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Based on a review of hospital records and interviews, it was determined the hospital failed to ensure the Governing Body evaluated hospital services related to Patient Rights, QAPI, and Infection Control. This deficient practice poses
the risk of the Governing Body being unaware of the overall function and management of the hospital and the inability to improve patient care services.

This was demonstrated by a failure to ensure:

Cross reference A-0047: The Medical Staff Bylaws were reviewed every two years, and any amendments made were approved by the Governing Board.
Cross reference A-0049: The quality of care provided by the medical staff was reported to and evaluated by the Governing Body.
Cross reference A-0057: The Chief Executive Officer (CEO) was responsible for hospital operations.
Cross reference A-0118: Policy and procedures were followed when investigating and responding to a complaint or grievance.
Cross reference A-0119: The Governing Body approved and was responsible for the operation
of the grievance process.
Cross reference: 0123: Written notice of the facility's decision regarding the grievances, the
hospital staff contact person, the steps to investigate the grievance, the results of the
investigation, and the date of completion/resolution.
Cross-reference A-0143: There was adequate privacy for patients with care and treatment.
Cross reference A-0144: Ensure patients received safe care in a ligature free environment;
Cross reference A0159: Patients receiving a physical restraint were recognized as being
under restraint.
Cross reference A0160: Patients receiving a chemical restraint were recognized and
documented a being under restraint.
Cross reference A0168: An order was received for the use of physical or chemical restraint on a patient.
Cross-reference: A0178: The patients were evaluated (seen face to face) by a physician or
other appropriately trained licensed individual Practitioner within one hour of the restraint.
Cross reference A0185: The requirement for restraint was documented in the patient's medical
record.
Cross reference A0186: That alternative measures were attempted before the use of a restraint.
Cross reference A0188: The patient's response to being put in restraints was documented in the medical record.
Cross reference A0308: The hospital developed, implemented, and maintained an effective hospital-wide quality assessment and performance improvement program.
Cross reference A309: The governing body provided evaluation and oversight to the Quality Assurance and Performance Improvement
(QAPI) program
Cross reference A-0386: Responsibilities of the Director of Nursing were carried out according to hospital policy and procedure.
Cross reference A0454: Provider telephone orders were authenticated within 48 hours of the order being placed.
Cross reference A-0749: There was an effective Infection Control Program, specific to the hospital, to prevent and control the transmission of infections within the Hospital.
Cross reference A-0750: The Infection Prevention Control Program addressed issues identified by public health authorities.
Cross reference A-0770: The Governing Board provided oversight of infection control activities within the hospital.
Cross reference A-0771: Infection Prevention data and activities occurring in the hospital were addressed with QAPI.
Cross reference A-0773: The Infection Preventionist had appropriate documentation of infection control activities.
Cross reference A-0774: The Infection Preventionist was responsible for the communication and collaboration with Quality Assurance Performance & Improvement related to Infection Control issues.
Cross reference A1716: A social worker with a master's level degree was employed to provide social services to patients.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meetthe requirement for the Condition of Participation for Governing Body.

Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A-0118: Ensure a patient receives a prompt resolution to a grievance;
Cross reference A-0119: Ensure the Governing Body is responsible for the grievance process;
Cross reference A-0123: Ensure patients received written notification of resolution of the grievance;
Cross reference A-0143: Ensure patients received care in a private setting;
Cross reference A-0144: Ensure patients received safe care in a ligature free environment;
Cross reference A-0159: Ensure patients who were placed under physical restraint were recognized and documented on as being in a restraint;
Cross reference A-0160: Ensure patients who were placed under chemical restraint were recognized and documented on as being under restraint;
Cross reference A-0168: Ensure patients were only restrained with an order from a physician or
licensed provider;
Cross reference A-0178: Ensure patients receive a one hour face to face evaluation when requiring the use of restraints;
Cross reference A-0185: Ensure documentation of a patient's behavior leading up to the need for a chemical restraint;
Cross reference A-0186: Ensure documentation of alternatives attempted before placing a patient in restraints;
Cross reference A-0188: Ensure documentation of a patient's response to being in a restraint.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from
harm.

Based on the review of facility records and interviews it was determined that the Hospital
failed to ensure:

Cross reference A0018: Policy and procedures were followed when investigating and responding to a complaint or grievance.
Cross reference A0308: The development, implementation, and maintenance of an effective hospital-wide Quality Assessment and Performance Improvement program (QAPI).
Cross reference A0309: The Governing Body provided evaluation and oversight to the Quality Assurance and Performance Improvement (QAPI) Program.
Cross reference A-0771: Infection Prevention data and activities occurring in the hospital were addressed with QAPI.
Cross reference A-0774: The Infection Preventionist was responsible for the communication and collaboration with Quality Assurance Performance & Improvement related to Infection Control issues.

The cumulative effect of these systemic problems resulted in the hospital's inability to have an effective quality assurance performance improvement program to assess opportunities for improvement.

Based on review of the hospital records and interviews, it was determined that the Hospital failed to ensure:

Cross reference A-0749: There was an effective Infection Control Program, specific to the hospital, to prevent and control the transmission of infections within the Hospital.
Cross reference A-0750: The Infection Prevention Control Program addressed issues identified by public health authorities.
Cross reference A-0770: The Governing Board provided oversight of infection control activities within the hospital.
Cross reference A-0771: Infection Prevention data and activities occurring in the hospital were addressed with QAPI.
Cross reference A-0773: The Infection Preventionist had appropriate documentation of infection control activities.
Cross reference A-0774: The Infection Preventionist was responsible for the communication and collaboration with Quality Assurance Performance & Improvement related to Infection Control issues .

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship and provide a safe
environment for patients to protect them from harm.

Based on a review of hospital records and staff interview, it was determined the hospital failed to ensure that Medical Staff Bylaws were reviewed every two years, and any amendments made were approved by the Governing Board. This
failure poses the risk of the medical staff operating under bylaws that the Governing Board has not approved.

Findings Include:

Document titled "Talas Harbor Behavior Health Hospital Medical Staff Bylaws," revealed: "...Approved: Amended: July, 2020 Approved: June 10, 2020...The responsibilities of the Medical Staff are...to monitor, enforce, review,
and, if necessary or desirable, recommend amendments to these Bylaws...."

