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Based on review and interview the governing body (GB) failed to ensure the bylaws were being followed to ensure board members were elected, received the proper orientation, continued education, and provided information to assist the governing board in making safe decisions to protect the patients and staff of the facility.

A.

4.1. ARTICLE IV
GOVERNING BOARD
Composition. The initial Governing Board shall consist of the Governing Body (Board of Directors). At any time, the Governing Body may appoint no fewer than five (5) members to serve on the Governing Board. The Chairman of the Board of Directors or his designee, are a physician member of the Board of Directors as Chairman of the Governing Board. The CEO of the Hospital shall be an ex officio member of the Governing Board with vote and shall serve as Vice Chairman/Secretary. The Chief of Staff shall be ex officio members of the Governing Board with vote. The Governing Board shall include at least one non-physician representative in addition to the Director of Nursing. The Assistant Administrator/Directors of Nursing shall be a non-voting member.

4.2 ... An orientation shall be provided for new Governing Board members, and continuing education provided for all Governing Board Members after the appointment."

A written and verbal request was given to the facility for a list of members of the Board of Directors (BOD) and the members of the Governing Board (GB). Staff # 16 Chairman of the Board provided the list. A review of the Board of Directors list revealed 7 members staff #16 and staff #47-52. There were no board of director meeting minutes found nor could be provided that revealed these individuals were elected as the governing board. A review of the organizational chart revealed that staff #16 was the only BOD listed.

A review of the members list for the Governing Board revealed there were only three people listed, staff #16 Chairman of the Board, staff # 9 Medical Director, and staff #51 Chief Medical Director. The GB by-laws stated no fewer than 5 members would serve. A review of the organizational chart does not show who the GB members were. There was no evidence found that the CEO, Medical Director, or the Director of Nursing was a GB member.
Governing Board Meeting minutes were requested for 2022-2023 in writing and verbally on 8/21/22. The facility was only able to provide GB meeting minutes for 6-20-23, 6-23-23, and 6-28-23. Staff #2 confirmed that there were no GB meeting minutes for 2022. There was no evidence or meeting minutes to show who was elected to the GB.

An interview with Staff #16 was conducted on 8/24/23. Staff #16 stated that he was the Chairman of the Board and he "sorta inherited this situation." Staff #16 stated that he is a physician with a busy practice and had other facilities under this board of directors. Staff #16 confirmed the board of directors was not actively involved with any daily activities and the running of the hospital. Staff #16 confirmed that the GB bylaws were not currently followed as written.

A review of the meeting minutes revealed staff #2 was leading the meeting and writing up the minutes. Staff #2 stated that other facilities with different provider numbers were being discussed and co-mingled with this facility's quality and GB minutes. Staff #2 confirmed she was not aware that all the facilities could not be combined all together.

A review of the meeting minutes for 6/20/23 revealed there was a list of 13 attendees in the meeting. There were documented motions put in place but no documentation on who made the motion. Staff # 9 seconds all the motions. There was no information on who was voting on the motions or if they had been elected to the GB.

There was no evidence found that all departments were being represented and brought to the GB for approval or to provide information to assist the governing board in making safe decisions to protect the patients and staff of the facility.

B.
the Governing Body (GB) failed to ensure the active medical staff contracted through Company A for telemedicine services were credentialed and performed patient care services according to their approved delineation of privileges.

Refer to Tag A0052

C.
ensure the Chief Executive Officer (CEO) was appointed as responsible for managing the hospital.

Refer to Tag A0057

D.
have any documentation to verify that the budget was reviewed and updated annually.

Refer to Tag A0076

E.
ensure all contracted services were listed, available, evaluated, and approved through quality and the GB in 91 of 91 contracts available.

Refer to Tag A0084

F.
ensure the facility had an easily attainable contract list that included the facility it was assigned to, the scope, and nature of the services provided in 91 of 91 contract names provided.

Refer to Tag A0085

G.
ensure the facility had an emergency room or treatment room, contracts for ambulance services or referring hospitals, and failed to follow the policy and procedure to ensure staff had emergency training in 3 of 3 (staff # 23,11, and 20) employee files. The GB failed to ensure that the facility did not rely on 911 for emergency care.

Refer to Tag A0093

Based on document review and interview the Governing Body (GB) failed to ensure the active medical staff contracted through Company A for telemedicine services were credentialed and performed patient care services according to their approved delineation of privileges.

Findings:

A review of the telemedicine contract for physician services through Company A revealed the contract was signed on 2/23/2014. There was no documentation or evidence that this contract was accepted by the GB nor was there any evidence that the GB ensured the contract was reviewed annually to ensure appropriate services, credentials, and privileges were provided.

A review of the contract for Telemedicine services from Company A revealed the following statement, "In connection with performing the telemedicine physician services, ______ Company A handles physician credentialing, privileging, and re-credentialing of its physicians."

An interview was conducted with Staff #2 and Staff #5 on 8/24/23. Staff #2 stated that she was not sure what the term "Pre-admission" included or meant regarding the physician delineation of privileges. Staff #2 provided an email dated 8/25/23 from Company A stating, "We use 'preadmission' interchangeably with 'admission'. We had been advised by previous surveyors to use a slightly different term for the admission evaluation and orders to distinguish them from the admission evaluation and orders provided by the attending psychiatrist."

A review of the document titled, "Physician Credentialing and Privileging Agreement" was as follows:

" ...THEREFORE, in consideration of the mutual covenants herein contained and other valuable consideration, which is hereby acknowledged as adequate, the parties agree as follows;
...
4. Hospital Reliance on Company A's Credentialing & Issuance of Privileges. Based on the above representations and assurances of Company A, Hospital hereby agrees to acknowledge and accept as valid for purposes of permitting Company A physicians to provide Telemedicine Services to Hospital's patients, the medical staff credentialing, and privileges as delineated in Attachment A hereto and granted by Company A to each physician identified therein. The parties acknowledge that nothing in this Credentialing Agreement shall be construed as guaranteeing the granting to any of Company A's physicians clinical privileges at the Hospital and Hospital shall retain the exclusive authority and responsibility to grant clinical privileges in accordance with Hospital's respective credentialing procedures ...

6. Clinical Privileges. During the term of this Agreement, all qualified Company A physicians who will be providing the Telemedicine Services shall be granted clinical privileges at the Hospital only after the Hospital has reviewed and approved each Company A physician. The parties acknowledge that Company A physicians will not be granted Active Staff membership at the Hospital.

Company A physician shall have no staff committee responsibilities, may not vote, and may not hold office at the Hospital. Notwithstanding the foregoing, upon a Company A physician ceasing to be affiliated with Company A, being administratively removed by Company A from performing services at Hospital, or no longer qualifying for clinical privileges at Hospital for any reason, such occurrence shall result in the automatic termination of such physician's clinical privileges at the Hospital without having any right to a fair hearing or appeal rights as set forth in any of the Hospital's Medical Staff Bylaws or fair hearing plan documents. Company A shall be responsible for informing all of its physicians of the foregoing. If the Services Agreement expires or is terminated for any reason, such occurrence shall result in the automatic termination of this Credentialing Agreement and the automatic termination of clinical privileges at the Hospital of every Company A physician having such clinical privileges without such Company A physician(s) having any right to a fair hearing or appeal rights as set forth in any of the Hospital's Medical Staff Bylaws. Any third-party requesting reference information about Company A's physician will be referred to Company A. Company A acknowledges and accepts its independent obligation to comply with the National Practitioner Data Bank reporting requirements for its physicians ..."

A telephone interview was conducted with Telehealth Physician #38 on 8/25/2023 at 11:37 AM.

Physician #38 was asked if the contract for telehealth services was current. Physician #38 stated, "Yes, it is the most current. The contract is old, and we have talked to the hospital about updating it, but nothing has changed yet. We make sure all of the credentials are up to date and anytime a physician is added or removed from the contract the hospital is notified and an updated list of physicians is sent to the hospital."

Physician #38 was asked if all physicians were granted full admitting privileges. Physician #38 replied the contract was unclear.

Physician #38 was informed that the only delineation of privileges documented at the hospital was "Pre-Admission." Physician #38 was asked what Pre-Admission privileges meant. Physician #38 stated, "That is what needs to be cleared up. Right now, we are basically just screening the patients and making recommendations for admissions. We document on the "Pre-Admission Order Set" that the Psychiatrist and a medical consult are to be completed within 24 hours. When we see the patients through telehealth visits, our records show "Admit Recommendation: Inpatient psychiatric unit, notify attending physician for admission."

Physician #38 confirmed the hospital requested they see every patient regardless of their legal admission status. Physician #38 stated, "If the patient has been seen by a physician within the past 48-72 hours, we review the clinical information sent to us by the admissions clerk and then we will do a telehealth visit once the patient arrives at the hospital. If a patient walks in on their seeking help, we will see the patient and based on the telehealth visit we will decide if the patient needs to go for medical clearance before they can be admitted."

During an interview with Staff #2 on 8/25/2023, it was confirmed that the delineation of privileges for the telehealth physicians with Company A was "Pre-Admission" privileges.

An email provided by Staff #2 revealed a list of 8 physicians (Physician #38, #42, #45, #56, #57, #58, #59, and #60) that had "Pre-Admission" privileges.

Staff #2 could not confirm if the telehealth physicians had full admitting privileges.


A review of 2 (Patient #20 and #23) of 2 medical records was as follows:

Patient #20

A review of the document titled, "PHYSICIAN'S PREADMISSION EXAMINATION ORDERS AND PRELIMINARY PLAN OF CARE" was as follows:

" ...Date & Time: 08/18/2023 9:23 PM

ADMIT RECOMMENDATION: Inpatient psychiatric unit, notify the attending physician for admission

PRESENTING LEGAL STATUS: Voluntary, per intake staff

ADMITTING LEGAL STATUS: Voluntary ..."


Patient #23

A review of the document titled, "PHYSICIAN'S PREADMISSION EXAMINATION ORDERS AND PRELIMINARY PLAN OF CARE" was as follows:

" ...Date & Time: 08/23/2023 12:22 PM

ADMIT RECOMMENDATION: Inpatient psychiatric unit, notify the attending physician for admission

PRESENTING LEGAL STATUS: Voluntary, per intake staff

ADMITTING LEGAL STATUS: Voluntary ..."


During an interview with Staff #2 on 8/24/2023 it was confirmed that 2 (Physicians #42 and #45) of 2 physicians admitted 2 (Patient #20 and #23) of 2 patients to the hospital without a clear delineation of privileges for admissions approved by the GB.

Based on review and interview the Governing Body failed to ensure the Chief Executive Officer (CEO) was appointed as responsible for managing the hospital.

Findings.
A review of the Governing Board (GB) bylaws revealed, "4.4 In consultation with the Governing Board, the Governing Body shall select the CEO to manage the day-to-day business of the Hospital. In managing the Hospital, the CEO communicates with the Medical Staff, the Governing Board, and the Governing Body."

An interview was conducted with Staff # 2 and Staff # 5 on 8/24/23 concerning the GB minutes. Staff # 2 stated that the GB had only met three times since Staff #5 was appointed on 05/15/23. Staff #5 stated that he was not appointed as far as he knew.

A review of the GB meeting minutes dated 6-20-23, 6-23-28, and 6-28-23 revealed there was no appointment of the CEO. Staff #5 was shown as present and representing the CEO position in all three meetings.

A review of the Board of Directors meeting held on 6-15-23 revealed there was no appointment of Staff # 5 as CEO.

Based on review and interview the facility failed to have any documentation to verify that the budget was reviewed and updated annually.

An interview was conducted with staff # 2 and staff # 30 concerning the budget approval. Staff #2 stated there was no update in the governing board minutes. Staff #30 was unable to provide an approved budget and via the governing board for the physical year 2022-2023.

A review of the Board of Directors Meeting Minutes dated 4/5/23 revealed quarterly profit and loss data but no confirmed budget.

Based on review and interview Governing Body (GB) failed to ensure all contracted services were listed, available, evaluated, and approved through quality and the GB in 91 of 91 contracts available.

