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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to conform to all applicable State regulations.

Endless Mountains Health Systems was not in compliance with the following state law:

Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. §1303.302 Definitions ... "Incident." An event, occurrence or situation involving the clinical care of a patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. The term does not include a serious event. ... "Serious event." An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an incident.

PS. §1303.313 Medical facility reports and notifications. (a) Serious event reports. --A medical facility shall report the occurrence of a serious event to the department and the authority within 24 hours of the medical facility confirmation of the occurrence of the serious event. The report to the department and the authority shall be in the form and manner prescribed by the authority in consultation with the department and shall not include the name of any patient or any other identifiable individual information. (b) Incident reports. --A medical facility shall report the occurrence of an incident to the authority in a form and manner prescribed by the authority and shall not include the name of any patient or any other identifiable individual information. (c) Infrastructure failure reports. -- A medical facility shall report the occurrence of an infrastructure failure to the department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure. The report to the department shall be in the form and manner prescribed by the department.

This is not met as evidenced by:

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to report reportable events through the Patient Safety Reporting System (PSRS).

Findings include:

Review on November 7, 2019, of the facility's "Patient Safety Plan," effective October 1, 2018, revealed "Purpose: The patient Safety Plan ensures that Endless Mountains Health Systems (EMHS) implements and maintains a safety program in accordance with Act 13 Medical Care Availability and Reduction of Error Act. This plan facilitates a patient safety program through education, communication and effectiveness of the program. The purpose of the plan is to provide a framework for the implementation of various components of the patient safety program. ... Event Definitions: ... Incident: An event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. The term does not include a serious event. ... Serious Event: An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an Incident. ... "

Review on November 7, 2019, of the facility provided "Serious Event Decision Algorithm Flowchart," dated March 18, 2015, revealed "Q1 Did the event involve the clinical care of a patient in a medical facility? ... Q3 Did the event result in the patient having any of the following: 1) an additional documented diagnosis as a result of the clinical care, or 2) a repeat of an invasive procedure for the original diagnosis, or 3) an unauthorized invasive procedure? ... Q4 Was there documentation that, before the event, the patient or surrogate could have anticipated this complication as a result of the physician disclosing to the patient or surrogate that 1) the complication occurs frequently or the risk of the complication was considered high for the particular patient and 2) the action associated with the complication and the possibility that the action (or inaction) could lead to an additional documented diagnosis or repeat invasive procedure? Q5 Did the management of the additional diagnosis require an invasive procedure that required its own informed consent? Q6 Did the event result in an unanticipated injury: 1) requiring therapeutic care that can only be provided by a licensed professional healthcare worker or 2) resulting in a long term disability, for which there is no treatment, but treatment would provided if options were available or 3) where additional healthcare services are possible for the risk of those services outweighs the negative consequences of the injury or 4) where additional healthcare services are required but are not provided because of unintentional omission or because the patient declines treatment or 5) did the event result in the patient having an unauthorized invasive procedure without medical justification? This event meets PA-PSRS interpretation of unanticipated injury requiring the delivery of additional healthcare services and therefore meets PA-PSRS interpretation of the definition of a Serious Event"

Review of MR39 on November 7, 2019, revealed this patient's physician ordered a Computerized (CT) scan of the head with contrast on May 30, 2019. Nursing documentation revealed this patient developed a rash over the entire body following the CT scan. MR39's physician instructed nursing staff to administer Benadryl 25 milligrams (mg) orally and Solu-Medrol 125 mg Intramuscular (IM) immediately. MR39's physician instructed nursing staff to administer a second dose of Solu-Medrol 125 IM. The facility identified MR39's rash as an allergic drug reaction to the CT contrast.

Interview with EMP2 on November 7, 2019, confirmed MR39's physician ordered a CT scan of the head with contrast; nursing documentation revealed this patient developed a rash over the entire body following the CT scan; MR39's physician instructed nursing staff to administer Benadryl 25 mg)orally and Solu-Medrol 125 mg IM) twice; and, the facility identified MR39's rash as an allergic drug reaction to the CT contrast. EMP2 revealed MR39's allergic drug reaction required additional health care services with the administration of medication. EMP2 revealed the facility reported this occurrence as an incident and did not think this occurrence was a serious event. EMP2 revealed the facility submitted this to PA-PSRS as an incident on July 22, 2019.