Document titled "Talas Harbor Governing Board Bylaws," revealed: "...The Medical Staff shall be governed by Medical Staff Bylaws, Rules and Regulations and applicable Rules and Regulations and policies adopted by the Governing Board which set forth its organization and government and which, when warranted, shall be reviewed and revised by the Medical Staff, or its departments, as appropriate or as required by law. The period between reviews should not exceed two (2) years. The Medical Staff shall recommend to the Governing Board and the adoption of proposed Bylaws, Rules and Regulations and amendments thereto, and such changes shall become effective when approved by the Governing Board...."

Employee #3 confirmed in an interview on 01/08/2024, that the last date the Medical Staff Bylaws had been approved was documented as June 10, 2020.

Based on a review of hospital record and staff interview, it was determined the hospital failed to ensure the quality of care provided by the medical staff was reported to and evaluated by the Governing Body. This failure poses the risk of
medical staff providing patient care that does not align with Governing Board standards, and no analysis of the quality of care that is provided.

Findings Include:

Document titled "Governing Board Bylaws,revealed: "...The Governing Board shall require,consider, and if necessary, act upon Medical Staff reports of medical care, evaluation, utilization review and other matters relating to the quality of care rendered in the Hospital. The executive committee of the Medical Staff shall, through its chairman or his designee, cause the preparation and presentation of such required reports to the Governing Board at each Governing Board meeting or otherwise. The Hospital Senior Executive Officer shall providethe Medical Staff with the necessary administrative assistance to facilitate such reporting, regular analysis of the clinical practice,
and the utilization review activities within the Hospital. The format and nature of the content of such reports shall be sufficient to document Medical Staff compliance with its responsibilities pursuant to law and accreditation standards while maintaining the confidentiality of such peer information, as directed by the Governing Board after consultation with the Medical Staff...For purposes of assisting the Governing Board in assessing the activities of the Medical Staff, a representative of the Governing Board may attend meetings of the Medical Staff ...The Medical Staff shall be governed by Medical Staff Bylaws, Rules and Regulations and applicable Rules and Regulations and policies adopted by the Governing Board which set forth its organization and government and which, when warranted, shall be reviewed and revised by the Medical Staff, or its departments, as appropriate or as required by law. The period between reviews should not exceed two (2) years. The Medical Staff shall recommend to the Governing Board and the adoption of proposed Bylaws, Rules and Regulations and amendments thereto, and such changes shall become effective when approved by the Governing Board...."

Document titled "Medical Staff Rules and Regulations," revealed: "...At least annually or as directed, by the Medical Director or Executive Director all physicians will have at least six ecords, peer reviewed for quality compliance.
The information data collected from peer review will be reported (anonymously) in Medical Executive and Governing Body on an annual basis...."

Governing Board Meeting Minutes were requested for the past 12 months and none were received.

Medical Executive Committee (MEC) Meeting Minutes were requested for the past 12 months and one MEC meeting minutes document dated 11/15/2023, was received.

Employee #3 confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the Governing Board and MEC Meeting Minutes. It was confirmed daily with Employee #3, prior to the exit interview, that the Governing Board meeting minutes had not been received and one set of minutes from the MEC had been received from Employee #15.

Based on review of hospital records, and interview, it was determined the Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients
when leadership does not provide proper guidance, enforcement of policies and procedures, and provide resources to provide care to meet the needs of patients.

Findings include:

Document titled " Governing Board Bylaws," revealed: "...The Hospital Senior Executive Officer shall provide the Medical Staff with the necessary administrative assistance to facilitate such reporting, regular analysis of the clinical
practice, and the utilization review activities within the Hospital. The format and nature of the content of such reports shall be sufficient to document Medical Staff compliance with its responsibilities pursuant to law and accreditation
standards while maintaining the confidentiality of such peer information, as directed by the Governing Board after consultation with the Medical Staff ...The Governing Board representative shall delegate responsibility and authority for the day-to-day management of the Hospital to the Hospital Senior Executive Officer...The Board of Directors or its designee shall appoint a chief executive officer of the Hospital (referred to herein as the "Hospital Senior Executive Officer")...Responsibilities: The Hospital Senior Executive Officer all {sic} represent the Hospital in all aspects of its
operations ...Implementation of policies of the Board of Directors and the Governing Board as approved by the Board of Directors or its designee ...Liaison among the Board of Directors, Governing Board, administrative staff
and the Medical Staff and between the Hospital and the local community ...Organization and management of the Hospital and its services, departments, and subdivisions, delegation of duties and establishment of formal means of
accountability of subordinates...."

Document titled "Performance Improvement Plan 2023," revealed: "...The Executive Director or designee is responsible for the review and submission of all reports to the PI Committee, Medical Executive Committee and Governing Board ...The Governing Board of Talus Harbor has authorized the Executive Director to implement and monitor the PI Plan The Executive Director or designed is responsible for facilitating the completion of PI activities defined by the scope of this plan, and to assist in resolution within his/her authority ...The Executive Director shall have overall responsibility for the implementation of the Performance Improvement Plan. The Executive Director or designee may develop committees to work on specific PI activities ...."

Document titled "Medical Staff Bylaws," revealed: "...Reports and other information which these Bylaws require the Medical Staff to transmit to the Board shall be deemed so transmitted when delivered to the Executive Director ...."

Policy titled "Restraint and Seclusion" revealed: "...all uses of restraint or seclusion in an emergency are reported daily to the Executive Director and Chief Nursing Officer or designee and appropriate action is taken to correct unusual
or unwanted {sic} ...."

Policy titled "Nursing Plan for Patient Care and Safety," revealed: "...The Chief Executive Officer (CEO), identifies a nurse leader at the executive level who participates in decision making ...."

Hospital document titled "Restraint Log," revealed no instances of seclusion or restraint for the year of 2023.

Governing Board, QAPI, and MEC meeting minutes were requested. One set of QAPI meeting minutes dated 08/11/2023, and one set of MEC minutes dated 11/15/2023, were received.

A review of patient medical records and incident reports, revealed that 4 patients (Patient s #8, 21,22, and 23), had been restrained.

Employee #1 confirmed in an interview conducted on 01/08/2024 at 12:00, when the hospital was entered by surveyors that the CNO and CEO were commuting from Las Vegas and would be arriving soon. Employee #1 confirmedthe CNO and CEO arrival at 13:50 on 01/08/2024.

Employee #3 confirmed in an interview conducted on 01/08/2024, that leadership duties are rotated and if the CNO is not on site, the CEO is on site.

Employee #10 confirmed in an interview conducted on 01/10/2024, it would be helpful if leaders were available more often because there are a lot of questions about how the hospital should operate. Employee #10 confirmed the
CNO and CEO were present one to two times a week.

