HospitalInspections.org

Based on record review, policy review, and staff interview, respiratory therapy staff failed to ensure the patient had a right to participate in the implementation of his plan of care by failing to provide communication in a language that the patient could understand, in one of one medical record reviewed (Patient #11).

The findings included ...

Cross Reference 0084

Based on Quality Assessment Performance Improvement (QAPI) Program review, record review, policy review, and staff interview, the hospital failed to set priorities for its performance improvement activities that focus on problem-prone areas related to collaboration of patient care between disciplines and failed to ensure compliance with the plan of correction (A-283).

The quality and patient safety program lacked evidence of structural, procedural or process changes to achieve sustainable remediation of deficient practices and care delivery issues. In addition, the corrective action plan (PoC) lacked evidence of implementation. Priorities and process improvement activities related to hospital-specific problem areas were lacking.

The quality plan failed to evaluate the quality of contracted services (respiratory) and ensure that those services are provided in a safe and effective manner.

The findings included...

The problem-prone areas identified by the surveyors include:

1. Failure to write medication orders in accordance with accepted standards of practice, and deliver safe and effective contracted (respiratory) services. Cross reference §482.12, A0049 and A0084 [medical staff and contracted services]

2. Failure to provide care and communicate in a language that the patient could understand. Cross reference
§482.13, A0130 [patient rights]

3. Failure to administer antihypertensive medications as prescribed. §482.23, A0395 [nurse supervision]

4. Failure to deliver respiratory care as prescribed §482.57, A1160 [respiratory services]

5. Failure to document the administration and handling of controlled substances §482.25, A0494
[pharmaceuticals]

6. Failure to maintain the physical plant and environment in a safe and sanitary manner §482.41, A-0701 [physical plant maintenance]

7. Failure to lead the development of a comprehensive Emergency Preparedness Plan that encompasses all required components. Cross reference 42 CFR 482.15.

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation in Quality Assessment and Performance Improvement Program.

On November 7, 2019, at approximately 4:00 PM, a face-to-face interview with Employees #2, #3 Nursing Performance Improvement, and #7, Compliance and performance Improvement Officers, was conducted to review the quality program and concerns identified during the complaint and revisit survey. It was conveyed that the hospital was in the process of procuring a new contract for the provision of respiratory services. The findings were reviewed, discussed, and acknowledged.

Based on a review of the facility's Emergency Preparedness Program and staff confirmation, the hospital failed to provide evidence that the facility developed an Emergency Preparedness Program that meets all of the standard requirements.

Findings included ...

The facility failed to provide documented evidence that the facility's Emergency Preparedness Program uses a comprehensive approach to meeting the health, safety and security needs of their staff and patient population during an emergency or disaster situation.

The facility failed to provide documented evidence to address how the facility coordinates with other facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility). There was no evidence to confirm that the facility used an all-hazards approach when developing its program.

On 11/07/19 at 9:30 AM, the surveyors conducted face-to-face interviews with Employee #8, Performance Improvement, Employee #10, Director of Facilities, Employee #24, Infection Control, Employee #62, and Life Safety. At that time a discussion with the hospital, employees revealed the following items were missing from the final EPP: supplemental pharmaceutical supplies, sewage and waste disposal, policies and procedures for managing volunteers. Additionally, the EPP documents were not compiled in a centralized location and accessible hospital wide (all departments cooperatively sharing the same information).

Representatives from various departments, (i.e. nursing, facilities management, and infection control) verbalized their roles in the event of an emergency as well as the actions that would be taken, however the EPP, lacked a centralized comprehensive and unified written plan. The surveyors discussed the items with the hospital staff however, the hospital failed to provide one comprehensive document.

28612


Based on a review of the facility's Emergency Preparedness Program, it was determined the emergency preparedness plan is located within the facility's Continuation of Operations Plan (COOP) documents and did not contain all of the required elements of an emergency preparedness plan to include a community-based risk assessment.
Findings included ...

The facility failed to provide evidence of annual emergency preparedness plan reviews and related updates based on the annual review to include the date of the review.

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Based on review of the Emergency Preparedness Plan (EPP) and staff confirmation, it was determined that the hospital failed to provide a community-based risk assessment, utilizing an all-hazards approach.
Findings included ...

On 11/07/19 at 9:30 AM, the surveyors conducted face to face interviews with Employee #8, Performance Improvement, Employee #10, Director of Facilities, Employee #24, Infection Control, Employee #62, Life Safety.

At that time, the hospital staff verbalized their collaborations with other outside entities (local state and federal government, and several local hospitals) However, hospital staff failed to provide written documentation of the collaboration.

The practice lacked evidence that the hospital staff provided documentation, showing collaboration with local state and federal government, and several local hospitals.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan and staff interview, the hospital staff failed to provide a written plan for at risk patients, for continued services during an emergency.

