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Based on record reviews and staff interviews, the CAH's governing body and/or responsible individual failed to ensure that the distant-site telemedicine entity fulfilled the terms of the Physician Professional Clinical Services Agreement ("Agreement") dated 3/20/13 - 3/19/15 with respect to the scope of service provisions the teleradiologists' must maintain, and thus failed to ensure the distant-site telemedicine entity complied with the terms of the Agreement for 3 of 6 teleradiology physicians' credentials files reviewed.

Findings include:

During the medical staff credentials file review on 4/3/14, six random teleradiologists' files were reviewed by the SA. The CAH's Agreement with the distant-site telemedicine entity revealed their obligations included a requirement that these physicians maintained Board Certification by the American Board of Radiology and a Federal DEA number.

Concurrent record review on 4/3/14 with the medical staff office personnel in charge of maintaining the credentials files found Physicians #9 and #13's Board Certifications had expired on 12/31/13. Physician #12's Federal DEA license had expired on 11/30/12 and Physician #13 did not have a current one on file. These findings were verified by the Medical Staff personnel on 4/3/14 at 11:05 A.M. during the review. In addition, the findings were also acknowledged by the Chief Executive Officer (CEO), Regional Medical Director (RMD), Corporate Compliance Officer (CCO) and Administrator during a meeting on 4/3/14 at 2:00 P.M.

Based on observation, record review, staff interview and review of the facility's policies, the facility failed to ensure the equipment in the physical therapy department was inspected to be in safe operating condition in accordance with the manufacturer's recommendations, and, the facility failed to maintain an on-going preventive maintenance/cleaning schedule to prevent grease build-up on kitchen equipment.

Findings include:

1. On 4/4/14 at 10:50 A.M., during the tour of the Rehabilitation Services department, several physical therapy equipment used for patient care was found overdue for inspection. The first equipment noted was the Ultrasound Solaris machine which was last inspected in January 2013 per the sticker. This was verified by the physical therapist assistant (PTA) and occupational therapist (OT), who stated, "it's overdue--it should be done annually." Additionally, per the physical therapist (PT) manager, he confirmed the ultrasound machine used "strictly for ultrasound" was last checked in January 2013 as well.

The department also had other equipment overdue for inspections. These included a patient care lift (last inspection date January 2013), a traction machine (to be done in January 2014), an ultrasound and electrical stimulation "combo" machine (initial check 1/17/13), and per the PT manager, he stated, "should be annual." The large and small whirlpool baths, hydrocollator hot pack and paraffin bath were also overdue for an inspection in January 2014.

The PT manager stated he was the technical representative for this department and said there was an email from the vendor they used. The PT manager provided a copy of the 10/29/13 email and stated the contractor/vendor did come to the department sometime in October 2013. He thought an inventory of the equipment was done, but did not know whether the equipment was actually inspected.

The facility's policy, "Safety Program - Physical Therapy" (Eff. 9/2/04, Rev. 7), stated, "...Regular inspections and maintenance shall be performed annually as scheduled or as required by plant services or by manufacturer's representative, and equipment shall be tagged, label containing inspection date, by whom and date of next inspection." This policy was not implemented by the rehabilitation department as evidenced by the overdue inspection dates on their equipment.

Cross-reference to findings at C 291 for contracted services.




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2. A kitchen tour was done on 4/2/14 at 8:30 A.M. The flat top griddle had heavy grease build-up, and it was most notable on the backsplash. The temporary assigned Kitchen Manager (KM) acknowledged the extent of the grease build-up and that it was a potential fire hazard.
The policy for daily cleaning in the dietary department was reviewed. The policy and procedure stated, "Cook III will list cleaning jobs that are needed to be done to maintain a clean and orderly kitchen." One of Cook III's duties was to, "clean cooking area, ranges, and counters in readiness for next meal preparation." There was a "Daily Cleaning" log sheet; however, it did not indicate when or whether the flat top griddle was recently cleaned as the documentation was incomplete. The Registered Dietician (RD) and KM concurred the cleaning log sheet should have documented the date and time for the cleaning, but that it was not being done.

Based on surveyor observation on 4/2/14 at approximately 10:30 A.M., the facility 1) failed to provide exit and directional signs in accordance with Section 7.10 & 18.2.10.1.; 2) based on surveyor observation on 4/2/14 at approximately 11:00 A.M., the facility failed to maintain the fire alarm system in accordance with Section 9.6 and NFPA 70 & 72.; and 3) based on surveyor observation and staff interview on 4/2/14 at approximately 9:30 A.M., the facility failed to maintain the emegency generator in accordance with NFPA 99, Section 3-4.1.1.15.

Findings include:

1. There was no directional exit sign located in the corridor outside of the Emergency Room adjacent to the E.R./Radiology corridor.

2. The internally illuminated directional exit sign located on the ceiling in the corridor adjacent to the "Quality Coordinator's" room was not functioning and the internal exit light bulb was not illuminated.

3. The fire alarm system annunciator panel displayed a "Trouble" condition.

4. The facility failed to provide remote annunciation of the emergency generator in a location readily observed by operating personnel at a regular work station.

Based on record review and staff interview, the facility failed to ensure the reappointment process included a review/evaluation by either the department chief, chief of staff or regional medical director, and in accordance with the current hospital bylaws for 1 of 14 physician credentials files reviewed.

Finding includes:

During a review of Physician #5's credentials file, it was found his medical staff reappointment was up for an upcoming two year term from 5/31/14 to 5/31/16. The Delineation of Privileges (DOP) form for Physician #5 indicated, "Reappointment is based upon unbiased, objective results of case review, including outcome data and evaluation of activity, utilization review data, citizenship, and compliance with medical records policies. In addition, continuing medical education related to psychiatry is required." On page 2 of the DOP, it was found this physician had met all the requirements and was recommended for approval.