Review of MR33 on November 7, 2019, revealed this patient was admitted on March 28, 2019, for a surgical hysterectomy. Nursing staff documented this patient had persistent intermittent vaginal bleeding with blood clots. MR33's physician took this patient back to the operating room (OR) for surgical intervention of post-operative bleeding under anesthesia. MR33's physician documented this patient was returned to the OR for repairs to the vaginal lining and application of vaginal packing under monitored anesthesia care (MAC) anesthesia.

Interview with EMP2 on November 7, 2019, confirmed MR33 was admitted for a surgical hysterectomy; nursing staff documented this patient had persistent intermittent vaginal bleeding with blood clots; MR33's physician took this patient back to the OR for surgical intervention of post-operative bleeding under anesthesia; and MR33's physician documented this patient was returned to the OR for repairs to the vaginal lining and application of vaginal packing under monitored anesthesia care (MAC) anesthesia. EMP2 revealed MR33's return to surgery was considered a requirement for additional health care services. EMP2 revealed the facility reported this occurrence as an incident and did not think this occurrence was a serious event. EMP2 revealed the facility submitted this to PA-PSRS as an incident on May 28, 2019.

Review of MR34 on November 7, 2019, revealed this patient was admitted on March 9, 2019, with a complaint of pain in the back of the head and neck following exercising. MR34's physician instructed nursing staff to administer Morphine 4 mg Intravenously (IV) for MR34's complaint of pain. Nursing documented MR34 complained of pain and redness at the IV site and also began to shake within 10 minutes of administration. MR34's physician instructed nursing staff to administer Benadryl 25 mg orally and Pepcid 20 mg IV. The facility identified MR34's reaction to the Morphine as an allergic drug reaction.

Interview with EMP2 on November 7, 2019, confirmed MR34 was admitted with a complaint of pain in the back of the head and neck following exercising; MR34's physician instructed nursing staff to administer Morphine 4 mg IV for MR34's complaint of pain; nursing documented MR34 complained of pain and redness at the IV site and also began to shake within 10 minutes of administration; MR34's physician instructed nursing staff to administer Benadryl 25 mg orally and Pepcid 20 mg IV and the facility identified MR34's reaction to the Morphine as an allergic drug reaction. EMP2 revealed MR34's allergic drug reaction required additional health care services with the administration of medication. EMP2 revealed the facility reported this occurrence as an incident and did not think this occurrence was a serious event. EMP2 revealed the facility submitted this to PA-PSRS as an incident on April 9, 2019.

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to complete an annual performance evaluation for three (3) of 3 certified registered nurse anesthetists (PF1, PF2, PF3).

Findings include:

Review on November 6, 2019, of facility policy, "Performance Evaluation," revised April 17, 2017, revealed "Policy 1. Department Heads and Supervisors are strongly encouraged to discuss job performance and goals on an informal, day-to-day basis. 2. This evaluation allows the supervisor and the employee an opportunity to discuss the job responsibilities, standards, and performance requirements of the new position. 3. Additional formal performance evaluations are conducted throughout the year to provide opportunity to discuss job tasks, identify and correct weaknesses, encourage and recognize strengths, and discuss positive, purposeful approaches for meeting goals. ..5. Performance evaluations will be given during the month of September. Procedure ...3. The Department Head/Supervisor will set up a conference with the employee to review the evaluation by September 30. ..5. If an evaluation is not received by the Human Resources Department by October 1, the Director of Human Resources will notify the Administrative Director of evaluations not received. The Administrative Director will notify the Department Head/Supervisor that evaluations must be received no later than October 15. ..."

Review on November 6, 2019, of PF1 revealed this employee is a certified registered nurse anesthetist currently employed by the hospital. This employee's last performance evaluation was dated September 20, 2017.