Findings included...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10 Facilities Director, #24, Infection control, and #62, Life Safety. At the time of the review, a written plan for the emergency provision of services, for identified at-risk and vulnerable patients was requested, the hospital staff was unable to provide documented evidence for at risk and vulnerable patients within the EPP.

The facility lacked documented evidence of an EPP that addressed the facility's populations the would be considered at risk during an emergency.

The facility's patient vulnerability assessment documentation was specific to Nursing Services but not addressed within the EPP. The Continuation of Operations Plan referenced the identification of staff at risk during an emergency but did not address at risk patient populations within the EPP.
The facility's plan lacked documentation of the strategy the facility used to address the needs of at-risk or vulnerable patient populations.

The facility failed to address succession planning within the EPP.

The facility failed to address essential personnel, essential functions, critical resources, vital records and IT data protection, alternate facility identification and location, and financial resources within the EPP.

The EPP lacked documentation to address the services the facility would be able to provide during an emergency.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan (EPP), and hospital staff confirmation, the hospital failed to provide annual documentation of the hospital's efforts to contact Emergency officials, of participation in a collaborative and cooperative planning effort in the event of an emergency.

Finding included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety.

At the time of the review, the hospital staff reported a verbal understanding of a process, but there was no documented evidence within the EPP of an integrated response process used to contact Emergency officials and when applicable to show participation in collaborative and cooperative planning efforts in response to and during an emergency.

The EPP lacked documented evidence of ongoing participation in cooperative and collaborative planning efforts.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan (EPP), and hospital staff confirmation, the hospital failed to develop and implement policies and procedures based on the emergency plan, risk assessment, and communication plan.

Findings included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety.

The facility lacked a documented EPP policy related to Cybersecurity and Missing Patients.
Further review of the plan revealed partial policies and procedures located in the facility's Continuation of Operations Plan last updated 08/2018.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan (EPP) and staff confirmation, the facility failed to have policies and procedures in place to maintain pharmaceutical supplies during an emergency event.

Findings included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety. The surveyor requested policies and procedures related to the provision of pharmaceutical services.

Further review revealed there was no documented evidence in the EPP to sustain pharmaceuticals during an emergency.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan (EPP) and staff confirmation, the facility failed to have policies and procedures in place for volunteers during an emergency.

Findings included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety. The surveyor requested policies and procedures related volunteers during an emergency.

Further review revealed that the EPP lacked policies and procedures and documented evidence for the use of volunteers and other staffing strategies used during emergencies.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

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Based on review of the Emergency Preparedness Plan (EPP) and staff confirmation, it was determined that the hospital failed to include an adequate communication plan.

Findings included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety. The hospital staff verbalized an understanding of the process for the overall communication plan, but lacked a written plan to incorporate communication plans involving all departments into a centralized hospital wide EPP manual.

There was no written plan to show how the facility interacts and coordinates with emergency management agencies and systems during an event of an emergency. The manual was not updated to include each of the requirements of a comprehensive communication plan. The EPP lacked documented evidence of a written communication plan that incorporates all departments of the hospital in one centralized manual, communication with other emergency agencies

The hospital staff verbalized the use of a radio system incorporated into the District of Columbia Emergency Communication system, cell phones, and a land line system, but EPP policy and procedure documentation was not provided. Each department of the hospital could verbalize their individual department communication plan but the EPP lacked documentation of contact information for staff and written policies and procedures for a hospital-wide communication plan and there was no evidence of an annual update.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan (EPP) and staff confirmation, it was determined that the hospital failed to provide information about the facility's occupancy/needs, and its ability to provide assistance to the authority having jurisdiction.

Findings included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety. There was no written plan to include information about the facility's occupancy/needs, and ability to provide assistance to the authority having jurisdiction.

The EPP lacked documented evidence of a written communication plan to include information about the facility's occupancy/needs during an emergency.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.

Based on review of the Emergency Preparedness Plan (EPP) and staff confirmation, it was determined that the hospital failed to conduct training related to the Emergency Preparedness Plan.

Findings included ...

The surveyor conducted a review of the hospital's Emergency Preparedness Plan (EPP), on 11/04/19 at approximately 3:30 PM, 11/5/19 at approximately 9:30 AM, and 11/07/19 at 9:30 AM, with Employees #8, Performance Improvement, #10, Facilities Director, #24, Infection Control, and #62, Life Safety. There was no evidence of training for existing employees based on the EPP risk assessment.

The facility's EPP provided evidence of training for new employees on Fire Safety, Bioterrorism, Active Shooter and Bomb Threats. However, the facility's training and testing program did not include training on the Emergency Preparedness Program nor did the training address the risks identified in the facility's risk assessment in their 2019 emergency plan.

The facility lacked a written training and testing program that meets the requirements of the regulation.

At the time of the interviews, the following staff, Employees #8, #10, #24, and #62, agreed to and acknowledged the findings.