manager #3 on 03/17/16, at 10:10 a.m., s/he stated when the facility first opened it was rare to stay open through the weekend. Currently, when there were no inpatients at Hospital A, it would close and no staff were present. S/he estimated this happened about once a month.

b) During an interview with Vice President of Patient Care Services (VP) #1, on 03/21/16, at 9:15 a.m., s/he stated that s/he would get notified via text message of the facility closing when all patients had been discharged. S/he estimated this would happen about twice a month. Upon review of his/her text messages, VP #1 reported the following closings: Sunday, February 14 at 4:00 p.m. until Monday, February 15; Sunday, January 31 at 4:25 p.m. until Monday February 1; and Thursday, December 24 at 2:30 p.m. until Monday, December 28.

c) During an interview with Chief Executive Officer (CEO) #16, on 03/21/16, at 4:07 p.m., s/he stated closing the hospital was a cost preventative measure that occurred when there were no patients. CEO #16 was unaware this was a concern.

2. The facility, Hospital A, relied on nursing staff of a separately certified hospital, Hospital B, to provide services while simultaneously working at Hospital B.

a) During an interview with Registered Nurse #2 (RN), on 03/13/16, at 12:29 p.m., s/he reported RNs employed by Hospital B would be notified to come to Hospital A to assist whenever it was needed, including with patients who had difficult venous access for IV placement and blood draws.

b) An interview with Hospital B's RN A, on 03/21/16 at 1:33 p.m., and a separate interview with Hospital B's RN B, on 03/22/16, at 1:00 p.m., revealed that part of Hospital B's orientation included how to respond to Hospital A's emergencies and how to be a resource RN for Hospital A, including difficult IV access.

Hospital A did not provide an orientation for RN A or RN B. RN A and RN B stated the employee badge issued at Hospital B provided him/her access to both Hospital A and Hospital B. Both RNs reported they did not report time spent at Hospital A and were never trained to do so. Any services provided for Hospital A or Hospital B were documented together on the Resource Nurse Daily Log.

c) Review of the Resource Nurse Daily Log, dated 02/01/16 through 03/21/16, showed multiple instances of Hospital B RNs providing services to Hospital A while working at Hospital B. As example,

- On 03/08/16, Hospital B's RN reported to room 364 in Hospital A to assist with a blood draw.
- On 03/05/16, Hospital B's RN reported to Hospital A to start an IV in room 380.
- On 02/26/16, Hospital B's Resource Nurse Daily Log revealed the day shift resource RN for Hospital B reported to Hospital A for an IV start.
- On 02/25/16, the day shift Resource RN for Hospital B reported to Hospital A for 2 IV starts in rooms 352 and 386.

A review of Hospital B's Resource Nurse Daily Log, for 49 days, revealed 20 examples when Hospital B's resource RN reported to Hospital A for RN resource services while concurrently working at Hospital B.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.24, MEDICAL RECORD SERVICES, was out of compliance.

A-0432 - Standard: The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. The facility failed to ensure staff responsible for managing medical records were employed by the facility. This failure allowed unauthorized personnel from a separately certified facility access to medical records and Protected Health Information (PHI).

A-0441 - Standard: The hospital must have a procedure for ensuring the confidentiality of patient records. The facility failed to ensure medical records were stored in a secure area within the facility. The failure created the potential for medical records to be compromised or tampered with by allowing unauthorized personnel from a separately certified facility access to medical records and Protected Health Information (PHI).

Based on observations, interviews and document review, the facility failed to provide medical records services but instead contracted the service to a separately certified hospital (Hospital B). Additionally, the facility failed to ensure staff responsible for managing medical records were employed by the facility.

This failure allowed unauthorized personnel from a separately certified facility access to medical records and Protected Health Information (PHI).

FINDINGS:

POLICY

According to Storage, Retention, and Destruction of Medical Records, medical records shall be maintained and their contents protected against loss, defacement, tampering, use by unauthorized individuals, and damage due to fire and or water.