Interview on November 6, 2019, with EMP1 confirmed PF1's last performance evaluation was dated September 20, 2017 and is currently employed by the hospital.

Review on November 6, 2019, of PF2 revealed this employee is a certified registered nurse anesthetist currently employed by the hospital. This employee's last performance evaluation was dated October 2, 2017.

Interview on November 6, 2019, with EMP1 confirmed PF2's last performance evaluation was dated October 2, 2017 and is currently employed by the hospital.

Review on November 6, 2019, of PF3 revealed this employee is a certified registered nurse anesthetist currently employed by the hospital. This employee's last performance evaluation was dated October 2, 2017.

Interview on November 6, 2019, with EMP1 confirmed PF3's last performance evaluation was dated October 2, 2017 and is currently employed by the hospital.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a pain reassessment was completed following pain medication administration in the emergency Department (ED) for five of seven applicable medical records reviewed (MR27, MR39, MR43, MR44 and MR45).

Findings include:

Review on November 6, 2019, of the facility's "Pain Assessment, Reassessment and Management" policy, last approved March 6, 2019, revealed "Scope: Nursing Staff Objective: It is the policy of Endless Mountains Health Systems to support the patient's right to optimal pain assessment, reassessment and management. Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness. ... Procedure: Using a pain scale with 0 being no pain and 10 being the worst pain imaginable, a numerical value can be assigned to the patient's perceived intensity of pain. ... The Patient Shall be Reassessed for Pain: at least once per shift and every eight (8) hours. 30 - 45 minutes after any intervention for pain control. ... The scale will be used to determine initial pain by assessment and evaluate effectiveness of pain-relieving efforts over a period of time. ..."

Review of MR27 on November 6, 2019, revealed this patient was admitted to the ED on October 27, 2019, with a complaint of upper extremity pain. Nursing staff assessed this patient's pain level as 5 on a scale of 1 to 10 with 10 being the worst pain. There was a physician order instructing nursing staff to administer Ibuprofen 600 milligrams (mg) orally at 11:34 AM. MR27 was discharged from the ED at 12:34 PM. There was no documentation nursing staff reassessed MR27's pain level before discharge.

Interview with EMP6 on November 6, 2019, at the time of the medical record review confirmed MR27 was admitted to the ED with a complaint of upper extremity pain. Nursing staff assessed this patient's pain level as 5 on a scale of 1 to 10 with 10 being the worst pain. There was a physician order instructing nursing staff to administer Ibuprofen 600 mg orally at 11:34 AM. MR27 was discharged from the ED at 12:34 PM and there was no documentation nursing staff reassessed MR27's pain level before discharge

Review of MR39 on November 6, 2019, revealed this patient was admitted to the ED on September 19, 2019 with a complaint of general illness. Nursing staff assessed this patient's pain level as 10 guarding pain on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Toradol (a nonsteroidal anti-inflammatory medication) 60 mg/2 millimeter (ml) Intramuscular (IM) at 11:27 AM. MR39 was discharged from the ED at 13:50 PM. There was no documentation nursing staff reassessed MR39's pain level before discharge.

Interview with EMP6 on November 6, 2019, at the time of the medical record review confirmed MR39 was admitted to the ED with a complaint of general illness. Nursing staff assessed this patient's pain level as 10 guarding pain on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Toradol 60 mg/2 ml IM at 11:27 AM. MR39 was discharged from the ED at 13:50 PM. There was no documentation nursing staff reassessed MR39's pain level before discharge.

Review of MR43 on November 6, 2019, revealed this patient was admitted to the ED on September 20, 2019, with a complaint of achy generalized pain. Nursing staff assessed this patient's pain level as 7 on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Toradol 60 mg/2 ml IM at 02:38 AM. MR43 was discharged from the ED at 06:42 PM. There was no documentation nursing staff reassessed MR43's pain level before discharge.