Employee #2 confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the Governing Board, QAPI, and MEC Meeting Minutes. It was confirmed daily with Employee #2, prior to the
exit interview, that the Governing Board meeting minutes had not been received and one set of minutes from the MEC, and QAPI had been received from Employee #15.

Based on review of facility documents and staff interviews, it was determined that the hospital failed to ensure that facility policy and procedure was followed when investigating and responding to a complaint or grievance. This deficient practice poses a potential risk to patient's health and safety when complaints and grievances are not investigated, eliminating the opportunity to identify and correct quality of care issues.
Findings Include:

Policy titled "Complaint and Grievance Process" revealed: " ...Purpose. To provide a means to identify and address patient complaints and grievances in a timely manner...DEFINITIONS:...B. Grievance is a formal or informal written or verbal complaint that is made at any hospital staff person by a patient, former patient, and patient representative, regarding the patient care, abuse or neglect, issues related to the hospital compliance with the CMS Conditions of Participation. A written complaint, regardless of source or format (fax, email, call,letter etc.) or a verbal complaint that a patient/representative requests to be handled as a grievance.Procedure: D. Within seven days of receipt of
the grievance, the Patient Advocate shall inform the patient/representative in writing of the investigation, actions being taken, the expected completion date, and the name of the contact information for the Patient Advocate. E. All
attempts to resolve the grievance shall be made within thirty days of the date that the seven-day notification was sent to the patient or representative. OF. Notification to the patient or representative will be sent to the patient or
representative at each thirty-day interval, describing the status of the investigation until the grievance is resolved ...."

Hospital document titled "Governing Board Bylaws" revealed: "...Article VIII Governing Board Operation ...Section 9. Risk Management. The Governing Board shall ensure that the hospital establishes and maintains an internal risk management program
the analysis of patient grievances that relate to patient care and the quality of medical services...."

Hospital document titled "Grievance and Complaint Log" for 2023, revealed: 2 grievances on July 28th, 2023 and December 5th, 2023.
No follow up was completed.

Employee #3 confirnmed on 01/09/2024 that there were only 2 complaint entries for 2023 in the Grievance and Complaint Log and no follow up had been carried out.

Based on the review of the facility documents it was determined that the hospital failed to ensure that the Governing Body approved and was responsible for the operation of the grievance process. This deficient practice poses a potential risk to patient health and safety when complaints and grievances are not investigated properly, eliminating the opportunity to identify and correct quality of care issues.

Findings Include:

Policy titled "Patient Complaint and Grievance Process" revealed: "...Procedure:...H. Any significant grievances involving patients rights, quality of care, patient safety, or ethical concerns will be reviewed in the COW and reported to the Governing Body as appropriate.

Hospital document titled "Governing Board Bylaws" revealed: "...Article VIII Governing Board Operation ...Section 5. Performance Improvement (PI). the Governing Board shall require the Medical Staff and staffs of the Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, and for resolving problems. The Governing Board,through the Hospital Senior Executive Officer, shall support these activities and mechanisms ...Section 9. Risk Management. The Governing Board shall ensure that the hospital establishes and maintains an
internal risk management program focusing on patient safety that includes the following elements: c. the analysis of patient grievances that relate to patient care and the quality of
medical services...."

Hospital document titled "Grievance and Complaint Log" for 2023, revealed: 2 grievances dated July 28th, 2023 and December 5th, 2023. No follow up was completed.

Document, Governing Body Meeting Minutes for 2023 requested, none provided.

Employee #3 confirnmed on 01/09/2024 that there were only 2 complaint entries for 2023 in the Grievance and Complaint Log and no follow up had been carried out.

Based on the review of facility documents it was determined the hospital failed to provide written notice of the facility's decision regarding the grievances, the hospital staff contact person, the steps taken to investigate the grievance, the results of the investigation, and the date of completion/resolution. This deficient practice poses a potential risk to the health and safety of a patient when hospital staff fails to document how/ if/when a grievance was resolved and communicate this information to patients.

Findings Include:

Policy titled "Complaint and Grievance Process" revealed: " ...Purpose. To provide a means to identify and address patient complaints and grievances in a timely manner ...D. Within seven days of receipt of the grievance, the Patient Advocate shall inform the patient/representative in writing of the investigation, actions being taken, the expected completion date, and the name of the contact information for the Patient Advocate...E. All attempts to resolve the grievance shall be made within thirty days of the date that the seven-day notification was sent to the patient or representative...F. Notification to the patient or representative will be sent to the patient or representative at each thirty-day interval, describing the status of the investigation until the grievance is resolved ...."

Hospital document titled "Grievance and Complaint Log" for 2023, revealed: 2 grievances dated July 28th, 2023 and December 5th, 2023.
No follow-up was completed.

Employee #3 confirnmed on 01/09/2024 that there were only 2 complaint entries for 2023 in the Grievance and Complaint Log and no follow up had been carried out.

Based on facility records and interview, it was determined the Hospital failed to ensure there was adequate privacy for patients with care and treatment. This deficient practice poses a risk to the health and safety of patients when the facility does not respect the patients right to privacy and confidentiality.

Findings Include:

Hospital document titled "Patient Rights" revealed: " ...A patient has the following rights...To receive privacy in treatment and care for personal needs ...."

Observation conducted on 01/09/2024 of the patient unit revealed that 6 out of 14 patient room windows lacked privacy covering (window film.)

Employee # 3 confirmed during an interview conducted on 01/09/2024, that the film on the
windows needed to be replaced.

Based on a review of hospital records, observation, and staff interview, it was determined the Hospital failed to provide a safe, ligature free environment for psychiatric patients. This failure poses the risk of a patient suffering
serious injury or death.

Findings Include:

Hospital document titled "Patient Rights," revealed: "...Each patient has the right to a safe, sanitary, and humane living environment...."

Policy titled "Nursing Plan for Patient Care and Safety" revealed: " ...Nursing Services participates in providing a safe, secure, and healthy environment for patients, staff and visitors and strives for excellence in service. The
plan consists of seven areas which are: 1 Safety..."

During a tour conducted on 01/09/2024, at 1100 hours, ligature risks were identified in fourteen out of fourteen patient rooms. This ligature risk was a metal bracket used to mount the privacy curtain between the patient bedroom and bathroom, which had a metal tab to feed the breakaway privacy curtain. The metal tab could be used to create a tie-off point.

Employee #3 confirmed in an interview on 01/09/2024, that s/he acknowledged the risk of the ceiling curtain mounts as a ligature point, it was a facilities issue and not a nursing issue, and would act immediately to mitigate the risk.