The surveyor requested a list of contracted services in writing and by verbal request on 8/21/23 through 8/24/23. Staff # 4 provided a 2-page list with very limited information on 8/24/23. The list gave the name of the company and service type (lease, service, utility). Staff #4 stated that was all he could find. On 8/24/23 staff # 16 stated he had a list on his laptop and provided 23 more names. Both lists provided were for other entities within the corporation. There was not a contracted list that separated out the contractors for this specific hospital. The surveyor was unable to determine if the contracts were for this facility or not.

An interview was conducted on 8/24/23 with staff # 30 CFO. Staff #30 confirmed that the contract lists that were provided were all he was aware of and had no other contracts to provide. Staff # 30 confirmed the list included contracts for other hospitals and outpatient service areas within the corporation. Staff #30 was unable to define what contracts were for this facility. Staff #30 confirmed that he was not sure when the contracts were reviewed or up for review. There was no chain of command on who was reviewing the contracts or if they had been reviewed.

A review of the governing bylaws revealed, "4. 7 .3 .18. Ensure that all contractors of services to the Hospital's patients furnish services in a safe and effective manner that permits the Hospital to meet the needs of its patients and to comply with all applicable federal and state laws and regulations, CIHQ standards and with professional standards for contracted services.

A review of the Quality Assessment Performance Improvement (QAPI) meeting minutes revealed there were no contracted services addressed in the meeting minutes for 6/8/23 or 7/6/23.

An interview was conducted with staff #2 on 8/24/23. Staff #2 confirmed that she had not included contracted services in her QAPI meeting minutes. Staff #2 stated she was not aware who was looking over contracted services or when they were last approved. Staff #2 confirmed the QAPI meeting minutes were a combination of three different entities that were not under the same provider number. The surveyor was unable to determine what facility was being discussed in the meeting minutes. Staff #2 confirmed that she was adding in all the facilities with different provider numbers. Staff #2 confirmed that she failed to identify quality and performance problems, implement appropriate corrective or improvement activities, and ensure the monitoring and sustainability of contracted services were performed.

Based on review and interview Governing Body (GB) failed to ensure the facility had an easily attainable contract list that included the facility it was assigned to, the scope, and nature of the services provided in 91 of 91 contract names provided.

The surveyor requested a list of contracted services in writing and by verbal request on 8/21/23 through 8/24/23. Staff # 4 provided a 2-page list with very limited information on 8/24/23. The list gave the name of the company and service type (lease, service, utility). Staff #4 stated that was all he could find. On 8/24/23 staff # 16 stated he had a list on his laptop and provided 23 more names. Both lists provided were for other entities within the corporation. There was not a contracted list that separated out the contractors for this specific hospital. The surveyor was unable to determine if the contracts were for this facility or not.

An interview was conducted on 8/24/23 with staff # 30 CFO. Staff #30 confirmed that the contract lists that were provided were all he was aware of and had no other contracts to provide. Staff # 30 confirmed the list included contracts for other hospitals and outpatient service areas within the corporation. Staff #30 was unable to define what contracts were for this facility. Staff #30 confirmed that he was not sure when the contracts were reviewed or up for review. There was no chain of command on who was reviewing the contracts or if they had been reviewed.

A review of the governing bylaws revealed, "4. 7 .3 .18. Ensure that all contractors of services to the Hospital's patients furnish services in a safe and effective manner that permits the Hospital to meet the needs of its patients and to comply with all applicable federal and state laws and regulations, CIHQ standards and with professional standards for contracted services.

Based on review and interview the Governing Body failed to ensure the facility had an emergency room or treatment room, contracts for ambulance services or referring hospitals, and failed to follow the policy and procedure to ensure staff had emergency training in 3 of 3 (staff # 23,11, and 20) employee files. The GB failed to ensure that the facility did not rely on 911 for emergency care.

A review of the facility revealed the facility had an Emergency Room (ER) that was not open or staffed. There was no emergency treatment room or suite designated to provide any emergency care.

According to the Texas Administrative Code "133.41(e) Emergency services. All licensed hospital locations, including multiple-location sites, shall have an emergency suite that complies with §133.161(a)(1)(A) of this title (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located) or §133.163(f) of this title, and the following."

An interview was conducted with Staff # 5 on 8/22/23. Staff # 5 confirmed the emergency room was closed and no emergency treatment room had been established to provide any emergency care to a patient or a visitor to the facility site. A review of the contract services revealed there were no contracted ambulance services or hospitals listed. Staff #5 stated that 911 would be called for emergency care.

A tour of the closed ER on 8/24/23 revealed there was a crash cart available with the necessary basic equipment for resuscitation. The cart was not immediately available to the staff of the only locked patient unit of the hospital.

A review of the facility policy and procedure "Emergency Medical Care" revised on 6/28/23 stated, "It is the policy of Aspire Hospital to provide basic emergency care to the patient in accordance with hospital policy. As directed by the attending physician or hospital DON, the patient will be transferred to a hospital medical-surgical unit or the Emergency Department for further evaluation and treatment ... Whenever there is any emergency condition, disease, or circumstance that is beyond the care that can be given at this hospital, on the main campus, or at any outpatient clinic location, 911 will be called and an MOT will be done. If there is any non-emergency condition, disease, or circumstance that is beyond the care that can be given at this hospital, an MOT will be done for a transfer."

A review of the facility policy and procedure "Emergency Medical Care" revised on 6/28/23 stated,
"If patient is discovered hanging, staff should support the body weight to relieve pressure in the neck, as they call for help. Remove the ligature material. When the patient is released, initiate CPR. If patient is bleeding, apply pressure and call for assistance.

Staff shall maintain Basic Life Support competency per hospital policy.As part of orientation and annual hospital training, staff will participate in emergency response training."

A review of the nursing employee files (staff # 23,11, and 20) revealed there was no training found for emergency response training.

Based on document review and interview the facility failed to provide the second IMM (Important Message from Medicare) letter before discharge in 2 (Patient #7 and #17) of 4 patient records reviewed.

Findings:


Patient #7
A review of Patient #7's medical record revealed the IMM letter was signed and dated on the admission date of 08/06/2023. A copy was not presented to the patient prior to the discharge date of 08/11/2023.

Patient #17
A review of Patient #17's medical record revealed the IMM letter was signed and dated on the admission date of 06/26/2023. A copy was not presented to the patient prior to the discharge date of 07/04/2023.


During an interview on 8/23/2023 after 11:00 AM Staff #1 confirmed the IMM letters were not given to Patient #7 and #17 within 2 days of their discharge. Staff #1 stated, "They know they are supposed to be doing this."

Based on review and interview the facility failed to ensure appropriate training was given to employees for abuse and neglect, monitoring for patient safety training, and no age appropriate training as required by the Texas Administrative Code (TAC) RULE §568.121(d)(2) in 4 of 4 (Staff #1, #23, #53,#54) employee files reviewed.

Findings included:

A review of 4 nursing staff files were reviewed. There was no documentation of abuse and neglect training, no monitoring for patient safety training, or age appropriate training as required by TAC RULE §568.121(2)(3)-(e)(1)(C) which is as follows:

A staff member shall receive the training in identifying, preventing, and reporting abuse and neglect of patients and unprofessional or unethical conduct required by subsection (a)(1)(D)(i) of this section annually throughout the staff member's employment or association with the hospital, as set forth in Texas Health and Safety Code §161.133.
(3) A staff member shall receive the training required by subsections (a)(1)(D) and (a)(2) - (5) of this section:
(A) before assuming responsibilities at the hospital; and
(B) annually throughout the staff member's employment or association with the hospital.
(4) A staff member shall have the certification required by subsection (b) of this section:
(A) before assuming responsibilities at the hospital; or
(B) not later than 30 days after the staff member is hired by the hospital if another staff member who has such certification is physically present and on-duty on the same unit on which the uncertified staff member is on-duty.
(5) A pre-admission screening professional (PASP) shall receive the training required by subsection (a)(7) of this section:
(A) before the PASP conducting a pre-admission screening; and
(B) annually throughout the PASP's employment or association with the hospital.
(6) A staff member shall receive the training required by subsection (a)(8) of this section:
(A) before conducting the intake process; and
(B) annually throughout the staff member's employment or association with the hospital.
(7) A staff member shall receive the training required by subsection (a)(9) of this section at the intervals described in 25 TAC Chapter 415, Subchapter F .
(e) Documentation of training.
(1) A hospital shall document that a staff member has successfully completed the training described in subsection (a) of this section including:
(A) the date of the training;
(B) the length of the training session; and
(C) the name of the instructor.

An interview with the Staff #55 on 08/25/2023 at 11:10 AM in the conference confirmed the above findings. She stated that some files were electronic and some were hard copies. She was unable to provide all necessary documentation by the end of the survey.

.

Based on document review and interview the nursing staff failed to notify the attending physician or other LIP (Licensed Independent Practitioner) responsible for the care of the patient after the completion of the 1-hour face-to-face evaluation in 2 (Patient #2, and #22 ) of 2 patient records reviewed.

Findings:

Patient #2
A review of the document titled "Restraint/Seclusion/Emergency Medication" revealed Patient #2 was administered a chemical restraint/emergency behavioral medication on 8/21/2023 at 11:29 AM. Staff #1 documented, "Seclusion/restraint was initiated due to disruptive behavior and to prevent any harm to self and others as evidenced by: agitated, yelling, hitting head on wall." A telephone order was received from Physician # 9 on 8/21/2023 at 11:20 AM that read, "Thorazine 50 mg (milligrams) IM (intramuscular) Now and Ativan 2 mg IM Now". The emergency behavioral medication was administered at 11:29 AM by Staff #1.

A review of the document titled "One Hour Face to Face Evaluation" revealed the 1-hour Face to Face evaluation was completed at 12:29 PM by Staff #3. Staff #3 documented Physician #9 was notified of the 1-hour face-to-face evaluation on 8/21/2023 at 11:19 AM. This was 10 minutes before the chemical restraint/emergency behavioral medication was administered.



Patient #22
A review of the medical record for Patient #22 revealed there were two chemical restraints given. One was administered on 8/08/2023 and one on 8/10/2023.

8/08/2023
A review of the document titled "Restraint/Seclusion/Emergency Medication" revealed Patient #22 was administered a chemical restraint/emergency behavioral medication on 8/08/2023 at 9:00 PM by Staff #40. Staff #40 documented, "Seclusion/restraint was initiated due to disruptive behavior and to prevent any harm to self and others as evidenced by: Screaming to (sic) staff." Further review revealed Patient #22 was going into other patients' rooms and had not slept in two nights. A telephone order was received from Physician # 9 on 8/08/2023 at 9:00 PM that read, "Geodon 50 IM and Ativan 2 IM". The physician's order did not include the dosage or frequency. The medication was administered at 9:10 PM by Staff #40.

A review of the document titled "One Hour Face to Face Evaluation" revealed the 1-hour Face to Face was completed by Staff #21 at 10:00 PM. Staff #21 failed to document a date or time when the attending physician was notified after the 1-hour Face to Face evaluation was completed.

During an interview with Staff #1 on 8/24/2023 after 1:00 PM, Staff #1 confirmed the order was incomplete. Staff #1 confirmed there was no dosage amount or frequency written on the order and stated, "I guess I missed this."


8/10/2023
A review of the document titled "Restraint/Seclusion/Emergency Medication" revealed Patient #22 was administered a chemical restraint/emergency behavioral medication on 8/10/2023 at 6:00 AM. Staff #33 documented, "Seclusion/restraint was initiated due to disruptive behavior and to prevent any harm to self and others as evidenced by: Patient is yelling and screaming, disrupting the whole facility." A telephone order was received from Physician # 9 on 8/10/2023 at 5:40 AM, "Geodon 50 mg IM Now and Ativan 2 mg IM Now." The medication was administered at 6:00 AM by Staff #33.

A review of the document titled "One Hour Face to Face Evaluation" revealed the 1-hour Face to Face evaluation was completed at 7:00 AM by Staff #40. Staff #40 documented that Physician #9 was notified at 5:30 AM. This was 30 minutes before the chemical restraint/emergency behavioral medication was given. There was no date documented for the notification.