Interview with EMP6 on November 6, 2019, at the time of the medical record review confirmed MR43 was admitted to the with a complaint of achy generalized pain. Nursing staff assessed this patient's pain level as 7 achy pain on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Toradol 60 mg/2 ml IM at 02:38 AM. MR43 was discharged from the ED at 06:42 PM and there was no documentation nursing staff reassessed MR43's pain level before discharge.

Review of MR44 on November 6, 2019, revealed this patient was admitted to the ED on October 24, 2019, with a complaint of sharp, throbbing back pain. Nursing staff assessed this patient's pain level as 7 on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Ibuprofen 800 mg at 20:44 PM. MR44 was discharged from the ED at 20:55 PM. There was no documentation nursing staff reassessed MR44's pain level before discharge.

Interview with EMP6 on November 6, 2019, at the time of the medical record review confirmed MR44 was admitted to the ED with a complaint of sharp, throbbing back pain. Nursing staff assessed this patient's pain level as 7 on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Ibuprofen 800 mg at 20:44 PM. MR44 was discharged from the ED at 20:55 PM and there was no documentation nursing staff reassessed MR44's pain level before discharge.

Review of MR45 on November 6, 2019, revealed this patient was admitted to the ED on September 26, 2019, with a complaint of sharp, throbbing shoulder pain. Nursing staff assessed this patient's pain level as 10 on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Toradol 60 mg/2 ml IM at 02:12 AM. MR45 was discharged from the ED at 08:34 PM. There was no documentation nursing staff reassessed MR45's pain level before discharge.

Interview with EMP6 on November 6, 2019, at the time of the medical record review confirmed MR45 was admitted with a complaint of sharp, throbbing shoulder pain. Nursing staff assessed this patient's pain level as 10 on a scale of 1 to 10, with 10 being the worst pain. There was a physician order instructing nursing staff to administer Toradol 60 mg/2 ml IM at 02:12 AM. MR45 was discharged from the ED at 08:34 PM and there was no documentation nursing staff reassessed MR45's pain level before discharge.

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Infection Control Committee had a physician that attended committee meetings to guide the committee on decisions for improvement of care through the prevention and control of infections.

Findings include:

Review on November 8, 2019, of the facility policy "Infection Control Committee Organization and Function," approved May 7, 2012, revealed "Policy: 1. Endless Mountains Health Systems' Infection Control Committee (ICC) is responsible for the Infection Prevention and Control Program. ...3. The Infection Control Committee shall be governed by a physician having knowledge of infection control practices and performance improvement methodologies. This physician guides the committee on decisions for improvement of care through the prevention and control of infections. ..."

Review on November 8, 2019, of the facility "Endless Mountains Health Systems Bylaws Rules and Regulations Of The Medical Staff," approved January 25, 2017, revealed " ...Section 9. Attendance Requirements Each committee member shall be required to attend not less than fifty percent of all meetings of his committees in each year. ..."

Review on November 8, 2019, of the facility Infection Control Committee Meeting Minutes dated March 29, 2018, June 18, 2018, September 17, 2018, December 10, 2018, March 25, 2019, June 18, 2019, and September 16, 2019, revealed OTH1 had not attended the meeting.

Interview on November 8, 2019, with EMP7 at approximately 10:00 AM confirmed OTH1 is the physician on the Infection Control Committee. EMP7 confirmed OTH1 had not attended the Infection Control Meetings dated March 29, 2018, June 18, 2018, September 17, 2018, December 10, 2018, March 25, 2019, June 18, 2019, and September 16, 2019.

Repeat deficiency
April 5, 2017

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure foods opened for patient use were dated when opened; the facility failed to perform and document cool down temperatures of left-over food items; and, the facility failed to ensure all foods served to patients on the tray line were checked for proper serving temperature.