Based on a review of hospital record and interview, it was determined the Hospital failed to ensure that patients receiving a physical restraint were recognized and documented as being under restraint. This failure poses the risk of
patients not having the monitoring and assessments in place to ensure their safety and rights, when restrained.

Findings Include:

Policy titled "Seclusion and Restraints," revealed: "...All patients have the right to be free from restraint and/or seclusion, of any form, that is imposed as a means of coercion, discipline, convenience, or retaliation by staff...Philosophy: A. Restraints/Hold is any method, physical or mechanical device, material, or equipment that
immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or had {sic} freely...Physical Escort: Using a light grasp to escort a patient to a desired location. If the patient can easily remove or escape the grasp, it is not a physical restraint. If the patient cannot early {sic} remove or escape, this would be a physical restraint...All uses of restraint or seclusion in an emergency situation are reported daily to the Executive Director & Chief Nursing Officer...Each instance of restraint or seclusion is documented in the restraint/seclusion log...Restraint and/or seclusion shall be ordered by a physician or a registered nurse practitioner primarily responsible for the patient's ongoing care authorized by the medical staff...The order shall specify the method of restraint (mechanical
or physical/protective hold)...."

Hospital document titled "Incident Report Form," dated 12/22/2023, for Patient #23, revealed: "...Patient then said don't put your hands on me as [he] was trying to go outside. Patient was then forcefully escorted to [his] room. Was trying to get out of room...."

Hospital document titled "Restraint and Seclusion Log," dated December 2023, revealed: "...0 Restraint/Seclusion Reported...."

Patient #23's medical record revealed no documentation of the restraint and no restraint orders.

Employee #8 confirmed in an interview on 01/09/2024 that being forcefully escorted would be considered a physical restraint and it was not included in the December Restraint and Seclusion Log.

Employee #9 confirmed in an interview on 01/09/2024, that there was not a restraint order in Patient #23's medical record.

Based on a review of hospital record and interview, it was determined the Hospital failed to ensure that patients receiving a chemical restraint were recognized and documented as being under restraint. This failure poses the risk
of patients not having the monitoring and assessments in place to ensure their safety and rights, when restrained.

Findings Include:

Policy titled "Seclusion and Restraints," revealed: "...Drugs used as Restrain/Chemical Restraint: A drug or medication when it is used as a restriction manage {sic} the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition...The use of this medication should be addressed in the patient's plan of care and medical record...Each instance of restraint or seclusion is documented in the restraint/seclusion log...Restraint and/or seclusion shall be ordered by a physician or a registered nurse practitioner primarily responsible for the patient's ongoing care authorized by the
medical staff...."

A review of patient records revealed three patients (Patients #8, #21, and #22), received intramuscular injections of a combination of
Haldol, Benadryl, and Ativan.

Patient #8's medical record dated 11/05/2023, contained a nursing note which revealed: "...Pt was severely agitated. [He] refused PO
medications. Threw a full cup of water on the nurses station. 1712- IM orders for Ativan/Benadryl/Haldol obtained. 1720- Medication administered in left deltoid...."

Document titled "Incident Report Form," for Patient #21, dated 08/09/2023, revealed: "...Pt became agitated and going into other patient's rooms. Patient was offered oral medications and refused multiple times...Paranoia, agitation and intrusiveness increased. B52 was given...."

Document titled "Incident Report Form," for Patient #22, dated 08/08/2023, revealed: "...During admission pt became threatening
toward staff and yelling and screaming. [She] refused to leave the exam room...Patient given B52 to calm down...."

Hospital document titled "Restraint and Seclusion Log," dated August 2023, revealed: "...0Restraint/Seclusion Reported...."

Hospital document titled "Restraint and Seclusion Log," dated November 2023, revealed: "...0 Restraint/Seclusion Reported...."

Employee #8 confirmed in an interview on 01/09/2024, that Patients #8, #21, and #22, received IM injections due to their behavior, but were not included on the restraint and seclusion log and did not have orders for a chemical restraint.

Based on a review of hospital records and interview, it was determined the Hospital failed to ensure an order was received for the use of a physical or chemical restraint on a patient. This failure poses the risk of a patient being
inappropriately restrained and not receiving adequate care or monitoring during a restraint episode.

Findings Include:

Policy titled "Seclusion and Restraints," revealed: "...Restraint and/or Seclusion shall be ordered by a physician or a registered nurse practitioner primarily responsible for the patient's ongoing care authorized by the medical staff...The order shall specify the method of restraint...The order shall include the following: a. Date b. Time of day c. The purpose of the restraint or seclusion...e. The type of restraint or seclusion f. The specific behavior that justifies or presents a danger to self or other in the need for restraint or seclusion...."

A review of medical records of patients receiving chemical or physical restraints, (Patients #8, #21, #22, and #23), revealed four out of four had no restraint orders from a physician or other licensed practitioner.

Employee #8 confirmed in an interview on 01/09/2024 that Patients #8, #21, #22, and #23, had no orders from a physician or licensed practitioner for the restraint.

Based on facility records and staff interview, the hospital failed to ensure the patients were evaluated (seen face to face) by a physician or other appropriately trained licensed individual Practitioner within one hour of the restraint. This deficient practice poses the risk of physical and/or psychological harm not identified and treated after the restraint.

FINDINGS INCLUDE:

Policy titled "Restraint/Seclusion" revealed: "...Philosophy: A. Restraints/Hold is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body,
or had freely ...D. Drugs Used as a Restraint/Chemical Restraint: A drug or medication when it is used as a restriction, manage the patient behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...E. Physical Escort: Using a light grasp to escort a patient to a desired location ...."

Policy titled "Seclusion/Restraint" revealed: "...Policy: " ...One-hour face-to-face assessment:1. The physician, LIP, or a registered nurse shall perform a one-hour face-to-face assessment of the patient's physical and psychological status
within 1 hour of the initiation of the Restraint or Seclusion ...."

Document titled "Incident Report Form," for Patient #22, dated 08/08/2023, revealed:"...During admission pt became threatening toward staff and yelling and screaming. [She] refused to leave the exam room...Patient given
B52 to calm down...."

Document titled "Incident Report Form," for Patient #21, dated 08/09/2023, revealed: "...Pt became agitated and going into other patient's rooms. Patient was offered oral medications and refused multiple times...Paranoia, agitation and intrusiveness increased. B52 was given...."