A review of the facility policy titled, "Behavioral Health Restraint and Seclusion" Policy # PC.027 with a reviewed/revised date on 6/28/2023 was as follows:

" ...POLICY
Aspire Hospital strives to provide patient care that is patient centered and trauma sensitive within the least restrictive, safe and clinically appropriate environment. The Hospitals mission, values and philosophy commit the staff to uphold the dignity of each individual by protecting the patients' rights and well-being ...
4.0 Restraint and Seclusion for Violent or Self-Destructive Behavior
...
5.0 Documentation of Restraint and Seclusion...
5.1.13 Completion of restraint/seclusion face-to-face assessment by a trained RN other than the RN when possible. Physician is to be immediately notified of the results of the face-to-face assessment ..."


An interview was conducted with Staff #1 on 8/24/2023 after 1:00 PM. Staff #1 was asked if the notification date and time at the bottom of the 1-hour Face-to-face evaluation document was when the physician was notified of the assessment when the evaluation was completed. Staff #1 confirmed the notification date and time should be when the physician was notified after the evaluation was complete. Staff #1 stated, "We document the summary of intervention/findings in that area and the time we notified the doctor. I guess I missed this because I am looking at every one of the restraint packets."

Based on review and interview the facility failed to ensure a quality assessment performance improvement plan (QAPI) had been approved by the governing board, had an ongoing program that identified and reduced medical errors, measured, analyzed, and tracked data for adverse patient events. The governing body failed to ensure a patient safety plan and risk assessments were performed to identify and resolve any safety concerns or issues.

A review of the facility's Quality Assurance & Performance Improvement (QAPI) Plan revealed it was for 2022. There was no evidence that the plan had been approved by the governing board (GB).

A review of the QAPI meeting minutes revealed there were only meeting minutes available for June 8th, 2023, and July 6th, 2023. The meeting minutes for June 8th and July 6th revealed that nursing was represented at the meeting but there was no data, monitoring, or performance improvement information documented. There was no representation concerning the previous nursing or restraint citations and how those were being monitored for sustainability. A review of the meeting minutes revealed there were 2 other facilities included in the QAPI meeting minutes. These other two facilities are within the corporate umbrella but are separate facilities with different provider numbers and licenses. The surveyor was unable to determine what information was for this facility or the other two facilities. There was no evidence that all departments were being represented in QAPI. There were no clear expectations, documentation, monitoring, or review of occurrences to establish a plan or monitoring of patient safety.

An interview was conducted with staff #2 on 8/24/23. Staff #2 stated that she had started at the facility in May of 2023 and there were no meeting minutes for QAPI, GB, or Medical Staff for any previous years. Staff #2 confirmed that the QAPI information and meeting minutes should be conducted monthly. Staff #2 stated that she had started the meetings in June but was not aware that the QAPI data she had presented needed to be focused on this facility. Staff #2 stated they just discussed all the corporation's other facilities within the same meeting and thought it would be easier to just put it all together. Staff #2 confirmed that the meeting minutes and data provided were difficult to determine due to data and information mixed in from other facilities that were under different provider numbers and licenses. Staff #2 was asked who the Risk Manager was. Staff #2 stated, "I guess I am." Staff #2 confirmed there was no risk committee, updated plan, or reporting. There was no evidence provided to ensure patient safety was being monitored within the facility.

A review of the medical staff bylaws approved on 7/21/23 revealed, "3. Environment of Care/Risk Management
The medical staff shall actively participate in the environment of care/risk management activities related to the clinical aspects of patient care and safety. The purpose of the EOC/Risk Management Committee is to provide a safe, functional, supportive environment for patients, staff member, and other individuals in the hospital and develop an "environment of care" plan made up of three basic components building, equipment, and people. It also is charged with identifying and discussing all occurrences, which may have medico-legal, implications and which demonstrate a developing pattern suggesting investigation. This shall include: The identification of general areas of potential risk in the clinical aspects of patient care and safety; the assistance in the development of criteria for identifying specific cases with potential risk in the clinical aspects of patient care and safety, and evaluation of these cases; the correction of problems in the clinical aspects of patient care and safety identified by risk management activities; and the design of programs to reduce risk in the clinical aspects of patient care and safety. Duties of the EOC/RM Committee
include:
A. Review building safety plans and issues.
B. Provide monitoring activities for the environment.
C. To advise the Risk Manager concerning data gathered by the Committee.
D. To analyze high risk/unusual occurrences.
E. To analyze claims involving allegations of malpractice.
F. To advise the Risk Manager on the medical implications of occurrences and claims.
G. To make recommendations to the Medical Executive Committee concerning the functions of the Committee."

Based on review and interview the facility failed to ensure all hospital departments and services were being monitored in the Quality Assurance & Performance Improvement (QAPI) program in 10 of (Respiratory, Emergency, Contracted Services, Nursing, Patient Safety/Risk, Outpatient, Medical Records, Employee Health, Dietary, Utilization Review (UR), Physical Environment) 17 ( Respiratory, Emergency, Social Services/ Therapy, Contracted Services, Nursing, Patient Safety/Risk, Outpatient, Laboratory, Pharmacy, Infection Control, Medical Records, HR, Employee Health, Radiology, Dietary, UR, Physical Environment) departments reviewed.

A review of the facility's Quality Assurance & Performance Improvement (QAPI) Plan revealed it was for 2022. There was no evidence that the plan had been approved by the governing board (GB).

A review of the QAPI meeting minutes revealed there were only meeting minutes available for June 8th, 2023, and July 6th, 2023. The meeting minutes for June 8th and July 6th revealed that nursing was represented at the meeting but there was no data, monitoring, or performance improvement information documented. There was no representation concerning the previous nursing or restraint citations and how those were being monitored for sustainability.

A review of the meeting minutes revealed there were 2 other facilities included in the QAPI meeting minutes. These other two facilities are within the corporate umbrella but are separate facilities with different provider numbers and licenses. The surveyor was unable to determine what information was for this facility or the other two facilities.

The facility failed to have a Utilization and Quality Control Quality Improvement Organization (QIO) or a Utilization Plan or program.

QAPI failed to ensure all contracted services were listed, available, evaluated, and approved through quality and the GB in 91 of 91 contracts available.

There was no risk management or committee established.

The facility failed to have a respiratory physician or any training for the nurses to provide respiratory care. There was no QAPI or risk program to ensure patient safety.

QAPI failed to monitor the Emergency Room or Emergency Treatment Room. There was no monitoring concerning transfers or patient emergency care required.

Outpatient services, Medical Records, or Employee Health were not addressed in the QAPI minutes provided.

Dietary was not represented or monitored by QAPI or Risk.

Physical Environment was not represented to ensure all monitoring was completed for patient safety. There was no Emergency Preparedness Plan.

An interview was conducted with staff #2 on 8/24/23. Staff #2 stated that she had started at the facility in May of 2023 and there were no meeting minutes for QAPI, GB, or Medical Staff for any previous years. Staff #2 confirmed that the QAPI information and meeting minutes should be conducted monthly. Staff #2 stated that she had started the meetings in June but was not aware that the QAPI data she had presented needed to be focused on this facility. Staff #2 stated they just discussed all the corporation's other facilities within the same meeting and thought it would be easier to just put it all together. Staff #2 confirmed that the meeting minutes and data provided were difficult to determine due to data and information mixed in from other facilities that were under different provider numbers and licenses. Staff #2 was asked who the Risk Manager was. Staff #2 stated, "I guess I am." Staff #2 confirmed there was no risk committee, updated plan, or reporting. There was no evidence provided to ensure patient safety was being monitored within the facility. Staff #2 confirmed that she had not included all departments in her meeting minutes. Staff #2 confirmed there was no set schedule for when departments would be reviewed.

Based on review and interview the medical staff (MS) and the governing body (GB) failed to;


A.
ensure the physician and provider credentials were completed, reviewed, and accepted by the medical staff and governing body in 4 out of 4(#9,61,63, and 64) credential files reviewed. The facility failed to ensure supervision was documented in 2 of 2(#63 and #64) provider files.

Refer to Tag A0341

B.
review and accept the credentials provided by the telemedicine physicians and practitioners, including any adverse events and complaints, and provided written feedback to the distant-site telemedicine entity.

Refer to Tag A0343


C.
failed to ensure the Medical Staff By-laws were approved through the GB.

Refer to Tag A0354

Based on review and interview the medical staff (MS) and the governing body (GB) failed to ensure the physician and provider credentials were completed, reviewed, and accepted by the medical staff and governing body in 4 out of 4(#9,61,63, and 64) credential files reviewed. The facility failed to ensure supervision was documented in 2 of 2(#63 and #64) provider files.

The purpose of delineating clinical privileges is to manage what services a provider is qualified and authorized to deliver to a patient for that specific facility. The delineation of clinical privileges designates the specific services and procedures that a physician is deemed qualified to provide or perform. An organization's delineation of privileges must always be current.

A review of the MS bylaws provided by the facility stated, "REQUESTS FOR DELINEATION OF PRIVILEGES IN GENERAL Each application for appointment and reappointment to the Medical Staff must contain a request for the specific Clinical Privileges desired by the applicant. A request by a Member for a modification of Clinical Privileges may be made at any time, subject to Section 5.5.l(c), but that request must be supported by documentation of training and/or experience supportive of the request."

A review of the physician and provider credentials revealed the files were incomplete as follows.

Physician #9-

Staff #9 was reappointed to active staff on 5/4/2022 - 5/11/2024. The delineation of privileges was signed and approved on 5/4/22. The delineation form had a blank date for recommendation by the credential and privileges committee, medical executive committee, and the governing board. The form was incomplete. There are no medical executive or GB meeting minutes available for 2022 to confirm the recommendation and approval.

Physician #61

Physician #61- The delineation of privileges was signed by staff #61 on 4/20/23. The medical director signed on the signature line with no date. The delineation form had a blank date for recommendation by the credential and privileges committee, medical executive committee, and the governing board. The form was incomplete. There are no medical executive or GB meeting minutes for 2023 to confirm the recommendation and approval. The form was incomplete.

There was no reappointment letter provided for 4/2023.

Physician #63-

Staff #63 was still a resident. There was no information in his file that he was no longer in a residency program. There was no evidence or information on what physician was supervising staff #63 or if he was completed with his residency.

A review of the delineation of privileges revealed he was granted core psychiatric privileges on 12/31/22 by the medical director. There was no category checked on whether he was active, courtesy, or associate. The delineation form had a blank date for recommendation by the credential and privileges committee, medical executive committee, and the governing board. The form was incomplete. There are no medical executive or GB meeting minutes available for 2022 to confirm the recommendation and approval.

Staff # 64

Nurse Practitioner- Had an expired CPR card.

The delineation of privileges was not signed by the Medical Director on 1/12/23. Staff #9 was signed as the supervising physician but there was no written documentation of any supervision in the file.

There was no letter with the date of appointment to the medical staff. There are no medical executive or GB meeting minutes for 2023 to confirm the recommendation and approval.

An interview was conducted with Staff #2 and #5 on 8/24/23. Staff #5 stated the facility was using an outside contracted service for credentialing. Staff #2 and #5 were shown the incomplete physician credentials. Staff #5 confirmed the findings and stated that they would have to do better.

Based on review and interview there was no evidence that the Medical Staff (MS) or Governing Body (GB) reviewed and accepted the credentials provided by the telemedicine physicians and practitioners, including any adverse events and complaints, and provided written feedback to the distant-site telemedicine entity.

A review of the contract services revealed the facility had a contract with Company A for telehealth services. A review of the contract revealed it had been signed on 2/23/2014. There was no documentation or evidence that this contract was accepted by the GB nor was there any evidence that the GB ensured the contract was reviewed yearly to ensure appropriate services and credentials were provided. The facility was unable to provide any information that Company A was included on any QAPI information, or any written feedback was discussed with the Company to ensure safe patient care.

