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Based on record reviews and staff interviews, it was determined the hospital failed to provide organized nursing services accordance with policies and procedures, licensing regulations and nursing standards of care.

Findings include:

The Condition level deficiency is the result of the standard deficiencies found in the following tag:

Cross reference A-0394 The facility failed to ensure appropriate licensure of nursing staff.

Cross reference A-0395 The facility failed to ensure appropriate supervision of non licensed staff providing nursing services.

These deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Nursing Services.

Based on a review of documentation and interviews, it was determined the Governing Body failed to have implement an effective utilization review plan that provided for review of services provided by the institution and the members of the medical staff to patients.

Findings include:

Cross reference A-0652 The Governing Body failed to convene a utilization review committee consisting of two or more practitioners.

Cross reference A-0654 The governing body failed to implement the utilization review policy for review for Medicare and Medicaid patients.

The cumulative effect of the systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Utilization Review, which poses a potential risk to the health and safety of patients when the facility fails to ensure appropriate utilization evaluation is ongoing for patients and reported to the Governing Body.

Based on review of facility policy, medical records and staff interview, the Administrator failed to ensure that the hospital did not engage in self-referral by the ownership entity. This deficient practice can result in patients not receiving appropriate referrals and appropriate care based on a vested financial interest.

Findings include:

Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), also known as the physician self-referral law: "...Prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship, unless the requirements of an applicable exception are satisfied; and Prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third-party payor) for any improperly referred designated health services. A financial relationship may be an ownership or investment interest in the entity or a compensation arrangement with the entity...."

A Change of Ownership application signed September 28, 2020, with the Department reported Vidushi Soni, MD as the owner of Destiny Springs Healthcare. No updated ownership information has been received by the Department since the change of owernship on September 28, 2020.


Review of Patient #20:

Pre Admission Assessment dated July 18, 2024, states "...arrived to DSH on 07/18/2024 as a walk in. Patient informed the writer he went to his schedule appointment to meet with his primary care, and was informed to come to DSH for Detox and depression behaviors...During the end of the assessment the Patient's Primary Care Dr. Ashish called the Intake Department to provide further collateral of the Patient's background for admission. Dr. Ashish informed the Intake nurse the Patient had suicidal ideation and was detoxing from alcohol. Dr. Ashish requested to speak with the Patient to know his status of the admission process. After an unknown conversation between Dr. Ashish and the Patient, Dr. Ashish was transferred to speak with the writer to provide further collateral of the Patient for the assessment. During the conversation the writer asked Dr. Ashish "Did the Patient stated to you that he was suicidal?". Dr. Ashish replied to the writer "no he did not really said he was suicidal, he said that he was having depression and anxiety because of the stress he was receiving from work ,and also drinking alcohol everyday for the past 6 months." The writer informed Dr. Ashish the admission process will move forward due to his referral of informing the Intake Department the Patient was suicidal. Dr. Ashish replied to the writer "that is just misunderstanding. Let the Patient leave and I will put the Patient in my Out Patient Program." The writer informed Dr. Ashish on what the discharge process will be for the Patient and that he does not have that approval to decide for the Patient to leave. Dr. Ashish informed the writer he will speak with Dr. Soni on this matter. After the conversation with Dr. Ashish, the writer recieved a call from Dr. Soni on this matter. The writer informed Dr. Soni all the information that occured in the Patient's assessment and the conversation that occured with Dr. Ashish. Dr. Soni recommended to continue with the admission process and to inform Gregory Carr, MD on this matter. The writer informed the Intake Nurse of the information that was shared by Dr. Ashish and Dr. Soni. The writer also informed the Intake Nurse an update needs to be made to Gregory Carr, MD of the status on the Patient...."

Nursing note dated July 19, 2024, states "...Pt stated;...I went to see a brand new PCP for an annual health check up...when when we sat down he asked me why my BMI is so high...PCP said it would be better to reduce body size...should think about Detox Center...we then asked how much it cost, he said that he had no details about it just stop by and inquire about the details and programs don't worry about the price I will include it as Stress and
SI that way insurance will pay for it all...while driving home decided to stop by to inquire further about the programs and how much it would cost...we inquired further about the programs...approximately 5:30pm and I started signing all the documentation,once completed and I selected to not sign the consent form said that we are free to go and once we signed, and that is when was not allowed to leave I then called my wife and she was shocked and so she called the PCP and he said it is ok it is just to cover the insurance part and he said don't worry I am giving them a call...." Nursing note from July 19, 2024, further states "...PT CAME TO FLOOR, PT VSS, PT DENIES ANXIETY, DEPRESSION, SI, HI AND AVH AT THIS TIME. PT STATED," I ONLY HAVE STRESS FROM MY BUSINESS...."

Nurse Practitioner note dated July 19, 2024, states "...Pt is future and goal oriented. Patient's mood is reported to be much improved. Symptoms of depression are convincingly denied. Feelings of anxiety are denied. Pt denies SI, HI, AVH. Pt is future oriented. Sleep quality has improved. Energy level is at baseline. Discussed discharge with
Dr. Soni and medical director Dr. Carr. Ok to discharge...."

Interview with Employee #2 on November 14, 2024, confirmed that Dr. Soni is the owner of Destiny Springs and is the owner of the private practice which refered Patient #20 to Destiny Springs on July 19, 2024.