1. The facility (Hospital A) utilized staff from a separately certified facility (Hospital B) to process and manage their medical records.

a) On 03/14/16 at 2:45 p.m., a tour of the area where Hospital A's medical records were processed and stored was conducted with the Administrative Director of Medical Records (DMR #4). The sign to the entrance of the medical records department stated Hospital B/Hospital A Medical Records, Hours: 8:00 a.m. - 4:00 p.m. DMR #4 explained that the area was owned by Hospital B but Hospital A utilized one corner of the area for their medical records. Upon observation, the area designated for Hospital A consisted of an open and unlocked shelf containing Hospital A's medical records. The area and medical records were accessible to staff from Hospital B, who used the same space to process and store their medical records.

b) On 03/15/16 at 11:19 a.m., an interview was conducted with a HIM front desk staff member (Staff O) who confirmed s/he was employed with Hospital B. Staff O explained his/her job responsibilities included printing out medical records and distributing them to patients from Hospital A and Hospital B upon request. Staff O further stated patients from both Hospital A and Hospital B would enter the medical records department to request copies of their medical records.

c) On 03/14/16 at 2:35 p.m., an interview was conducted with a HIM Technician (Tech L) who confirmed s/he was an employee of Hospital B. Tech L stated his/her main job responsibilities involved scanning and processing medical records of patients from Hospital A. Tech L explained that s/he would perform duties related to the processing of medical records from Hospital A at his/her desk, which was located in Hospital B. S/he added that occasionally, if there was extra time and help was needed, s/he would help with Hospital B's medical record processing.

d) On 03/21/16 at 2:20 p.m., an interview was conducted with a HIM Technician (Tech I) who stated s/he was an employee of Hospital B. Tech I explained if needed s/he would go to Hospital A to help process medical records during his/her shift at Hospital B. Tech I further stated s/he had access to Hospital A and their medical records although s/he had never received orientation or signed a confidentiality agreement to access PHI with Hospital A.

e) On 03/21/16 at 2:45 p.m., an interview was conducted with a HIM Technician (Tech J) who confirmed s/he was an employee of Hospital B. Tech J stated s/he was able to gain access to locked areas at Hospital A using his/her identification badge from Hospital B in order to help process their medical records. Tech J further stated s/he had received training from the manager of Hospital B on processing medical records for Hospital A and had never had a formal employee orientation at Hospital A.

f) Review of a contract dated 06/15/10 between Hospital B and Hospital A included the following documentation:

The services to be provided by Hospital B shall include associates from the following departments: Clinical Information Management: process all records for completion; notify physicians of record completion; scan records to Meditech; process transcription; complete release of information/records requests; provide access to records upon request.

g) On 03/21/16 at 3:32 p.m., an interview was conducted with the Chief Executive Officer (CEO #16) who stated s/he was aware the facility's medical records staff were not employed by the facility but were utilized through a contracted agreement from a separately certified facility. CEO #16 stated s/he did not consider contracting medical records services an issue that needed to be discussed at a Governing Board meeting.

Based on observations, interviews and document review, the facility failed to ensure medical records were stored in a secure area within the facility.

This failure created the potential for medical records to be compromised or tampered with by allowing unauthorized personnel from a separately certified facility access to medical records and Protected Health Information (PHI).

FINDINGS:

POLICY

According to Storage, Retention, and Destruction of Medical Records, medical records shall be maintained and their contents protected against loss, defacement, tampering, use by unauthorized individuals, and damage due to fire and or water.

1. The facility (Hospital A) utilized unsecured office space from a separately certified facility (Hospital B) to store their medical records.

a) On 03/14/16 at 2:45 p.m., a tour of the area where Hospital A's medical records were processed and stored was conducted with the Administrative Director of Medical Records (DMR #4). DMR #4 explained that the area was owned by Hospital B but Hospital A utilized one corner of the area for their medical records. Upon observation, the area designated for Hospital A consisted of an open and unlocked shelf containing Hospital A's medical records. The area and medical records were accessible to staff from Hospital B, who used the same space to process and store their medical records.

b) Review of a contract dated 06/15/10 between Hospital B and Hospital A included the following documentation:

As part of the Support Services, (Parent Company) shall maintain back up files of Hospital A data and off-site storage for Hospital A data in accordance with the manner in which such back up and storage is performed for all (Parent Company) facilities.

c) On 03/21/16 at 3:32 p.m., an interview was conducted with the Chief Executive Officer (CEO #16). CEO #16 stated s/he was familiar with the office space in Hospital B that was used to store Hospital A's medical records; however, s/he did not consider it to be an issue that needed to be discussed at a governing board meeting.