An interview was conducted on 8/24/23 with staff # 2. Staff # 2 confirmed that the facility had no written feedback to the distant-site telemedicine entity concerning any changes and confirmed that there were no GB meeting minutes for 2022. There was no evidence or meeting minutes for 2023 that Company A's contract had reviewed, approved, or validated the telehealth physician credentials.

Based on review and interview the Medical Staff (MS) and Governing Body (GB) failed to ensure the Medical Staff By-laws were approved through the GB.

A review of the GB meeting minutes for 7/6/2023 revealed an agenda item that stated, "recommendations of the GB bylaws. Discussion- Revised bylaws to address History and Physical." There was no further information that the bylaws were accepted or approved. The GB minutes included other facilities. There was no evidence or written documentation that the amended bylaws were for the facility and not another facility within the system.

A review of the Medical Staff Bylaws Article 15 Adoption and Amendment of Bylaws revealed Staff # 16 signed the approval of the bylaws on 7/21/23. There were no GB meeting minutes on 7/21/23 that addressed the approval of the medical staff bylaws on this date. There was no agenda, attendance sheet, or any information that a quorum of the GB met to approve these bylaws.

An interview was conducted with Staff # 2 on 8/24/23 concerning the GB minutes. Staff #2 confirmed there was no GB meeting on 7/21/23 and the GB minutes for 7/6/23 included two other facilities with no documented evidence that medical staff bylaws were approved for this facility.

Based on review and interview the facility failed to ensure nursing personnel had a current license in the 4 of 4 (Staff #1, #23, #53,#54) employee files.

Findings included:

A review of 4 nursing files revealed there was no current license in the employee files.

An interview with the Staff #55 on 08/25/2023 at 11:10 AM in the conference confirmed the above findings. She stated that some files were electronic and some were hard copies. She was unable to provide all necessary documentation by the end of the survey.

Based on record record review and interview the facility failed to ensure that each patient had a complete nursing care plan/Interdisciplinary Treatment (IDT) plan on 5 of 5 (pt # 24, 25, 26, 28, and 29) charts reviewed.

Record review of "policy and procedure for IDT " updated in year 2022, "Each patient admitted to _____ (the facility) shall have a written, individualized, comprehensive, outcome-oriented interdisciplinary treatment plan of care. Based on assessments of clinical needs (as well as reassessments and results of diagnostic testing) and the patient's goals (and the time frames, settings, and services required to meet those goals), the plan for the patient's care, treatment, and services shall describe patient strengths and limitations; short and long term goals of treatment; clinical interventions prescribed; patient progress in meeting treatment goals; criteria for discharge from treatment; and provisions for aftercare. Treatment shall be planned, reviewed, and evaluated at regular intervals by the Interdisciplinary Treatment Team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate."

A record review of patient #24's medical chart under Interdisciplinary Master Treatment Plan" review, revealed an unknown author, dated 08/03/23 no time was noted, and showed a status of treatment goals. The writer had options to an abbreviation list as follows.

RS is resolved
RD is redefined.
E is extended.
N is new.
D is deferred.

Review of Patient #24's nursing care plan stated,
Patient #24 will identify 3 healthy coping skills to utilize to decrease depressed mood in seven days. The status was documented as R, there was no definition of what R was, it was not a choice of abbreviations listed on the form.

Patient #24 will continue to identify and replace cognitive self-talk that is engaged in to support depression daily. The status is unknown, documented as R.

A record review of patient #24's medical chart, Interdisciplinary Master Treatment Plan review, Unknown author, dated 08/03/23 (no time noted) stated, "Discharge." the follow up section was left blank. The patient discharged the next day to his home. It is unknown if the patient was given any prescriptions for his medications, in a safe environment, was able to obtain medication, had a reliable transport for appointments/follow ups, or what psychiatrist he was referred to.

A record review of patient #25's discharge planning showed an IDT treatment plan for discharge as d/c home to husband and follow up with psychiatrist upon discharge. The second page of the IDT which contains information for short and long terms goals as well as criteria for discharge was not included within the chart. No other discharge planning information was documented. The patient was discharged on 08/22/23.

Record review of patient's #26, 28, 29 revealed there was no discharge planning record in the patient's chart.

Based on observation, record review, and interview, the facility failed to:

A. have a qualified, full-time Food and Dietetic Services Director responsible for the daily management of the dietary services.

Refer to Tag A0620


B. have a qualified dietician to supervise the nutritional aspects of patient care.

Refer to A0621


C. Ensure dietary staff had education, experience, or training and were competent in their assigned duties.

Refer to A0622


D. Follow the prescribed diets to meet the nutritional needs in 7 (Patient #3, #2, #4, #5, #6, #7, #8) of 7 patient records reviewed.

Refer to Tag A0629


E. Ensure a current therapeutic diet manual approved by the Dietician and the medical staff was readily available to all medical, nursing, and food service personnel

Refer to Tag A0631



These deficient practices were identified under the following Conditions of Participation, CFR 482.28 Dietary Services, determined to pose an Immediate Jeopardy (IJ) to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or possible death.


An IJ template was presented to the facility administration on 08/23/2023 at 4:25 PM in the conference room.

The facility provided an acceptable plan of removal of the IJ on 08/28/2023 and review of the plan and policies provided along with the training confirmed the IJ was abated on 08/28/2023.

Based on record review and interview the facility failed to employ a full-time qualified Dietary Director responsible for the daily management of the dietary services. Also, a review of facility records revealed the Dietary Services Director was not involved in the QAPI (Quality Assessment Performance Improvement) program or meetings.



Findings:


A review of the employee file for Staff #35 revealed a signed job offer for the position of a "Part-time Certified Dietary Manager." The job offer was signed by Staff #35 on 1//21/2020. Staff #35 did not have a signed job description in her employee file.

An interview was conducted with Staff #1 on 08/22/2023 at 2:30 PM. Staff #1 was asked who the dietary services manager was. Staff #1 confirmed Staff #35 was the dietary services manager.


An interview was conducted with Staff #35 on 8/22/2023 at 5:10 PM. Staff #35 confirmed she was not a full-time employee, and her only responsibilities were to ensure the logs (freezer, refrigerator, and maintenance logs) were accurately completed. She stated she was also a liaison between the hospital and kitchen staff. Staff #35 stated Staff #36 oversaw the management of the dietary services.


An interview was conducted with Staff #36 on 8/22/2023 at 5:10 PM. Staff #36 confirmed she was not responsible for the daily management of the dietary services and she did not oversee any training for the kitchen staff. Staff #36 stated, "My only responsibility is to provide a patient nutritional assessment within 72 hours when it is warranted."

A review of the employee file for Staff #36 revealed a signed job description titled, "Dietician" was signed by Staff #36 on 5/23/2023 and included the following job functions:

"...General - A currently competent Clinical Dietician who contributes to patient care by performing nutritional assessments of patients. The Clinical Dietician plans and monitors the nutritional care and education of patients. Collaborates with physicians and other interdisciplinary team members to develop a comprehensive/goal-directed plan of care regarding nutritional care requirements. Supports staff, patient, and caregiver education to enhance knowledge, skills, and necessary behavior to facilitate positive outcomes. He/she utilizes skills found in the Clinical Dietician Core Competency inventory. The Clinical Dietician acts as a liaison between the Hospital and the Host Hospital's Dietary Department.

Quality - Participates in performance improvement activities that ensure important processes and activities are measured, assessed, and improved systematically. Supports the Think Quality (Trademark) culture and is committed to key constituent satisfaction.

Safety/Risk/Compliance/OSHA - Maintains and supports a safe and compliant environment. Complies with all hospital, Federal, Medicare/Medicaid/State standards, policies, and rules..."


A review of the QAPI meeting minutes dated 6/8/2023 did not reveal any data reported by the Dietary Services Department or Staff #36.

During an interview on 8/22/2023 after 12:00 PM, Staff #35 and #36 confirmed they did not participate in any QAPI meetings regarding menus or dietary staff.

An interview was conducted with Staff #1 on 08/23/2023 at 05:10 PM. Staff #1 confirmed Staff #35 and #36 were the only employees supervising the kitchen staff and monitoring their performances. Also, Staff #1 confirmed there was no documentation of the work assignments, menu planning, training for safe practices of food handling, or personnel performances available for review on any dietary staff.

Based on record review and interview the facility failed to ensure a qualified dietician:

A. approved patient menus and nutritional supplements
B. documented nutritional assessments or evaluation of a patient's tolerance to therapeutic diets
C. collaborated with other hospital services to meet the nutritional needs of the patients.


Findings:

A.

A review of the patient menus provided to this surveyor revealed the facility used a 2-week rotating patient menu plan. The menus provided to the surveyor for review and the menus posted in the kitchen were different. The menu posted on the kitchen wall had a handwritten notation of "vegetable" on Tuesday and Wednesday's lunch menu.

An interview was conducted with Staff #36 on 8/22/2023 at 5:15 PM. Staff #36 confirmed the menus provided for review were not approved by her. She discussed with the kitchen staff about adding vegetables to the menus, but did not know what vegetables would be added or if any substitutions were made. Staff #36 was asked if she was responsible for the kitchen. Staff #36 stated, "I do not oversee the kitchen or the staff. The staff make substitutions to the patient menus with whatever is available." She further stated that she provided the dietary staff with a program (diningRD.com) to use for patient menus and that they worked independently to revise the menus without her approval.


B.

A random review of patient charts from July to August 2023 revealed no documentation of a nutritional assessment and/or evaluation of diets provided by Staff #36..


A review of 7 (Patients #2, #3, #4, #5, #6, #7, #8) of 7 patients diet orders revealed all 7 patients required special diets.

The patients reviewed and the diets were as follows:

" ...Patient #2 - regular diet, double portion
Patient #3 - diabetic diet
Patient #4 - low-fat diet
Patient #5 - diabetic diet with a seafood food allergy
Patient #6 - diabetic diet
Patient #7 - heart-healthy diet
Patient #8 - handwritten orders for "no gluten, can only eat fish and vegetables."


A review of the facility policy titled, "Nutritional Screening/Assessment/Consultation" with an effective date of 12/08/2014 was as follows:

" ...All patients will receive a nutritional screening as part of a nursing admission assessment. A nutritional assessment is completed for patients determined to be at nutritional risk ..."


None of these patients reviewed had triggered a nutritional assessment per the facility policy; therefore, the dietician never performed a nutritional assessment to ensure the patients received the prescribed diets as ordered. After review of the patient records, Staff #1 confirmed that no nutritional assessments were performed.



C.

After multiple requests, no documentation was provided of Staff #36 collaborating with other hospital services to meet the nutritional needs of the patients.


A review of the employee file revealed Staff #36 signed a job description titled, "Dietician" on 5/23/2013. The job description included the following job functions:

" ...General - A currently competent Clinical Dietician who contributes to patient care by performing nutritional assessments of patients. The Clinical Dietician plans and monitors nutritional care and education of patients. Collaborates with physicians and other inter-disciplinary team members to develop a comprehensive/goal directed plan of care regarding nutritional care requirements. Supports staff, patient, and caregiver education to enhance knowledge, skills and necessary behavior to facilitate positive outcomes. He/she utilizes skills found in the Clinical Dietician Core Competency inventory. The Clinical Dietician acts as liaison between Hospital and the Host Hospital Dietary Department.

Quality - Participates in performance improvement activities that ensures important processes and activities are measured, assessed, and improved systematically. Supports the ThinkQuality (Trademark) culture and is committed to key constituent satisfaction.

Safetv/Risk/Compliance/OSHA - Maintains and supports a safe and compliant environment. Complies with all hospital, Federal, Medicare/Medicaid/State standards, policies and rules ..."


In an interview with Staff #36 on 08/22/23 at 5:20 PM, she confirmed she had not received any training specific to her role and responsibilities from the hospital leadership team. Staff #1 also confirmed that Staff #36 is a part time employee. However, she does not maintain any records of her (Staff #36) time when she is on site performing her duties.

Based on observation, record review and interview the hospital failed to ensure 2 (Staff #34 and Staff #35) of 2 staff had experience, education, and were trained in their respective duties.