Hospital document titled "Incident Report Form," dated 12/22/2023, for Patient #23, revealed: "...Patient then said don't put your hands on me as [he] was trying to go outside. Patient was then forcefully escorted to [his] room. Was trying to get out of room...." Patient #8's medical record dated 11/05/2023, contained a nursing note which revealed: "...Pt was severely agitated. [He] refused PO medications. Threw a full cup of water on the nurses station. 1712- IM orders for Ativan/Benadryl/Haldol obtained. 1720- Medication administered in left deltoid...."

Medical Record: A review of 4 medical records of patients who were restrained. 4 out of 4 patient records (# 8, 21, 22, 23) did not contain documentation to include a one-hour face-to-face assessment after the use of restraints.

Employee # 9 confirmed during an interview conducted on 01/09/2024 that there was no documentation of a 1-hour face-to-face
assessment for patients # 21,22, and 23 after the use of restraints.

Employee # 8 confirmed during an interview conducted on 01/09/2024 that there was no documentation of a 1-hour face-to-face
assessment for patient # 8 after the use of restraints.

Based on facility records and interview, the hospital failed to ensure the requirement for restraint was documented in the patient record. This deficient practice poses a risk to patient safety when unapproved methods of restraint
could be used.

FINDINGS INCLUDE:

Policy titled "Restraint/Seclusion" revealed: "...Philosophy: A. Restraints/Hold is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body,
or had freely ...D. Drugs Used as a Restraint/Chemical Restraint: A drug or medication when it is used as a restriction, manage the patient behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...E. Physical Escort: Using a light grasp to escort a patient to a desired location...."

Policy titled "Restraint/Seclusion" revealed: " ...Documentation: 1. Each episode of the use of Restraint and Seclusion is documented in the patient's medical record and contains the following:6. Each episode of use: a. Circumstances that led to restraint or seclusion...."

Document titled "Incident Report Form," for Patient #22, dated 08/08/2023, revealed: "...During admission pt became threatening toward staff and yelling and screaming. [She] refused to leave the exam room...Patient given B52 to calm down...."

Document titled "Incident Report Form," for Patient #21, dated 08/09/2023, revealed: "...Pt became agitated and going into other patient's rooms. Patient was offered oral medications and refused multiple times...Paranoia, agitation and intrusiveness increased. B52 was given...."

Document titled "Incident Report Form," dated 12/22/2023, for Patient #23, revealed: "...Patient then said don't put your hands on me as [he] was trying to go outside. Patient was then forcefully escorted to [his] room. Was trying to get out of room...."

Medical Record: A review of 4 medical records of patients who were restrained. Three (3) out of four (4) patient records (# 21, 22, 23) did not contain documentation to include the patient's behavior leading up to the reason for restraint.

Employee # 9 confirmed during an interview conducted on 01/09/2024 that there was no documentation to include the patient's behavior leading up to the reason for restraint.

Based on facility records and interviews the hospital failed to ensure that alternative measures were attempted before the use of a restraint. This deficient practice poses a health and safety risk to the patient if alternative measures are not attempted and the patient is restrained unnecessarily.

FINDINGS INCLUDE:

Policy titled "Restraint/Seclusion" revealed: "...Philosophy: A. Restraints/Hold is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body,
or had freely ...D. Drugs Used as a Restraint/Chemical Restraint: A drug or medication when it is used as a restriction, manage the patient behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...E. Physical Escort: Using a light grasp to escort a patient to a desired location...."

Policy titled "Restraint/Seclusion" revealed: " ...Documentation. 1. Each episode of the use of Restraint or Seclusion is documented in the patient medical record and contains the following:...4. Least restrictive measures ...6. Each
episode of use ...b. Consideration of failure of alternatives ...."

Document titled "Incident Report Form," for Patient #22, dated 08/08/2023, revealed: "...During admission pt became threatening toward staff and yelling and screaming. [She] refused to leave the exam room...Patient given
B52 to calm down...."

Document titled "Incident Report Form," for Patient #21, dated 08/09/2023, revealed: "...Pt became agitated and going into other patient's rooms. Patient was offered oral medications and refused multiple times...Paranoia, agitation and intrusiveness increased. B52 was given...."

Hospital document titled "Incident Report Form," dated 12/22/2023, for Patient #23, revealed: "...Patient then said don't put your hands on me as [he] was trying to go outside. Patient was then forcefully escorted to [his] room. Was trying to get out of room...."

Medical Record: A review of 4 medical records of patients who were restrained.Three (3) out of four (4) patient records (# 21, 22, 23) did not contain documentation to include alternate methods attempted before the restraint.

Employee # 9 confirmed during an interview conducted on 01/09/2024 that there was no documentation on the use of alternative methods before restraint,

Based on a review of facility records and interviews, the hospital failed to ensure that the patient's response to being put in restraints was documented in the medical record. This deficient practice poses a health and safety risk to the
patient when you do not assess the effect that the restraints may have on patient behavior.

FINDINGS INCLUDE::

Policy titled "Restraint/Seclusion" revealed: " ...Philosophy: A. Restraints/Hold is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body,
or had freely ...D. Drugs Used as a Restraint/Chemical Restraint: A drug or medication when it is used as a restriction, manage the patient behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...E. Physical Escort: Using a light grasp to escort a patient to a desired location...."

Policy titled "Restraint/Seclusion" did not specify that the patient's response to the restraint had to be documented.

Hospital document titled "Medical Staff Rules and Regulations" revealed: "...7. Seclusion and/or Restraint...Evaluation 7.4.1 The Attending LIP or his designee (who must be an LIP with appropriate privileges at the facility) shall conduct an in-person evaluation of the patient within 24 hours of the initiation of the restraint or seclusion ...7.4.4 Notwithstanding any evaluation requirements for LIPs or their designees to the contrary, as set forth in Section 7.4, the condition of the patient who is in restraint or seclusion must be continually assessed, monitored, and reevaluated by appropriately trained staff ...."

Document titled "Incident Report Form," for Patient #22, dated 08/08/2023, revealed: "...During admission pt became threatening toward staff and yelling and screaming. [She] refused to leave the exam room...Patient given
B52 to calm down...."

Document titled "Incident Report Form," for Patient #21, dated 08/09/2023, revealed: "...Pt became agitated and going into other patient's rooms. Patient was offered oral medications and refused multiple times...Paranoia, agitation and intrusiveness increased. B52 was given...."

Hospital document titled "Incident Report Form," dated 12/22/2023, for Patient #23, revealed: "...Patient then said don't put your hands on me as [he] was trying to go outside. Patient was then forcefully escorted to [his] room. Was trying to get out of room...."