Based on facility job descriptions, personnel files, and staff interviews, the Department determined the administrator failed to ensure personnel records contained evidence that Employee #45 had a current Arizona Registered Nursing License. This deficient practice poses a potential risk to the overall health and safety of patients at the facility if personnel members do not have a current license necessary to provide patient care services.

Finding include:

Documentation from Arizona State Board of Nursing, Nurse Licensure Compact (NLC) revealed, "...When relocating to another compact state, it is the nurse's responsibility to apply for licensure by endorsement. This should be completed within 60 days of relocation ...."

Facility document titled "Job Description Registered Nurse" revealed, "...Required Education/Experience: Must possess a current Arizona RN license ..."

Request for Employee #45's current Arizona RN license was made on November 15, 2024.

A Multistate license for Mississippi with an expiration date of 12/31/2024, for Employee #45 on November 15, 2024.

Employee #2 confirmed on November 15, 2024, that Employee #45 had a start date of 02/01/2021, with the facility, and had no Arizona License for review.

Based on review of policy, facility documents, personnel records, and interview, the Department determined the Nurse Executive failed to document that clinical oversight was provided for 12 Behavioral Health Technicians (BHT) at least once each two-week period if the BHT provides services related to patient care at the health care institution during the two-week period. This deficient practice poses a potential risk that staff is not adequately supervised by Behavioral Health Professionals (BHP) to provide services to patients that they do not have the education background to do independently.

Findings include:

Policy titled, Clinical Oversight, #PC049 last revised: July 12, 2022, revealed "...Clinical oversight is provided at a minimum once every two weeks if the behavioral health technician or paraprofessional provides services related to client care...."

Documentation for clinical oversight review was reviewed on November 13, 2024, for Employees #12, #15, #16, #21, #22, #23, #24, #26, #30, #32, #33, and #35 for the months of August, September, and October 2024. The following clinical oversights were missing:

Employee #12 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & three clinical oversights in October 2024. Seven total missing.

Employee #15 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversight in October 2024. Five total missing.

Employee #16 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing.

Employee #21 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & two clinical oversight in October 2024. Six total missing.

Employee #22 was missing two clinical oversights in August 2024, missing one clinical oversight in September 2024 & three clinical oversight in October 2024. Six total missing.

Employee #23 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing.

Employee #24 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & three clinical oversights in October 2024. Seven total missing.

Employee #26 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing.

Employee #30 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing.

Employee #32 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & three clinical oversight in October 2024. Six total missing.

Employee #33 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing.

Employee #35 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & three clinical oversight in October 2024. Seven total missing.

A total of 69 sessions were missing for the 12 employees.

Employee #9 confirmed in an interview on November 13, 2024, that available documentation of Clinical Oversight is located in individual employee files.

The Department requested additional Clinical Oversight documentation on November 15, 2024 at 09:16, documentation for clinical oversight from October 30, 2024 was provided and reviewed.

Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to have a Utilization Review committee with two or more practioner's. This deficient practice poses a risk to the health and safety of the patients, when there is not at least two doctors on the Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

Findings include:

Review of policy titled "Utilization Review Plan," Policy #LD035, Last Reviewed July 24, 2024, states "...Destiny Springs Hospital meets this CMS provision through a contract with a Quality Improvement Organization (QIO). This organization is LIvanta. Livanta is reposible for reviewing services furnished to Medcicare benificiaries....." A contract with Livanta was requested on November 13, 2024. Interview with Employee #1 and Employee #3 on November 13, 2024 confirmed that the facility does not have a contract with a QIO and does their own Utilization Committee. "Utilization Review Plan" states "...Destiny Springs montors service utilization through an interdepartmental Utilization Review Committee (URC) which consists of clinical, nursing, admissions, finance, and administration...."

A request for Utilization Committee meeting minutes were requested on November 13, 2024, for the past year.

Employee #3 provided "UM Committee" notes dated October 18, 2024, which states "...UM Committee will be meeting quarterly...." A request was once again made for the previous three quarters. None was provided.

UM Committee attendees for October 18, 2024, included a list of "Staff Attending" which included one doctors of medicine or osteopathy.

Interview with Employee #3 on November 13, 2024, confirmed that the UM Committee on October 18, 2024, had one doctors of medicine or osteopathy present.

Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to implement a Utilization Review process. This deficient practice poses a risk to the health and safety of the patients, when there is not a Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

Findings include:

Review of policy titled "Utilization Review Plan," Policy #LD035, Last Reviewed July 24, 2024, states "...Destiny Springs Hospital meets this CMS provision through a contract with a Quality Improvement Organization (QIO). This organization is Livanta. Livanta is responsible for reviewing services furnished to Medicare beneficiaries....." A contract with Livanta was requested on November 13, 2024. Interview with Employee #1 and Employee #3 on November 13, 2024 confirmed that the facility does not have a contract with a QIO and does their own Utilization Committee. "Utilization Review Plan" also states "...Destiny Springs monitors service utilization through an interdepartmental Utilization Review Committee (URC) which consists of clinical, nursing, admissions, finance, and administration...."

A request for Utilization Committee meeting minutes were requested on November 13, 2024, for the past year.

Employee #3 provided "UM Committee" notes dated October 18, 2024, which states "...UM Committee will be meeting quarterly...." A request was once again made for the previous three quarters. None was provided.

Interview with Employee #3 on November 13, 2024, confirmed that there is no additional documentation that the UM Committee has met once over the course of the year and not quarterly and they do not have a QIO contract in place as per policy.