Based on the nature of standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.56, REHABILITATION SERVICES, was out of compliance.

A-1125 - Standard: The director of the services must have the necessary knowledge, experience and capabilities to properly supervise and administer the services. The facility failed to employ a director of rehabilitation services that had the necessary education, experience, and specialized training to oversee and administer the facility's rehabilitation services. The failure increased the risk of negative patient outcomes and created a lack of oversight by an individual who was qualified to evaluate rehabilitation staff using acceptable standards of practice to determine if patients were offered safe and effective care by the service.

Based on interviews and document review, the facility failed to employ a director of rehabilitation services that had the necessary education, experience, and specialized training to oversee and administer the facility's rehabilitation services.

The failure increased the risk of negative patient outcomes and created a lack of oversight by an individual who was qualified to evaluate rehabilitation staff using acceptable standards of practice to determine if patients were offered safe and effective care by the service.

Findings:

POLICY

According to the document, OrthoColorado Hospital Plan of Care & Scope of Service, OrthoColorado leadership is responsible for providing appropriate direction, management, leadership of all services and departments, and delivering care in a safe manner. Physical Therapy (PT) is a patient care service provided in response to a wide range of rehabilitation care needs of inpatients and outpatients. This service is provided 7 days a week. Qualified personnel provide examination, treatment, and instruction to patients and family members to assure a safe return to the patient's previous living arrangements. Occupational Therapy (OT) plays a contributing role in the rehabilitation of the physically, neurologically, cognitively and/or physiologically impaired patient. At OrthoColorado Hospital, the OT focuses on the patient's ability to return to their normal activities of daily living, understanding the patient's goals, and enlisting the associated interventions and educating the patient and his/her family accordingly. Speech Language Pathology (SLP) plays a contributing role in the rehabilitation of physically, cognitively, and psychologically impaired individuals. SLP includes the examination, treatment, and instruction of patients to assess, prevent, mediate, and limit impairments related to cognitive abilities, auditory comprehension, verbal expression of language, articulation, memory, voice, fluency, and swallowing. SLP includes the administration, interpretation, and evaluations of tests and measurements related to all of these areas.

1. The facility did not employ an individual who had the necessary education, experience, and specialized training to oversee and administer the facility's rehabilitation services.

a) An interview was conducted with the Physical Therapy Supervisor (PT Supervisor #15) on 03/16/16 at 3:10 p.m. PT Supervisor #15 stated s/he supervised a staff of ten therapists, but did not direct the rehabilitation service. S/he stated s/he reported to the Clinical Nurse Manager (Nurse Manager #3) who was a Registered Nurse responsible for the rehabilitation program of the facility.

b) Review of Nurse Manager #3's personnel file revealed s/he did not possess Physical Therapy, Occupational Therapy, Speech Language Pathology, or other rehabilitation education, experience, or specialized training, despite overseeing the facility's rehabilitation service.

c) During an interview conducted with Nurse Manager #3 on 03/17/16 at 10:10 a.m., s/he stated PT Supervisor #15 reported to him/her.

d) During an interview conducted with Vice President of Patient Care Services (VP #1) on 03/21/16 at 09:15 a.m., s/he stated his/her job title was also referred to as Chief Nursing Officer (CNO). S/he confirmed Nurse Manager #3 oversaw the facility's rehabilitation program, and PT Supervisor #15 reported to the nursing manager. VP #1 stated s/he restructured the leadership of the facility's rehabilitation services program so Nurse Manager #3 oversaw the rehabilitation services and reported to him/her. VP #1 stated she was unaware the individual directing the rehabilitation services program needed to demonstrate through education, experience, and specialized training that s/he had the necessary knowledge, experience, and capabilities to properly supervise and administer the rehabilitation program of the facility.