Medical Record: A review of 4 medical records of patients who were restrained. Three (3) out of four (4) patient records (# 21, 22, 23) did not contain documentation to include a response to the intervention and or a plan for the continued use of restraint.

Employee # 9 confirmed during an interview conducted on 01/09/2024 that there was no response to the restraint documented.

Based on a review of hospital records and staff interviews, it was determined the hospital failed to develop, implement and maintain an effective hospital-wide quality assessment and performance improvement program. This
deficient practice poses a health and safety risk to patients when the hospital cannot ensure the provision of quality health care and a safe environment.

Findings Include:

Hospital document titled "Performance Improvement Plan 2023," revealed: "...The purpose of this plan is to ensure the delivery of quality care to all patients. This is established through consistent monitoring of the clinical services of the unit...The important aspects of care shall be determined by the Executive Director, Chief Nursing Officer, Nurse Manager, Infection Control Nurse, physicians etc. and shall be reviewed by the Talas Harbor Performance
Improvement Committee...The activities of the PI plan are reported at least quarterly to the Performance Improvement Committee...Performance Improvement Indicators/Initiatives will be reviewed at least
quarterly in the PI meeting...."

Hospital document titled "Governing Board By-Laws," revealed: "...The Governing Board shall require the Medical Staff and staffs of the Hospital departments/services to implement and report on the activities and mechanisms for
monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, and for identifying and resolving problems....The Governing Board shall consider, and if necessary, act upon the results reported from the PI activities...."

Hospital document titled "Nursing Plan for Patient Care Safety," revealed: "...Nursing will participate in the Hospital's Performance Improvement Plan to assist in the quality and appropriateness of the patient care services given to our patients...Data is collected and organized for each indicator...The data is analyzed with input from other departments...Results are shared through the committee process up to and including Governing Board...."

Hospital document titled "Medical Staff By-Laws," revealed: "...Quality Management. a. The duties involved in the overseeing quality assessment and improvement are to: i. coordinate and integrate all quality assessment and
improvement components of the quality management program to reduce or eliminate duplications, omissions, inconsistencies, and failure to effect change; ii. Monitor the quality management program to the extent that it is
comprehensive and that it conducts appropriate evaluations...document performance of this function in a report on at least a quarterly basis...The Quality Management Committee will be actively involved in the following processes: i. medical assessment and treatment of patients...."

QAPI meeting minutes and activities were requested for 2023. Activities related only to nursing care, were provided.
Meeting minutes were provided only for 08/11/2023.

Employee #3 confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the QAPI Meeting Minutes. It was confirmed daily with Employee #3, prior to the exit interview, one set of minutes
from QAPI had been received from Employee #15.

Based on a review of hospital records and interviews, it was determined that the Governing Body failed to provide evaluation and oversight to the Quality Assurance and Performance Improvement (QAPI) program. This deficient
practice poses a significant risk for patients' health and safety when the hospital's Governing Body and Quality Management committees fail to ensure that quality improvement, quality assessment, quality of care, and performance
improvement projects are evaluated and follow-up recommendations are provided.

Findings Include:

Hospital document titled "Performance Improvement Plan 2023," revealed: "...The purpose of this plan is to ensure the delivery of quality care to all patients. This is established through consistent monitoring of the clinical services of the unit...The activities of the PI plan are reported at least quarterly to the Performance Improvement Committee...The Executive Director or Designee is responsible for the review and submission of all reports to the PI Committee, Medical Executive Committee and Governing Board...Performance Improvement Indicators/Initiatives will be reviewed at least quarterly in the PI meeting...."

Governing Board meeting minutes wererequested for the last 12 months and none were received.

QAPI meeting minutes were requested for the last 12 months and provided only for 08/11/2023.

Employee #2 confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the Governing Board
and QAPI Meeting Minutes. It was confirmed daily with Employee #2, prior to the exit interview, that the Governing Board meeting minutes had not been received and one set of minutes from the QAPI had been received from Employee #15.

Based on a review of hospital records and staff interview, it was determined the Hospital failed to ensure the Director of Nursing participated in activities pertaining to the overall function of the hospital, to provide integrated, organized, quality of care to patients. This failure poses the risk of the Director of Nursing being unable to identify care issues, and implement effective, quality improvement activities related to performance, safety, in ection control, and medical care of patients.

Findings Include:

Policy titled "Nursing Plan for Patient Care and Safety" revealed: " ...The Chief Executive Officer (CEO) identifies a nurse leader at the executive leader who participates in decision making...The Directors of nursing are assisted in the clinical and administrative management of the patientcare units by the nursing manager and the nursing supervisor/designee who are qualified by education and experience. The directors of Nursing delegates to the Nursing Managers/Supervisors/designee the authority and responsibility to provide nursing care to the patients with the facility. Together, Together, {sic} the Directors of Nursing and the Nursing Managers/Supervisor/designee(s) assure that there are sufficient personnel in number and skill to care for the patients. The Nursing Managers/Supervisor/designee(s) maintain 24 hour responsibility and accountability for theprovision of care in their areas...The Governing Board and the Administrator of the hospital havegiven the Director of Nursing the responsibility and authority to provide for the nursing care of the patients of the hospital...The Director of Nursing attends the Medical Executive Committee and attends Governing Board meetings to allow participation in policy decisions affecting patient care. The Director of Nursing ensurs the quality of nursing standards of patient care, treatment, services, and practice by incorporating current nursing research findings, nationally recognized professional standards, and other literature into the policies and procedures governing the provision of nursing care, treatment, and services ...Participation in policy decisions affecting patient care services to enhance improvement in patient care by
attending the Governing Board Meeting...Acting as a formal liaison between Medical Staff and the Nursing Department Develops an organizationalplan to delineate the responsibility and accountability of nursing personnel...Multidisciplinary Clinical Teamfunctions include...Review of Policies and Procedures ...Patient Safety Goals...Committee attendance includes: Hospital Governing Board; Medical Executive Committee...Quality Council;
Environment of Care; Infection Control Antibiotic Stewardship...Nursing Services participates in providing a safe, secure, and healthy environment for patients, staff and visitors andstrives for excellence in service. The plan
consists of seven areas which are: 1 Safety..."

Policy titled "Infection Control Plan," revealed: "...Talas Harbor Behavioral Health Hospital's Infection Control Nurse and CNO, through the authority of the Governing Board shall have clinical authority over the infection prevention 80% or higher influenza vaccination for the 2022-2023 season... Talas Harbor Behavioral Health Hospital has a 2022 goal of 80% influenza vaccination...Planning for 2022-2023 flus season to consider the implementation of...Factors That Increase Risks 1. Located in Phoenix, AZ Talas Harbor is a 40-bed psychiatric hospital that
provides care for behavioral health issues,chemical dependency, and co-morbidity of medical issues...Located in a dry environment, wildfires pose a particular threat to MaricopaCounty...Outbreaks are being tracked through
communication with the State of Phoenix and the Maricopa County Health District...."