Findings included:


Staff #35
A review of the employee file for Staff #35 revealed she accepted the position as Dietary Manager on 1/21/2020. There was no signed job description available for review.

An interview was conducted with Staff #35 on 8/22/2023 at 4:35 PM. Staff #35 stated, "My main responsibility is to be the liaison for the kitchen staff and the nursing staff. I ensure that logs (freezer, refrigerator, maintenance logs) are filled out. I do not order supplies, train the staff in appropriate and safe food handling, or oversee the sanitary environment in the kitchen. The contracted kitchen staff does all their training online."

Staff #35 confirmed she had not received any training from the hospital in her respective duties.


An observation was conducted in the kitchen on 8/22/2023 at 11:00 AM of Staff #34. Staff #34 was observed using the 3-compartment sink for manual ware washing. Staff #34 stated he only used the dishwasher for trays and that he washed all pots and pans by hand in the 3-compartment sink.

This surveyor observed Staff #34 using all three sinks to scrub dirty pots and pans. Staff #34 applied dish soap directly onto the baking sheet, and then scrubbed and rinsed the baking sheet in the empty middle sink. He then proceeded to spray sanitizer (Q Rinse) on the baking sheet, then rinsed it in the 3rd compartment of the sink, and left it to dry on a cart with a visibly used parchment paper liner.

According to the FDA the following steps ensure proper dishware sanitizing and to prevent food borne illnesses.

"...A. Prep- The staff should ensure each sink is clear of food debris and any remaining residue from the last wash session. The sinks can then be prepared for use.

B. Wash- The first sink is for washing the dishes. The pot and pan detergent should have been diluted into the water during the prep step. You should not apply pot and pan detergent directly to the wares. The proper dilution can be found on the detergent's label. The wash sink needs to maintain a temperature of at least 110 degrees Fahrenheit but no more than 120 degrees Fahrenheit throughout the wash procedure. The water should be changed frequently when it becomes dirty during the washing process. After the wares are washed, they are placed into sink two.

C. Rinse- The second sink is used to remove all detergent and residues from the wares. There should be no soap or chemicals placed in this water. The ware should be submerged. The water in this bay will need to be replaced when the water becomes too soapy.

D. Sanitizing- The final sink in the 3-sink method is used for sanitizing the wares. The wares can be sanitized using either chemical sanitizer or hot water sanitization. "Sanitizing kills 99.99% of bacteria and germs on the wares."

If a chemical sanitizer is used the facility must follow the directions of the proper amount of chemical per "parts per million." There is a minimum concentration of the sanitizer that must be present to effectively kill germs. The solution is mixed with the water in the 3rd sink.."

A review of the Q-Rinse Directions For use on the bottle was as follows:

" ...Prior to application, remove gross food particles and soil by a pre-flush, pre-scrape or when necessary, pre-soak. Then thoroughly wash or flush objects with a good detergent or compatible cleaner followed by a potable water rinse before application of the sanitizing solution...surfaces must remain wet for at least 60 seconds followed by adequate draining and air drying ..."


During the observation tour on 08/22/2023 at 11:40 AM, this surveyor observed an ice machine with visible hard water stains on the top and sides of the machine.

An interview was conducted with Staff #34 on 08/22/23 at 11:45 AM. Staff #34 confirmed the daily maintenance of the ice machine only included taking a clean wet towel and wiping the front and inner door of the ice machine. Staff #34 confirmed there was no other routine maintenance completed on the ice machine.

A review of the user's manual for the Manitowoc ice machine (Part Number 0966 9/08) under Maintenance was as follows:

" ...Clean and sanitize the ice machine every six months for efficient operation ...use only Manitowoc approved ice machine cleaner and sanitizer for this application ...ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime ..."

Staff #34 confirmed he had never completed the above maintenance. Staff #34 stated Staff #25 performed maintenance for the ice machine, but he was unsure what that included.


An interview was conducted with Staff #25 on 08/24/2023 at 11:50 AM. Staff #25 confirmed he does not perform any routine maintenance on the ice machine. Staff #25 stated, "I have only replaced the filter as needed."

An interview was conducted with Staff #35 on 08/23/2023 at 2:35 PM. Staff #35 confirmed she tried to use the 3-compartment sink and found that the first sink could not hold water as the stopper was not working. There was no way for the water to reach a level to submerge any of the cookware for washing. Also, Staff #35 confirmed she was aware of the ice machine and had advised the facility to "get rid of it." She also acknowledged that she had not provided any training to the staff in the proper use of the 3-compartment sink. She stated she "assumed" they knew how to use it since they did their online training to be certified.

Based on observation, record review, and interview the hospital failed to follow the prescribed diets to ensure the nutritional needs were met in 7 (Patients #3, #2, #4, #5, #6, #7, #8) of 7 patient records reviewed.

Findings:

A 2-week rotating menu was provided for review by Staff #1 on 8/22/2023. The menu read, "The meal items shown are those served on a regular diet. If your physician has ordered you a therapeutic or texture-altered diet, you may be served a different menu item, a different portion of the menu item or the item may be eliminated entirely in order to comply with your current diet order."

Staff #1 confirmed the hospital used a program called diningRD.com (a comprehensive food and nutrition program that has recipes and common foods that are assessed for nutritional values.) The dietary services department selected dishes from the program's database and used it as a guide for the patient's weekly meal plan.

Observations of the kitchen on 08/22/2023 and 08/23/2023 revealed the kitchen prepared baked fish and homemade meatballs using Staff #34s personal recipe.


An interview was conducted with Staff #34 on 8/23/2023 at 11:50 AM. Staff #34 confirmed he used his own personal recipes for the prepared food, and they were not assessed by the dietician for their nutritional values. Staff #34 stated he did not upload any of his personal recipes into the diningRD program for a nutritional assessment. He also confirmed he did not order any of the food that the program had assessed for nutritional value because he did not have access to it. Staff #34 stated, "The hospital orders the food through Costco and a local grocery store."



A review of 7 (Patients #2, #3, #4, #5, #6, #7, #8) of 7 patient charts and the prescribed diets was as follows:

" ...Patient #2 - regular diet, double portion
Patient #3 - diabetic diet
Patient #4 - low-fat diet
Patient #5 - diabetic diet with a seafood food allergy
Patient #6 - diabetic diet
Patient #7 - heart-healthy diet
Patient #8 - handwritten orders for "no gluten, can only eat fish and vegetables ..."

Further review revealed;

Patient #2
A review of Patient #2 medical record indicated a regular diet was prescribed. A review of the preadmission assessment revealed Patient #2 was allergic to lettuce and tomatoes. On the front of Patient #2's paper chart was a handwritten label that documented she was also allergic to fish, peanut butter, leafy greens, peas, and beans.

A review of the diet orders received in the kitchen, read, "Regular diet with double portions." There were no food allergies listed on the diet order.


Patient #3
A review of Patient #3's medical record indicated a diabetic diet was prescribed.

During an interview with Staff #34 on 08/23/2023 at 11:00 AM it was confirmed the kitchen staff was aware that Patient #3 had a diabetic diet ordered. Staff #34 stated, "The regular diet, which was meatballs in marinara sauce, and white rice with vegetables, was OK for Patient #3. Staff #34 confirmed there was no other lunch meal prepared for Patient #3.



Patient #4, #5, #6, #7, #8
A review of the computerized diet orders was conducted on 8/23/2023 with Staff #1. Staff #1 confirmed the prescribed diets for Patients #4, #5, #6. #7, and #8. Staff #1 stated, "The kitchen does not prepare any special meals and the only adjustment to meals was the portion size."

Staff #1 confirmed she was unaware if the menus or portion size met the nutritional needs of special diets.


An interview was conducted with Staff #1 on 08/23/2023 at 3:20 PM. Staff #1 stated, "The regular diet on the menu was the same as the diabetic diet, but only in smaller portions. We do not have alternatives, just smaller portions."



A review of the facility policy titled, "Nutritional Screening/Assessment/Consultation" with an effective date of 12/08/2014 was as follows:

"PROCEDURE
1.0 All patients will receive a nutritional screening as part of admission nursing admission assessment.

2.0 A nutritional assessment is completed for patients determined to be at nutritional risk. The assessment is completed by a dietician within 72 hours of notification by nursing staff of nutritional screening results or receipt of a physician' s order. Nutritional risk is the presence of two or more of the following defined parameters and criteria:

2.1 BMI less than 19 or greater than 39 for adults.
2.2 Unintentional weight loss greater than 10% in last 6 months.
2.3 Eating disorders.
2.4 Medical diagnosis/problem effecting nutrition.
2.5 Special diets or food allergies.
2.6 Pregnancy or recent surgery.
2.7 Patients on medications that may cause a food reaction"


7 (Patients #2, #3, #4, #5, #6, #7, #8) of 7 patient's diet orders reviewed with Staff #1 had sufficient nutritional risk that required a dietician consultation per the facility policy. However, there were no methods or frequency to monitor the nutritional needs of patients with specialized needs.



An interview with Staff #36 on 08/22/2023 at 5:35 PM confirmed the above findings. Staff #36 confirmed the kitchen staff prepared many of their patient's meals themselves and purchased food from the local grocery stores. Staff #36 stated she was unaware of how the food was prepared or if any substitutions were made. She also confirmed the food prepared by the kitchen staff had not been evaluated for its nutritional assessments.

Based on record review and interview the facility failed to have a therapeutic diet manual approved by the dietician readily available to medical, nursing, and food service personnel.

Findings:

After multiple requests on 8/22/2023 and 8/23/2023 for the approved therapeutic diet manual, one was not provided for review by the survey exit date of 8/25/2023.


During an interview on 08/23/2023 at 3:30 PM with Staff #1, it was confirmed there were no special provisions for special diets and that there was only a varying serving size to accommodate the patient's special dietary needs. Staff #1 confirmed the facility's current practice for special diets was not in an approved hospital policy. Staff #1 also confirmed there was not an approved therapeutic diet manual readily available to hospital staff.

Based on review and interview the facility failed to;

A.
have a Utilization and Quality Control Quality Improvement Organization (QIO) or a Utilization Plan or program.

Refer to Tag A0653

B.
have an active Utilization Review (UR) committee and failed to have an appointed UR director or committee.

Refer to Tag A0654

C.
have a Utilization Review Plan. The facility failed to ensure reviews were conducted on admissions, professional services offered, duration of stays, outlier cases based on extended stays or high costs.

Refer to Tag A0655

Based on review and interview the facility failed to have a Utilization and Quality Control Quality Improvement Organization (QIO) or a Utilization Plan or program.


An interview was conducted with Staff #2, #10 and #30 on 8/24/23. Staff #2 stated that there were no UR meeting minutes that she was aware of and quality was not following UR. Staff #10 stated that he was over UR and he was not aware of who the QIO was, confirmed that he had not been meeting with a UR committee or a appointed UR physician. Staff #10 confirmed he did not know what regulatory was required for utilization review. Staff #30 was asked for a contract for the facility's QIO. Staff #30 was not aware who was the QIO and was unable to provide any contracted service.

Based on review and interview the facility failed to have an active Utilization Review (UR) committee and failed to have an appointed UR director or committee.

An interview was conducted with Staff #2 and #10 on 8/24/23 at 11:39 a.m. Staff #2 stated that there were no UR meeting minutes that she was aware of and quality was not following UR. Staff #10 stated that he was over UR and he was not aware of who the QIO was, confirmed that he had not been meeting with a UR committee or an appointed UR physician. Staff #10 confirmed he did not know what regulatory was required for utilization review.

Based on review and interview the facility failed to have a Utilization Review Plan. The facility failed to ensure reviews were conducted on admissions, professional services offered, duration of stays, outlier cases based on extended stays or high costs.


An interview was conducted with Staff #2 and #10 on 8/24/23 at 11:39 a.m. Staff #2 stated that there were no UR plan, meeting minutes that she was aware of and quality was not following UR. Staff #10 stated that he was over UR and he was not aware of who the QIO was, confirmed that he had not been meeting with a UR committee or a appointed UR physician. Staff #10 confirmed he did not know what regulatory was required for utilization review. Staff #10 provided a 2 page list of insurance information that was faxed into the insurance company. Staff #10 stated that was all he had.

