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GLENBEIGH HEALTH SOURCES
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on staff interview and review of the Delinquent Records Report, the facility failed to ensure all medical records were completed within 30 days of discharge from the facility. This affected 209 medical records. The facility census was 113 at the time of the survey.
Findings include:
Staff D was interviewed on 09/14/11 at 10:15 AM. Staff D stated that 209 medical records were delinquent or incomplete after 30 days post discharge. Staff D provided a Delinquent Records Report that showed 209 incomplete medical records past 30 days.
PHYSICAL ENVIRONMENT
Tag No.: A0700
Based on interview and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility failed to ensure at least a two-hour fire barrier between the existing building and the new addition, and failed to maintain a one hour smoke barrier in the existing building. This has the potential to affect all 113 patients in the facility.
Findings include:
Please see A710.
LIFE SAFETY FROM FIRE
Tag No.: A0710
Based on observation and interview, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 113 patients in the facility.
Findings include:
The facility was found to have a fire barrier between the existing building and the new addition that was not a two hour barrier. Please see K 11.
The facility was found to have an opening in a smoke barrier. Please see K 25.
ORGAN, TISSUE, EYE PROCUREMENT
Tag No.: A0884
Based on staff interview and review of electronic communication from the local organ procurement organization, the facility failed to ensure that there was a written contract with an organ procurement agency and to have policies and procedures in place to meet the organ, tissue, and eye procurement requirements. The facility census at the time of the survey was 113.
Findings include:
During the initial entrance conference at 11:05 AM on 09/12/11, Staff A stated the facility did not have a contract with any organ procurement organization (OPO) or any policies that pertained to organ procurement requirements. On 09/12/11 at 3:00 PM, Staff A presented the surveyor with an electronic communication from the local OPO that stated this facility had never had a contract with the OPO.