Hospital document titled "Performance Improvement Plan 2023," revealed: "...Thepurpose of this plan is to ensure the delivery of quality care to all patients. This is established through consistent monitoring of the clinical services of the unit...The important aspects of care shall be determined by the Executive Director, Chief Nursing Officer, Nurse Manager, Infection Control Nurse, physicians etc. and shall be reviewed by the Talas Harbor Performance
Improvement Committee...The activities of the PI plan are reported at least quarterly to the Performance Improvement Committee...Performance Improvement Indicators/Initiatives will be reviewed at least quarterly in the PI meeting...."

Policy titled "Restraint and Seclusion" revealed: "...all uses of restraint or seclusion in an emergency are reported daily to the Executive Director and Chief Nursing Officer or designeeand appropriate action is taken to correct unusual or unwanted(sic) ...."

Hospital document titled "Restraint Log" requested: Log did not contain any patients that were restrained.

A review of 23 patient medical records revealed that 4 patients had been restrained.

A review of the facility policies and procedures revealed multiple outdated policies and policies with another company's name including:
CORE: Surveillance of HealthCare Associated Infection dated 12/20/20 Kindred Behavioral Health
CORE: Reporting of Diseases dated 12/20/2020, Kindred Behavioral Health
CORE: Bloodborne Pathogen Exposure Control Plan dated 02/21, Kindred Behavioral Health
Infection Prevention and Control Program, Date of Origin: 2022
Utilization Review Plan 2019-2020
Transfer of patients to Another Facility, 05/2020
AMA, Leaving Against Medical Advice 08/2019
Admissions Assessment 08/2019
Administration of Medications 12/2019
Handoff Communication 08/2019
Formulary Management 12/2019
Organ Tissue Donation Policy 08/2019
Performance Improvement Plan 2022

Hospital document titled "Governing Board Bylaws" revealed: ' ...Section 7. Regular meetings of the Governing board shall be held at least quarterly ...."

Hospital documents Governing Board Meeting minutes for 2023. None provided.

Hospital documents Medical Executive Committee meeting minutes requested for 2023. One set provided dated 11/15/2023.

Hospital documents QAPI meeting minutes for 2023 requested. One set was provided dated
8/11/2023.

Hospital documents Infection Control meeting minutes were requested and one set, dated 08/11/2023, was provided.

Hospital document titled" Organizational Chart" revealed Employee # 3 as CNO directly below, is a spot for the Nurse Manager, left blank.

Employee #1 confirmed in an interview conducted on 01/08/2024 at 12:00, when the hospital was entered by surveyors that the CNO and CEO were commuting from Las Vegas and would be arriving soon. Employee #1 confirmed the CNO and CEO arrival at 13:50 on 01/08/2024.

Employee # 3 confirmed in an interview that Employee # 8 covers [her] when [she] is out of the facility. Employee # 8 is not named in writing. Employee #3 also confirmed in an interview conducted on 01/08/2024, that leadership duties are rotated and if the CNO is not on site, the CEO is on site. Employee # 3 confirmed in an interview on
01/08/2024 that several of the policies given to the surveyor were outdated. Updated policies were given to the survey team on 01/09/2024 Employee # 3 confirmed in an interview conducted on 01/09/2024 that several policies
given to the surveyor were from Kindred Behavioral Health. Employee #3 confirmed during an interview conducted on 01/09/2024 that [she] is at the facility 3 days a week. Employee #3 confirmed in an interview on 01/09/2024, that s/he acknowledged the risk of the ceiling curtain mounts as a ligature point, it was a facilities issue and not a nursing issue, and would act immediately to mitigate the risk.

Employee #10 confirmed in an interview conducted on 01/10/2024, it would be helpful if leaders were available more often because there are a lot of questions about how the hospital should operate. Employee #10 confirmed the
CNO and CEO were present one to two times a week.

Based on review of facility records and interview, the hospital failed to ensure that provider telephone orders were authenticated within 48 hours of the order being placed. This deficient practice poses a potential risk to the health and
safety of patients due to an increased risk of medical errors that may lead to an adverse patient event.

Findings Include:

Policy titled " Verbal-Telephone Orders" revealed: " ...PROCEDURE:...E. Authentication of orders: 1. All verbal and telephone orders must be authenticated and countersigned by the prescriber or other responsible practitioner within 48 hours (per Medical Staff rules and regulations)...."

Hospital document titled "Medical Staff Rules and Regulations" revealed: "...5.4 Member Orders 5.4.1 ...A verbal order or telephone order shall be considered to be written if accepted by a licensed nurse or licensed pharmacist and signed and dated. Physicians making verbal or telephone orders shall countersign within 48 hours ...."

A review of 20 medical records revealed 7 (Patients #4,8,10,14,15,21 22 ) had telephone orders that were not authenticated by the physician.

Employee # 11 confirmed during an interview conducted on 01/10/2024, that the telephone orders for 7 out of the 20 patients ( Patients # 4,8,10,14,15,21,22) had verbal orders that were not authenticated by the physician.

Based on review of facility records, the hospital failed to ensure an infection control plan specific to Talas Harbor Bullhead was in place. This deficient practice poses a health and safety risk to patients when infection control practices are not implemented.

FINDINGS INCLUDE:

Hospital document Infection Control Plan requested, Plan for Talas Harbor in Phoenix was provided.

Hospital document Infection Control Meeting minutes for 2023, requested, none provided.

Employee # 3 confirmed during an interview dated 01/09/2024 that the Infection Control plan received was for Talas Harbor Phoenix.
.

Based on a review of hospital record and staff interview, it was determined the Hospital failed to establish infection control practices and surveillance based on data from local health authorities. This failure poses the risk of
exposing patients, visitors, and staff to infection from a community outbreak.

Findings Include:

Hospital Document titled "Infection Control Plan," revealed: "...Talas Harbor is a 40-bed facility consisting of approximately 30 employees offering a comprehensive adult inpatient psychiatric treatment facility located in Phoenix,
AZ...Infection Control Risk Assessment...Factors That Increase Risks 1. Located in Phoenix, AZ
Talas Harbor is a 40-bed psychiatric hospital that provides care for behavioral health issues, chemical dependency, and co-morbidity of medical issues...Located in a dry environment, wildfires pose a particular threat to Maricopa County...Outbreaks are being tracked through communication with the State of Phoenix and the Maricopa County Health District...."