.

Based on observation, document review, and interview the facility failed to ensure:

1. The Infection Control Preventionist was appointed by the Governing Body.

Cross Refer to Tag A0748

2. The Infection Control Program was implemented and followed according to the Infection Control Plan.

Cross Refer to Tag A0749

3.
a. A clean and sanitary environment was maintained to mitigate the spread of infectious diseases and hospital-acquired infections in 13 (Patient Room #202, Biohazard Room, Soiled Linen Room, Patient Common Area, Storage Room #1, Shared Patient Shower, Medical Equipment Room, Patient Laundry Room, Storage Room #2, Clean Linen Room, Nurse's Station Pill Room, Nurse's Station Records Room, and kitchen) of 13 areas observed.

b. The Infection Control Professional effectively and timely reported notifiable conditions to the public health agencies as required in 4 of 4 communicable diseases.

Cross Refer to Tag A0750

4. The infection preventionist, Staff #37, maintained written or electronic documentation of the infection prevention and control programs surveillance, prevention, and control activities.

Cross Refer to Tag A0773

5. The Infection Control Professional was involved and reported to the QAPI (Quality Assessment Performance Improvement) program on infection prevention and infection control issues.

Cross Refer to Tag A0774

6. The infection preventionist, Staff #37 was actively involved with the Antibiotic Stewardship Program

Cross Refer to Tag A0777


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.

.

Based on record review and interview, the hospital failed to ensure Staff#37 was appointed by the Governing Body as the Infection Control Preventionist.

Findings:

A review of Staff #37's employee file confirmed Staff #37 signed a job description for the position of Infection Preventionist on 07/25/2019.


During an interview on 8/25/2023 at 9:55 AM, Staff # 2 confirmed Staff # 37 was not appointed by the Governing Body as the Infection Control Preventionist.

.

Based on document review and interview the hospital failed to ensure the infection prevention and control program was implemented to control the transmission of infections within the hospital.

Findings:

A review of the document titled, "Infection Control, Prevention & Management Plan 2023-2024" was as follows:

" ... 1. Purpose
The purpose of this Aspire Hospital Infection Control, Prevention & Management Plan is to provide a safe and secure environment of care which minimizes the risks of infection for patients, visitors, staff and the environment of care. In addition to reducing the risk of occupationally-associated infections in employees, physicians, students/interns, and contracted personnel..."

2. Scope and Multidisciplinary Integration
Surveillance prevention and control of infection covers a broad range of processes and activities that are coordinated and carried out by the hospital through multidisciplinary involvement and integration.

Aspire Hospital uses the information gathered to improve infection prevention and control activities to reduce nosocomial infection rates to the lowest possible levels.

The scope of the Infection Control, Prevention and Management Plan includes all policies, procedures, programs, and functions that have been developed and implemented to address the organization's infection control risks and meet requirements of CIHQ.

Aspire Hospital policies and procedures are based on applicable law and regulations (including local, state, and federal) as well as The Joint Commission Standards and other recognized guidelines (including CDC)

Aspire Hospital Policies & Procedures address prevention and control mechanisms used in all patient, staff and visitor areas to prevent the transmission of infection; and, also addresses specific environmental issues as warranted.

The Aspire Hospital Infection Control, Prevention and Management Plan includes all departments, services, disciplines and practitioners ...

3. Authority, Leadership and Responsibility
...
Infection Preventionist Team (IPT)
The IPT consists of the Director of Behavioral Health & Compliance, Director of Nursing, IC Practitioner.

The IPT assumes the responsibility of managing and carrying out the infection surveillance, prevention and control functions within Aspire Hospital and all Outpatient Clinics.

The IPT:
*Are members of the Infection Control Committee (ICC) and Quality Assurance Performance Improvement Committee (QAPI)
*Collaborate along with Director of Nursing (DON) as warranted to develop and coordinate the activities within the Infection Control, Prevention and Management Plan; these individuals have the authority to intervene whenever conditions exist which pose an immediate threat to life or health, or pose a threat of damage to equipment or buildings
*Communicates information to the Medical Executive Committee
*Compiles and analyzes data, and reports trends on infection control related issues
*Conducts an annual appraisal of hospital-wide risk management activities and reports to QIC, MEC and Governing Board
*Conducts specific risk assessments per policy and as needed
*Confers with all involved departments, including the Medical Staff as the need arises to investigate infection control issues
*Coordinates education, training, policy & procedure implementation, and drills (if warranted) to ensure infection control emergency preparedness
*Coordinates planning and implementation of hospital emergency procedures (as warranted) concerning infection
*Establishes a hospital-wide risk assessment and education program that is described in the Infection Control, Prevention and Management Plan
*Evaluates information concerning incidents involving infection
*Implements isolation procedures in accordance with policy
*Investigates and follows-up on employee occurrences identified through the incident reporting system as they relate to employee health
*Is knowledgeable in adult education and customer care/satisfaction principles and practices
*Maintains records and logs incidents related to infections and communicable disease management as well as knowledge and job experience in the areas of epidemiological principles and infectious disease, sterilization, sanitation and disinfection practices
*Manages processes to collect and evaluate information about infection control practices and possible associated hazards that are used to identify infection control management issues to be addressed by the ICC and QIC
*Participates in surveillance and incident reporting
*Participates in the development of organization wide and departmental safety policies and procedures as well as the Infection Control, Prevention and Management Plan
*Reports at least every month to the ICC and QIC on findings, recommendations, actions and outcomes
*Reports findings to the ICC and QIC on internal and external occurrences that present the possibility of loss or injury to the patient, visitor, employee or institution
*Reports suspected infections
*Reports to QIC on statistical data or occurrences
*Responds to and participates in actual infection control emergency preparedness activities
*Reviews antibiotic usage reports
*Reviews culture and sensitivity testing
*Works with the DBHS and DCQA to develop the Hospital Infection Control policies and plan components as directed ..."

An interview was conducted with Staff #1 and Staff #2 on 8/23/2023 after 2:00 PM. Staff #2 confirmed the Infection Control Plan was not specific to the hospital and incorporated five other locations.

Staff #1 was asked who was responsible for ensuring the plan was implemented and followed. Staff #1 replied, "Staff #37 was the infection control preventionist, but she was never at the hospital."

Staff #1 confirmed there were no documented surveillance rounds for infection control surveillance throughout the facility, no collaboration with the QAPI (Quality Assessment Performance Improvement) program, no monthly Infection Control Committee meetings, no employee infection control training directed by Staff #37, no annual evaluation of the risk assessment, objectives, scope performance, and effectiveness of the documented "Infection Control, Prevention and Management Plan."

During an interview with Staff #1 on 8/25/2023 it was confirmed the Infection Control Plan provided to this surveyor for review was not fully implemented or being followed to prevent and control the transmission of infections within the hospital.

.

Based on observation, record review, and interview, the facility's infection prevention and control program failed to:

A. provide and maintain a clean and sanitary environment to avoid sources and transmission of infection in 13 (Patient Room #202, Biohazard Room, Soiled Linen Room, Patient Common Area, Storage Room #1, Shared Patient Shower, Medical Equipment Room, Patient Laundry Room, Storage Room #2, Clean Linen Room, Nurse's Station Pill Room, Nurse's Station Records Room, and Kitchecn) of 13 areas observed.

B. ensure the Infection Control Professional failed to report 4 of 4 patients with a reportable communicable disease as required by Texas Administrative Code (TAC) Title 25 Part 1 Chapter 97 Subchapter F Rule 97.134 (a)(d) within a 1-day time frame for reporting primary and secondary Syphilis. Syphilis was detected in two patients on 6/15/2023 and two patients on 6/18/2023.

TAC 97.134(a)(d)


Findings:

A.
An observation tour was conducted on 08/21/2023 through 08/24/23 with Staff # 1 and Staff # 5. The following infection control issues were observed.


Patient Room # 202
This room was ready to receive a new patient. Inside the bathroom was a brown paper trash bag with white paper trash inside. There were insects inside the light covers on the ceiling in the bathroom. There were blue-colored stains noted on the flat sheet of the made bed. Holes were observed in the fitted sheet. Behind the patient's bed, a dried brown colored liquid was on the wall. At the base of all four walls, the paint was peeling exposing the bare sheetrock. The porous surface cannot be sanitized to prevent the spread of infectious diseases or hospital-acquired infections (HAIs).

Biohazard Room
The biohazard room was in the back hallway. A ceiling tile located next to the light fixture had a brown-colored stain resembling dried water. A brown-colored stain was noted on the wall below the stained ceiling tile.

Soiled Linen Room
The soiled linen room was located in the back hallway of the facility. To the left of the employee handwashing sink was an incomplete repair of a hole in the wall. The hole had been partially repaired with a piece of sheetrock. The original piece of the drywall that was removed was on the countertop to the right of the sink. The incomplete repair left openings that could allow small and large insects to enter the room. Chipped white drywall was noted on the countertop. Behind the large black rolling laundry bin, the wall was chipped and missing paint exposing the surface beneath the paint. Also, the walls were noted to have black marks, dirt, and debris.. A dried liquid resembling a water stain was also noted on the wall directly above the rolling laundry bin.

Patient Common Area (Back by Dining Room)
The hospital had two hallways where patient rooms were located. There was a common area for patients to gather at the front and back of the hallways. In the patient's common area in the back hallway next to the doorway of the dining room, dirt and debris were noted on the walls. Black-colored scuff marks were also visible on the walls.

Storage Room #1 (Common Area Back)
This storage closet was a locked storage closet at the end of the hallway located near the back common area where patient's gathered, This room was storing tools, equipment, replacement parts for hospital equipment, and multiple cans of paint and chemicals. There was dust and debris noted on the shelves and floor.

An interview was conducted with Staff #25 on 8/24/2023 after 9:00 AM. Staff #23 was asked if the paint and the chemicals that were stored in the closet at the end of the hallway were always there. Staff #25 replied, "No, they need to be moved out of that closet and put into the storage with the rest of the paint. They can't be stored in the building."


Shared Patient Shower
The facility had two shared patient showers. The one located in the front hallway was in service at the time of the tour. The soap dispenser in the shower was broken and had what appeared to be black colored mold on the exterior cover. The floor of the shower was discolored with black colored stains. Along the edge of the shower door there was a black colored stain that appeared to be mold. There were visible cracks and holes in the shower wall. The cracks and holes prevented the surfaces from being thoroughly cleaned and sanitized to prevent the spread of infectious diseases and/or hospital-acquired infections (HAIs). The vent above the shower was dirty and the cover was rusted.

Medical Equipment Room
The medical equipment room was in the front hallway. There was peeling paint and holes in the wall exposing the drywall. There were ceiling tiles falling leaving an opening for insects to enter the room. There were scuff marks, dust, and dirt on the floor. The automated external defibrillator (AED- a portable device that delivers an electric shock through the chest to the heart when it detects an abnormal rhythm and changes the rhythm back to normal) had a black, sticky material on the outside case and lid. There was hair or fabricated material under the lid on the face of the AED.

Patient Laundry Room
The facility had a laundry room for staff/patients to wash their own clothing in the front hallway. The patient washing machine was missing disinfectant dates on the log sheet for 08/19/2023, 08/20/2023, 08/21/2023, and 08/22/2023. The dryer had lint buildup in the lint trap.

Storage Room #2 (Hallway)
Storage room #2 was located in the front hallway. This was where the facility kept the patient's personal belongings. An overfilled box of clothing and shoes was noted on the floor with no patient identification labels. There were empty trash bags and dust noted on the floor. The air conditioning vent in the ceiling was dusty and the filter was dirty.

Clean Linen Room
The clean linen room was in the front hallway. This room was used to store clean linen for patient use. There was a large hole in the wall behind the door. This could allow for various insects to enter the room contaminating the clean linen.