However, there was no "Reviewer" attestation by signature and date to indicate Physician #5's reappointment packet had been reviewed. Thus, during the concurrent review of the file with the medical staff office personnel, she confirmed she had prefilled the second page of the DOP form on her computer, which she acknowledged were the check marks. She stated because she obtained the credentialing information for the upcoming review, she went ahead and prefilled the DOP form. She verified there was no physician reviewer who had reviewed the reappointment file. She stated, "I see what you mean, I can print out a clean one."

A concurrent review of the Medical Staff Bylaws at Section 7.5 Reappointment Process (provided to the SA on 4/2/14 as the "revised" version) was done with the regional medical director (RMD). During the review, the RMD confirmed the facility's medical director of the acute/long term care setting would have been the "Reviewer" to ensure Physician #5 was competent and eligible for reappointment, and not the medical staff office personnel. The RMD said, "this has to stop," and acknowledged it was his responsibility as the regional director to review each practitioner up for reappointment.

Based on observation, staff interviews and a review of the facility's policy, the facility failed to ensure expired items were not in use, and that patient use supplies/items were kept separate and clean from employee use supplies/items.

Findings include:

On 4/4/14 at 10:50 A.M., during the tour of the Rehabilitation Services department, there was a alcohol hand sanitizer on a countertop with an expiration year of 2008. The PT manager was asked whether it was currently in use, and his reply was, "Not any more." There also were four povidone-iodine swabs in one of the drawers with an expiration date of May 2012. One staff stated it was part of their first aid kit.

In addition, two drawers revealed there were patient care equipment/items mixed with a staff's personal use equipment. Within both drawers, various items such as a blood pressure monitor, hand weights, ace wrap, colored exercise bands, Tens electrode gel, clamps, etc. were all combined together with no separation of items labeled for patient use. Review of the facility's policy, "Safety Program - Physical Therapy" (Eff. 9/2/04, Rev. 7), stated, "C. Storage Procedures: 1. ...patient supplies, isolation supplies shall all be kept in cupboards separate from each other."

Prior to the afternoon survey exit, the CEO acknowledged the infection control issues found in the physical therapy department. The CEO stated it would be corrected.

Based on observation and interview, the facility failed to ensure that safety practices for food handling and storing were maintained.

Finding includes:

During a concurrent tour of the kitchen with the KM on 4/2/14 at 8:30 A.M., there were 6 small cups of thickened supplements, 3 cups of milk, 1 small cup of thickened juice, 1 small cup of poi, and 1 cup of pudding without any written date of use/preparation. These items were found inside Cook 2's special diet refrigerator. Within the two-door freezer, there also was a tray full of frozen pureed prunes and a tub of frozen strawberries with no use by or expiration date written/labeled on them. In the walk-in meat chiller, there were 2 white bucketfuls of "frozen whole eggs." Per the facility's "Eggs Shelf Life" guideline, both the RD and KM concurred the frozen whole eggs had a 2-4 day shelf life once they were taken out of the freezer. However, as the two bucketful of eggs had no use by date nor a date when the buckets were taken out of the freezer, it was unknown when the expiration date was.

Based on record review and review of the facility's policy, the facility failed to ensure it maintained a list of all services furnished under arrangements or agreements, including a description of the nature and scope of the services provided.

Finding includes:

During the entrance conference on 4/1/14 with the Administrator and Director of Nursing, a request was made for a listing of all contracted services for the CAH. The initial list included an abbreviated list of contractors/vendors with no description of the services or contract expiration dates.

By 4/4/14 at 11:50 A.M., a re-revised list was provided; however, the list was still incomplete. An example included a contractor Premium, Inc. who recently serviced the kitchen dish machine on 3/27/14 per the equipment service record, but was not on the list. The Administrator acknowledged the list was still incomplete after the SA brought it to her attention. In addition, there were other contractors/vendors identified during an interview with the maintenance manager on the morning of 4/4/14, where he provided names of contractors used by the hospital that were not included on the "final" list provided to the SA at 11:50 A.M.

Review of the facility's policy, "Contract Technical Representative Duties" (Eff. 10/07, Rev. 1) stated the purpose of the policy was, "To establish and define contract technical representative duties and authority in order to enhance efficient administration of contracts for the purchase of services, goods, or construction...The technical representative is the primary point person responsible for ensuring compliance with a contract by both the contractor and [corporate] once it is executed. The Regional CEO shall oversee this function at the respective facilities within his/her region and shall consider compliance with this policy in evaluating personnel performance." Although this policy was provided, the technical representatives were not identified and the contractor/vendor list remained incomplete by the end of the survey.

Cross-reference to findings at C 222.

Based on record review and staff interview, the facility was not in compliance with several SNF requirements contained in subpart B of part 483 for SNF services for 1 of 22 patients reviewed in the CAH sample.

Finding includes:

Patient #10 was admitted to the facility on 2/13/14 for rehabilitation/skilled nursing services status post right humerus fracture and weakness after an acute hospital admission on 1/31/14 at another hospital. Record review found the facility's Admission Acknowledgement and Signature Sheet, although signed by the patient and admitting staff on 2/13/14 at 10:00 A.M., was incomplete. It was found that on the form, Nos. 1-6, were left unmarked, which were for the Resident Bill of Rights, Advance Directives, Amendments (Revocations), Organ Donation, Conditions of Admission and General Admission Information. On 4/4/14 at 10:05 A.M., a concurrent review of Patient #10's Admission Sheet was shown to the Administrator who confirmed it was incomplete.