Infection Control Surveillance, Activities, and Meeting Minutes were requested for the past 12 months. Infection Control meeting minutes were provided for a meeting on 08/11/2023.

Employee #3 confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the Infection Control Committee meeting minutes. It was confirmed daily with Employee #3, prior to the exit interview, one set of minutes from the Infection Control Committee had been received from Employee #15. Employee #3 also confirmed that they recently closed a Talas Harbor location in Phoenix. Employee #3 further confirmed this was the Infection Control Plan for the present location.

Based on facility records and staff interview, the Hospital failed to ensure that the Governing Board provided oversight of infection control activities within the hospital. This deficient practice poses a health and safety risk to patients when there is a greater potential for hospital acquired infections.

FINDINGS INCLUDE:

Hospital document titled "Governing Board By-Laws" revealed: "...Purpose. The Purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management and planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment, and services rendered in the Hospital...Article II. Governing Board-Structure and Procedures ...Section 7. Regular Meetings. Regular meetings of the Governing Board shall be held at least quarterly at the Hospital or as
such other places as may be designated by the Board of Directors or the Governing Board ...."

Hospital document Infection Control Plan requested. Received the Infection Control plan for Talas Harbor Phoenix.

Governing Board meeting minutes were requested for the year 2023, none were provided.

Employee #3 confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the Infection Control Committee meeting minutes. It was confirmed daily with Employee #3, prior to the exit interview, one set of minutes from the Infection Control Committee had been received from Employee #15. Employee # 3 confirmed that the Infection Control plan received was for Talas Harbor Phoenix.

Based on a review of hospital records and interview it was determined the hospital failed to report infectious diseases found within the hospital, as well as infection control programa and goals to the Governing Body and QAPI. This
deficient practice poses the risk of hospital leadership being unaware of infectious risks in the hospital, the outcome of infection control activities, and the spread of communicable diseases or hospital acquired infections among patients and staff.

FINDINGS INCLUDE:

Hospital document Infection Control Plan requested, Plan for Talas Harbor in Phoenix was provided.

Hospital document Infection Control Meeting minutes for 2023, requested, none provided.

Hospital document QAPI meeting minutes for 2023 requested, I set provided dated 08/11/2023. No Infection Control Activities, HAI's, or results of antibiotic stewardship were addressed.

Employee # 3 confirmed during an interview dated 01/09/2024 that the Infection Control plan received was for Talas Harbor Bull Head.

Based on a review of hospital documents and interview, it was determined the hospital failed to ensure the infection preventionist performed surveillance and documentation of infectious diseases within the hospital. This deficient
practice poses the risk of communicable disease going unnoticed and untreated, as well as proper precautions to prevent the spread of disease among patients and hospital staff.

Findings Include:

Hospital document titled "Infection Control Plan," revealed: "...Talas Harbor is a 40-bed facility consisting of approximately 30 employees offering a comprehensive adult inpatient psychiatric treatment facility located in Phoenix,
AZ...Talas Harbor Behavioral Health Hospital's Infection Control Nurse shall have the authority to institute any appropriate surveillance, prevention, and/or control measures when any condition exists that could result in the spread of infection with the hospital...Talas Harbor Behavioral Health Hospital will set an organizational goal of 80% or higher influenza vaccination for the 2022-2023 season... Talas Harbor Behavioral Health Hospital has a 2022 goal of 80% influenza vaccination...Planning for 2022-2023 flus season to consider the implementation of...Surveillance data is reported internally at appropriate committees as required. A dashboard is kept by the Infection Control Nurse and updated monthly...Outbreaks are being tracked through communication with the State of Phoenix and the Maricopa County Health District...."

Hospital document titled "Job Description Job Title: Quality/Infection Control Practitioner/Case Management," revealed: "...Provides consultative services to hospital departments and acts as a liaison with public health authorities for the purpose of prevention of infection...Actively participates on various committees relative to infection control and employee health; completes reports as needed...Maintains and files reports and other required information...Plans and implements a health program to meet current needs of the hospital...Maintains records; report statistics...."

Infection Control Surveillance, Activities, and Meeting Minutes were requested for the past 12 months. Infection Control meeting minutes were provided for a meeting on 08/11/2023, along with antibiotic surveillance. No other documents provided.

Employee #3, the Infection Preventionist, confirmed in interviews on 01/08/2024, 01/09/2024, and 01/10/2024, that Employee #15 would bring the Infection Control Committee meeting minutes. It was confirmed daily with Employee #3, prior to the exit interview, one set of minutes from the Infection Control Committee had been received from Employee #15. Employee #3 also confirmed that they recently closed a Talas Harbor location in Phoenix. Employee #3 further confirmed this was the Infection Control Plan and documents for the present location

Based on interview and document review the hospital failed to ensure that the Infection Preventionist was responsible for the communication and collaboration with Quality Assurance Performance & Improvement related to Infection Control issues . This deficient practice poses the risk of hospital leadership being unaware of infectious risks in the hospital, the outcome of infection control activities, and the spread of communicable diseases or hospital acquired infections among patients and staff.

Findings Include:

Hospital document "Infection Control Practitioner Job Description" revealed: " ...To assure that facility is compliant with the regulations of all Federal, State, local and other regulatory bodies with jurisdiction over its clinical activities. To
continuously monitor the outcomes of hospital clinical care activities (in partnership with the medical staff). To identify opportunities for improvement and to direct clinical re-engineering activities as required to improve the measured
outcomes of patient care activities...."

Hospital document Infection Control Meeting minutes for 2023, requested, none provided.

Hospital document QAPI meeting minutes for 2023 requested, 1 set provided dated 08/11/2023. No Infection Control Activities were addressed.

Employee # 3 confirmed during an interview dated 01/09/2024 that the Infection Control plan received was for Talas Harbor Phoenix.

Based on a review of hospital record and staff interview, it was determined the hospital failed to ensure a social worker with a master's level degree was employed to provide social services to patients. This failure poses the risk of patient's
not receiving adequate hospital social services during their admission.

Findings Include:

A review of employee files revealed there were no employees who held a master's level degree
in social work.

Employees #2 and #3 confirmed in an interview on 01/09/2024, that the previous social worker who resigned July 2023, also had a bachelor's level social work degree. Employees #2 and #3 could not remember when there was a social worker with a master's degree last employed.