Nurse's Station Pill Room
The hospital had a pill room located within the centralized nurse's station. The patient's medications were administered and stored in this area. There was dust and a dried, brown-colored liquid noted on top of the medication disposable canisters. Dust was found on top of the bloodborne pathogen spill kit stored on the counter top. Dust and debris were noted on the countertops. There was an unknown dried brown liquid splattered on the blinds in the pill room window. There was dust on top of the refrigerator and on top of the hazardous waste container that was attached to the wall. The paint on the wall was chipped exposing the drywall. There were plastic storage containers on top of the countertop used to store different sized needles and syringes. The top drawer labeled "Diabetic" was storing unused insulin syringes. This surveyor was unable to verify the sterility or the expiration dates of the syringes because they had been removed from their original container they were shipped in. A small plastic drawer labeled "Lubricating Jelly" was storing individual packets of lubricating jelly. The expiration date on the lubricating jelly was dated 03/24/2022 and 10/2022. Staff # 1 disposed of the items before the surveyor could obtain an accurate count. In the cabinet above the sink, there were expired AED (Automated External Defibrillator-pads used to shock a patient's heart back into a normal rhythm) pads dated 08/12/2023 and Glucose test strips (strips used to test a patient's blood sugar) with an expiration date of 06/13/2023. There were 42 Sureprep wipes (used as a skin protectant, may be used on wounds, peristomal, or areas that come in contact with bodily fluids) that expired on 02/2020. A single-use, non-adhering dressing was opened and available for patient use. Multi-use wound cleanser with a past use date of 07/08/2023 was located in the wound care tote.


During an interview on the afternoon of 8/21/2023 Staff #1 confirmed the insulin syringes, Sureprep wipes, AED pads, and glucometer strips were past their expiration date and should have been removed from the medication room.

Nurse's Station Records Room
A dried liquid stain and dirt was visible on the wall in between the alcohol dispenser and a red outlet plug.

Kitchen
Staff # 5 provided a tour of the hospital kitchen on 08/21/2023; and surveyor observed lunch service on 08/22/2023 and 08/23/2023. The following infection control findings were observed:

No name or expiration date of frozen meat stored in the freezer. No name or expiration date of cut up vegetables stored in the freezer.

An interview with Staff #34 on 08/22/2023 at 11:35 AM in the kitchen confirmed that he did not label the raw meat and/or prepared meatballs stored in the freezer. He stated that he prepared the meatballs with spices but did not label the ingredients. He stated he only "puts the date he stored the meat."

No name or expiration date of frozen meat thawing in the refrigerator. Vegetables stored in an opened plastic bag in an opened box with no documentation of the name and/or expiration date. Fruits and vegetables stored in box without a name, received date, opened date, or expiration date.

Unlabeled oil was noted in a pitcher with no received date or expiration date stored under the prep table. Rusty and grimy can opener and peeler observed on top of the prep table. An interview with Staff #34 on 08/22/2023 at 11:40 AM, he stated that the can opener and peeler were ready for use.

Food processer with visible mold, water, and leftover food. An interview with Staff #34 on 08/23/2023 at 11:40 AM, he stated that he used it to prep the onions for the rice dish for lunch and that he had cleaned it and it was ready for use.

Visible dirt and grease were found along the stove and hood.

The oven was found to be heavily soiled with dried on food particles and liquids. The inside of the oven and racks had a heavy caked on carbon stains.

The walls from the pantry, entering the main kitchen, was heavily soiled with dust, dirt, and grease.

The floors in the kitchen were heavily soiled with old food particles and dried liquids.

The lower shelves of the metal table used for food preparation were found covered in dried foods and liquids.

Plastic cutting boards were put away with visible water spots.

In observations on 08/23/2023 at 11:45 AM, Staff #34 washed his hands in the 3-compartment sink, not in the designated hand washing station. He also used a tray to deliver strawberry cake to the tables and replaced the tray back onto the stack of cleaned trays above the warming station without washing the tray.


An interview was conducted with Staff #1 and #2 after 9:00 AM on 8/22/2023. Staff #2 was asked who the Infection Prevention Coordinator was at the facility. Staff #2 replied Staff #37 was the infection control preventionist.

Staff #2 stated, "She only works part-time and she is over 3 different hospitals." Staff #2 was asked if she comes to the hospital to do surveillance rounds or provide education to the staff on infection control preventions. Staff #2 confirmed Staff #37 had not been at the facility anytime she was there.

After multiple requests for hospital-wide surveillance rounds and infection control education to employees, none was provided for review.


40989


B.

Findings:

The Infection Control Professional failed to report 4 of 4 patients with a reportable communicable disease as required by Texas Administrative Code (TAC) Title 25 Part 1 Chapter 97 Subchapter F Rule 97.134 (a)(d) within a 1-day time frame for reporting primary and secondary Syphilis. Syphilis was detected in two patients on 6/15/2023 and two patients on 6/18/2023.
TAC 97.134(a)(d)

A review of the Antibiotic Stewardship Committee Log for June 2023 revealed a positive RPR (a blood test that looks for specific antibodies when a person's immune system is fighting syphilis) in 4 inpatients. All 4 inpatients were started on antibiotic therapy.

TAC 97.134(a)(d) is as follows:
(a) All reportable information received by the health authority or the department is confidential as provided by law, including (but not limited to) Texas Health and Safety Code, §81.046 and §81.103.
d) Health professionals and other persons as specified by §97.132(a)(1) - (3) of this title must submit reports of suspected primary or secondary syphilis and acute HIV infection by telephone within one working day of a suspected diagnosis. All other reports of suspected STD cases and HIV-exposed infants from health professionals and other persons as specified by §97.132 of this title must be submitted within seven calendar days of that determination.

After multiple requests for documentation of the communicable diseases that are required to be reported, there was none provided for review.

An interview was conducted with Staff #1 on 8/23/2023 after 10:00 AM. Staff #1 was asked to provide the documentation that the communicable diseases were reported as required by the Texas Notifiable Conditions. Staff #1 stated, "Staff #37 only worked part-time but that the facility would try and get in touch with her to see where they could get that information."

A review of the document titled, "Infection Control, Prevention & Management Plan 2023" was as follows:

" ...Infection Preventionist Team (IPT)

The IPT consists of the Director of Behavioral Health & Compliance, Director of Nursing, IC Practitioner.
The IPT assumes the responsibility of managing and carrying out the infection surveillance, prevention and control functions within Aspire Hospital and all Outpatient Clinics ..."

A review of the signed job description by Staff #37 on 7/24/2019 was as follows:

" ...Job Scope
Provides professional infection control and prevention services to 30-bed hospital and five outpatient clinic centers located in Conroe, Huntsville, and The Woodlands (Texas). Requires consistent exercise of discretion and judgment. Performs duties as assigned.
...
Specific...

Assist in ensuring the hospital is in compliance with Joint Commission, CMS, and the state of Texas standards/regulations.
Ensure communicable diseases are reported as required by law
Participate in developing a system in identifying, reporting, investigating, and controlling infections and communicable diseases. ..."


As of the survey exit date on 8/25/2023, Staff #37 did not provide any documentation to the hospital for review. On 8/25/2023 a telephone interview was requested with Staff #37. After multiple attempts by the hospital to reach Staff #37 by telephone Staff #37 did not answer any phone calls.

Staff #1 and #2 confirmed the lab results of 4 patients with a positive RPR test. Also, it was confirmed that no one at the hospital had access to any of the infection control reports or information.

.

Based on an interview the infection preventionist failed to maintain written or electronic documentation of the infection prevention and control programs surveillance, prevention, and control activities.


An interview was conducted with Staff #1 on 8/22/2023 at 12:50 PM. Staff #1 was asked if the infection preventionist had any documentation to ensure that surveillance, prevention, and control activities were being conducted at the hospital. Staff #1 replied, "She emailed some information, but I am unable to determine the meaning of the information and she will not return any phone calls. She only works part-time, and she covers 3 different locations, but no one here has access to anything that she does."

Staff #1 confirmed there was no current documentation available from Staff #37 regarding surveillance rounds, prevention, or control activities being performed at the hospital.

.

Based on document review and interview, the Infection Control Preventionist, Staff #37, failed to communicate and collaborate with the QAPI (Quality Assessment Performance Improvement) program regarding infection control issues.



Findings:

A review of the QAPI meeting minutes dated 6/08/2023 revealed Staff #37 did not attend the scheduled meeting. Further review revealed Staff #37 emailed handwashing posters to be placed at handwashing stations and no other findings were presented by her at that time.

After multiple requests for documentation that Staff #37 was currently involved with the QAPI program, none was provided for review.

A review of Staff #37's job description dated 7/24/2019 was as follows:
" ...Essential Job Functions

General
Promotes and maintains health and compliance by providing Infection Preventionist services under the supervision of the Director of Compliance.

Specific
...
Participate at least monthly as a member of the QAPI Committee, including data submission as agreed upon and participation in the monthly meeting ..."

During an interview on 8/24/2023 after 1:30 PM Staff #2 confirmed Staff #37 did not present any infection control concerns and that she only emailed posters to be placed at the handwashing stations during the last QAPI meeting 6/08/2023. Staff #2 was asked if Staff #37 attended the QAPI meetings. Staff #2 replied, "She is only a part-time employee, and she covers 3 locations. We do not see her here. I think she will attend some of the meetings but its usually over the telephone or through a Zoom call but she has not presented any information at any of the meetings that I have been on."

.

Based on document review and interview the hospital failed to ensure the infection preventionist, Staff #37, was actively involved with the Antibiotic Stewardship Program.



Findings:

A review of the Antibiotic Stewardship Committee Meeting minutes dated 6/29/2023 and 8/02/2023 confirmed Staff #37 attended the meeting via Zoom. Further review of the meeting minutes did not reveal any documentation of the collaboration between the Infection Control Preventionist and the Antibiotic Stewardship Leadership team.

Staff #6 confirmed there was no documented information provided by Staff #37 to discuss at the meetings dated 6/29/2023 and 8/02/2023.


An interview was conducted on 08/25/2023 at 9:12 AM with Staff #6. Staff #6 stated, "Staff #37 had not been having monthly infection control meetings nor had she been attending any of the P&T (Pharmaceutical and Therapeutic) committee meetings."

Staff #6 confirmed the infection control preventionist did not report any data regarding prevention or control of active infections to the Antibiotic Stewardship Program.

Based on record review and interview the facility failed to;

A.
ensure that the discharge planning process was evaluated, re-evaluated, and documented for its patient population in 7 of 7 (#24, 25, 26, 27, 28, 29, and 30) patient charts reviewed.

Refer to Tag A0802

B.

the discharge planning process was assessed on a regular basis to ensure that the plans were responsive to the patient's post-discharge needs.

Refer to Tag A0803

C.
ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient's goals and treatment preferences when referring to HHA, SNF, IRF, or LTCH.

Refer to Tag A0804

D.
ensure that arrangements made for discharge were documented in 3 of 3 charts patient charts (# 26, 28, and 29).

Refer to Tag A0805

Based on record review and interview the facility failed to ensure that the discharge planning process was evaluated, re-evaluated, and documented for its patient population in 7 of 7 (#24, 25, 26, 27, 28, 29, and 30) patient charts reviewed.


A record review of patient charts #26, 28, and 29 revealed there was no discharge planning record in the patient's chart.

A review of the facility provided a document titled "Discharge Process", dated 12/14/2022, which stated,

"...before the patient is discharged, the hospital informs the patient and the patient's family when it is involved in its decision-making or ongoing care...

...conducts reassessment of the discharge planning process includes a review of discharge plans.....

The patient, the patient's family, licensed independent practitioners Physicians, clinical therapists, and staff involved in the patient's treatment and services participate in planning the patient's discharge..."

A record review of patient #24's medical chart, Interdisciplinary Master Treatment Plan review, Unknown author, dated 08/03/23 (no time noted) stated, "Discharge." the follow-up section was left blank. The patient was discharged the next day to his home. It is unknown if the patient was given any prescriptions for his medications, was in a safe environment, was able to obtain medication, had reliable transport for appointments/follow-ups, or what psychiatrist he was referred to.

A record review of patient #25's discharge planning showed an IDT treatment plan for discharge as d/c home to husband and follow up with psychiatrist upon discharge. The second page of the IDT which contains information for short and long-term goals as well as criteria for discharge was not included in the chart. No other discharge planning information was documented. The patient was discharged on 08/22/23.






32143

Findings;

A review of patient # 30's chart revealed he had an initial discharge plan that stated, " ... patient request assistance of location housing placement." There was no further discharge information, updates, or solutions documented. A review of the physician discharge plan stated, "discharged to shelter." There was no information if the patient was given any other options than to go to a shelter.

Based on review and interview the facility failed to ensure the discharge planning process was assessed on a regular basis to ensure that the plans were responsive to the patient's post-discharge needs.

A review of the Quality Assurance Performance Improvement (QAPI) meeting minutes for 6/2023 and 7/2023 revealed there was no evaluation or reviews of discharged patients to ensure patient's post-discharge needs were met.

An interview was conducted with Staff # 10 on 8/24/23. Staff #10 confirmed there was no ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient's post-discharge needs.

Based on review and interview the facility failed to ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient's goals and treatment preferences when referring to HHA, SNF, IRF, or LTCH.

A review of the Quality Assurance Performance Improvement (QAPI) data and dashboards revealed there was no collection of data from facilities to ensure a safe discharge to a reputable company was relevant and applicable to the patient's goals and treatment preferences.

An interview was conducted with Staff #2 on 8/23/23. Staff #2 confirmed there was no collection of data to ensure a safe discharge to a reputable company was relevant and applicable to the patient's goals and treatment preferences.

Based on review and interview, the facility failed to ensure that arrangements made for discharge were documented in 3 of 3 charts patient charts (# 26, 28, and 29).

A review of patients #26, 28, and 29 charts revealed no discharge planning was found.

.


32143

An interview was conducted with Staff # 10 on 8/24/23. Staff #10 confirmed there were some charts that were not completed and had no discharge planning. Staff #10 stated that the staff talk about the care and discharge planning daily but have not been consistant with charting. Staff #10 stated he had not taken this problem to QAPI and had no performance improvement plan in place.

Based on review and interview the facility failed to have written policies and procedures to address its organ procurement responsibilities.

An interview was conducted with Staff #2 and #30 on 8/25/23. Staff #2 was unable to provide an organ procurement policy and procedure. Staff #2 stated the policy and procedures were not all updated and she was unable to find a policy. Staff #30 was unable to provide a contract with any facility to provide organ procurement for the facility.

Based on review and interview the facility failed to provide an agreement with an Organ Procurement Organization (OPO) designated for the facility.

An interview was conducted with Staff #2 and #30 on 8/25/23. Staff #2 was unable to provide an organ procurement policy and procedure. Staff #2 stated the policy and procedures were not all updated and she was unable to find a policy. Staff #30 was unable to provide a contract with any facility to provide organ procurement for the facility.

Based on review and interview the facility failed to have a organ procurement policy and failed to have a agreement with any tissue or eye bank.

An interview was conducted with Staff #2 and #30 on 8/25/23. Staff #2 was unable to provide an organ procurement policy and procedure. Staff #2 stated the policy and procedures were not all updated and she was unable to find a policy. Staff #30 was unable to provide a contract with any facility to provide organ procurement, eye or tissue bank for the facility.

Based on review and interview the facility failed to provide any policy or procedure for organ procurement or information to be provided to the patient or family of options to donate organs, tissues, or eyes, or to decline to donate.

An interview was conducted with Staff #2 and #30 on 8/25/23. Staff #2 was unable to provide an organ procurement policy and procedure. Staff #2 stated the policy and procedures were not all updated and she was unable to find a policy. Staff #2 was unable to provide any information to be provided to family or patients on how to donate organs, tissues, or eyes, or to decline to donate. Staff #30 was unable to provide a contract with any facility to provide organ procurement, eye or tissue bank for the facility.

Based on review and interview the facility failed to have an organ procurement representative or a designated requestor.

An interview was conducted with Staff #2 and #30 on 8/25/23. Staff #2 was unable to provide an organ procurement policy and procedure. Staff #2 was unaware of any organ procurement representative or a designated requestor.

Based on review and interview the facility failed to have an Organ Procurement Plan. The facility failed to have staff education for organ procurement or donation issues.

Review of Staff #20 RN, #18 RN, and # 23 RN employee files on 8-25-23 revealed there was no education found for organ procurement education.

Based on record review and interview the facility failed to,

1.
have an updated Emergency Preparedness Plan (EPP) every two years for the safety of staff, patients, and visitors.

Refer to Tag E0004

2.
provide a community- based risk assessment to develop and maintain an Emergency Preparedness Plan (EPP).

Refer to Tag E0006

3.
have an Emergency Prepardness Plan (EPP) that addressed the high risk population of psychiatric patients, their higher care needs, the delegation of authority, and how the continuity of providing care would be maintained.

Refer to Tag E0007

4.
have an Emergency Preparedness Plan (EPP) that included the Local and Federal officials so that the response would be timely, efficient, and provide safety to staff, patients, and visitors.

Refer to Tag E0009

5.
have a policy and procedure for an Emergency Prepardness Plan (EPP).

Refer to Tag E0013

6.
have an emergency preparedness policy and procedure for documentation preservation, protecting confidentiality, secure, and maintain availability of patient records.

Refer to Tag E0023

7.
have a contact information list of federal, state, and local emergency staff and resources.

Refer to Tag E0030

8.
have an emergency preparedness communication plan that listed federal, state, regional, and local emergency preparedness staff.

Refer to Tag E0031

9.
ensure they had a training program, policy, and procedures for an Emergency Preparedness Plan (EPP), and failed to update the plan every two years.

Refer to Tag E0036

10.
have an Emergency Preparedness Plan (EPP). The facility failed to have any drills for emergencies or disasters annually. This practice puts the community, staff, visitors, and patients at risk for harm.

Refer to Tag E0039

Based on record review and interview the facility failed to have an updated Emergency Preparedness Plan (EPP) every two years for the safety of staff, patients, and visitors.



Findings:

A record review of the EPP revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provided a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010 and had not been renewed. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building. The last documented EPP and updated education for staff training was on 03/12/10.

An interview was conducted with the Employee #5 on 08/22/23. Employee #5 confirmed that he did not know the fire safety and disaster plan was outdated and needed to be updated. Employee #5 stated he was a new hire within the last six weeks and was trying to bring the hospital into compliance.

An interview was conducted with Employee #16 on 08/23/23. Employee #16 stated, "I know there are a lot of problems". Employee #16 confirmed that he was not aware that the EPP program was outdated by 13 yrs.

Based on record review and interview the facility failed to provide a community- based risk assessment to develop and maintain an Emergency Preparedness Plan (EPP).

Record review of the EPP was dated 2010, this surveyor asked multiple times during the survey for a copy of the risk assessment. A paper copy of all the needed materials was handed to both Employee #5 and Employee #2. The facility was unable to provide any documentation.

An interview was conducted with Employee #2 on 08/25/23. Employee #2 confirmed there had been no risk assessment performed.

Based on record review and interview the facility failed to have an Emergency Prepardness Plan (EPP) that addressed the high risk population of psychiatric patients, their higher care needs, the delegation of authority, and how the continuity of providing care would be maintained.

Record review of the Emergency Preparedness Plan revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provided a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010 and had not been renewed. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building. The last documented EPP and updated education for staff training was on 03/12/10.

A record review of a second EPP presented to the surveyor on 08/24/23 revealed an plan dated January 2021 consisting of 30 pages. This EPP was not approved by the governing board, nor was this policy in use. Upon further review, the plan was not a EPP plan but definitions. No direction was given for safe egress of the building during emergency situations, or how personnel would safely remove patients from an at-risk area.

A third EPP was given to this surveyor on 08/25/23 at 10:00AM and was dated 2023. This plan did not indicate what should be done in any emergency but was more of a definition of each role. It lacked the appropriate direction to assist staff if there was an actual emergency of where and when to evacuate patients safely and where supplies were located.

An interview was conducted with Employee #5 on 08/22/23. Employee #5 confirmed he was unaware that the EPP was outdated and needed to be updated. He indicated he was a new hire within the last six weeks and was trying to bring the hospital into compliance.

An interview was conducted with Employee #4 and #16 on 08/23/23. Employee #4 confirmed he did not know, that the EPP was outdated, nor the location of the EPP. Employee #16 stated, "I know there are a lot of problems". Employee #16 confirmed he was not aware that the EPP plan was had not been updated for 13 years.

Based on record review and interview the facility failed to have an Emergency Preparedness Plan (EPP) that included the Local and Federal officials so that the response would be timely, efficient, and provide safety to staff, patients, and visitors.

Record review of the Emergency Preparedness Plan (EPP) revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provides a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building since that plan was made. The date of the last employee/staff education for an EPP was documented on 03/12/10.

An interview was conducted with Employee #5 on 08/23/23. Employee #5 confirmed he was unaware that the EPP was outdated and needed to be updated. Staff #5 confirmed the local authorities had not been included for a risk or safety plan.

Based on record review and interview the facility failed to have a policy and procedure for an Emergency Prepardness Plan (EPP).

A record review of the Emergency Preparedness Plan revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provided a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010 and had not been renewed. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building. The last documented EPP and updated education for staff training was on 03/12/10.

An interview was conducted with Employee #5 and #2 on 08/22/23. Employee #5 confirmed he was unaware that the EPP was outdated and needed to be updated. Staff #2 and #5 confirmed there was no policy and procedure for the EPP.

Based on record review and interview the facility failed to have an emergency preparedness policy and procedure for documentation preservation, protecting confidentiality, secure, and maintain availability of patient records.

A record review of the Emergency Preparedness Plan (EPP) revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provides a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building since that plan was made. The date of the last employee/staff education for an EPP was documented on 03/12/10.

An interview was conducted with Employee #5 on 08/22/23. Employee #5 confirmed he was unaware that the EPP was outdated and needed to be updated. Staff #5 confirmed that there was no emergency preparedness policy and procedures to include the security and integrity of patient medical records.

Based on record review the facility failed to have a contact information list of federal, state, and local emergency staff and resources.

Record review of the Emergency Preparedness Plan (EPP) revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provides a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building since that plan was made. The date of the last employee/staff education for an EPP was documented on 03/12/10.

An interview was conducted with Employee #5 and #1 on 08/23/23. Employee #5 and #1 confirmed there was no contact information list of federal, state, and local emergency staff and resources.

Based on record review and interview the facility failed to have an emergency preparedness communication plan that listed federal, state, regional, and local emergency preparedness staff.

A record review of the Emergency Preparedness Plan (EPP) revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provides a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building since that plan was made. The date of the last employee/staff education for an EPP was documented on 03/12/10.

An interview was conducted with Employee #5 and #2 on 08/23/23. Employee #5 and #2 confirmed there was no emergency preparedness communication plan.

Based on record review and interview the facility failed to ensure they had a training program, policy, and procedures for an Emergency Preparedness Plan (EPP), and failed to update the plan every two years.

A record review of the Emergency Preparedness Plan (EPP) revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provides a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building since that plan was made. The date of the last employee/staff education for an EPP was documented on 03/12/10.

An interview was conducted with Employee #5 and #2 on 08/23/23. Employee #5 and #2 confirmed there was no EPP training or policy and procedures on EPP training.

Based on record review and interview the facility failed to have an Emergency Preparedness Plan (EPP). The facility failed to have any drills for emergencies or disasters annually. This practice puts the community, staff, visitors, and patients at risk for harm.

A record review of the Emergency Preparedness Plan (EPP) revealed that the emergency plan was written by the Stericycle Company called the Steri-Safe Program. The Steri-Safe Program provides a detailed EPP plan when you have a contract with them. The last known contract was documented as of 2010. This plan indicated routes that no longer existed due to a remodel of the building, it also did not include the new departments that were added to the building since that plan was made. The date of the last employee/staff education for an EPP was documented on 03/12/10.

An interview was conducted with Employee #5 on 08/23/23. Employee #5 confirmed there was no EPP plan nor any drills for emergencies performed.