Findings include:

Review on November 5, 2019, of the facility's "Nutritional Services Department Policy And Procedure Subject Infection Prevention and Control" policy, last reviewed April 21, 2017, revealed "Purpose: To prevent and control contamination and the spread of infection within the department and the hospital. Policy: Nutritional Services staff shall follow all appropriate infection prevention and control measures for all food service. Responsibilities: Nutritional Services Director shall: ... Develop written standards and work procedures for daily operations. Procedures for preparation and serving of food must be such as to minimize contamination by microorganisms or be chemicals that may result in food poisoning. ... Fruits, vegetables, dairy products, raw meat, poultry and fish shall be stored at temperatures 40 degrees F [Fahrenheit] or below. ... Infection Prevention and Control Practices: ... Foods stored in opened original containers must be covered and dated. ... "

Interview with EMP5 on November 5, 2019, at approximately 1:45 PM revealed the dietary department also follows ServSafe food safety guidelines.

Review on November 5, 2019, of documentation provided by EMP5 from the ServSafe manual revealed "... Cooling and Reheating Food When you don't serve cooked food immediately, you must get it out of the temperature danger zone as quickly as possible. That means cooling it quickly. ... Temperature Requirements for Cooling Food ... pathogens grow well in the temperature danger zone. However, they grow much faster at temperatures between 125 degrees Fahrenheit (F) and 70 degrees F... Food must pass through this temperature range quickly to reduce this growth ... First, cool food from 135 degrees F to 70 degrees F ... within two hours ... Then cool it from 70 degrees F to 41 degrees F ... or lower in the next four hours. If food has not reached 70 degrees F in less than two hours, it must be reheated and then cooled again. ... the total cooling time cannot be longer than six hours. ..."

1) Observation of the dietary freezer on November 5, 2019, revealed the following open and partially used food items:
- One bag of cauliflower
- One bag of peas
- One bag of mixed vegetable
- One bag of asparagus
- One bag of yellow squash
- One bag of fish
- One bag of ravioli
- Two bags of onions
- Two bags of zucchini
There was no date of opening on these open and partially used food item packages.

Observation of the dietary dry storage area on November 5, 2019, revealed the following open and partially used food items:
- Two bags of pasta
- Two bags of dried bread crumbs
There was no date of opening on these open and partially used food item packages.

Interview with EMP5 on November 5, 2019, at the time of the observation confirmed the opened, partially used and undated food items in the freezer and dry storage area. EMP5 revealed it is the expectation that all foods be dated when opened.

2) Interview with EMP5 on November 5, 2019, at approximately 12:00 PM revealed the dietary department has leftovers following meal service to patients.

A request was of EMP5 on November 5, 2019, for the log of cool down temperatures of left-over foods.

Interview with EMP5 on November 5, 2019, at approximately 12:00 PM revealed the facility does not perform or record cool down temperatures of left-over foods.

3) Review on November 5, 2019, of the "Daily Food Temperature Log", no review date, revealed a list of food items, a space to document the temperature, the desired temperature and any correction staff needed to do. The desired temperature for eggs is 140 degrees F; yogurt is 40 degrees F and milk is 40 degrees F.

Review on November 5, 2019, of the "Daily Food Temperature Logs" for May, June, August, September and October 2019 revealed no documentation dietary staff checked and documented the temperature for yogurt prior to serving for May 2019; June 2019; July 2019 August 2019, September 2019 and October 2019.

Interview with EMP5 on November 5, 2019, at approximately 2:00 PM confirmed yogurt is served to patients from the tray line. EMP5 confirmed dietary staff did not check and record the temperature of the yogurt to ensure it was at 40 degrees F prior to serving it to patients.

Review on November 5, 2019, of the "Daily Food Temperature Log" revealed no documentation dietary staff checked and documented the temperature of eggs prior to serving on May 7, 16, 17, 22, 25, 27 and 30, 2019; June 9, 11, 15, 27 and 30, 2019; July 29, 2019; August 1 and 9, 2019; September 1, 9, 10, 12, 15, 17, and 23, 2019; and, October 1, 2, 15 and 18, 2019.

Interview with EMP5 on November 5, 2019, at approximately 2:15 PM confirmed dietary staff did not check and document the temperature of eggs prior to serving on the dates listed above.

Review on November 5, 2019, of the " Daily Food Temperature Log " revealed no documentation dietary staff checked and documented the temperature of milk prior to serving on June 29, 2019; August 25 and 26, 2019 and on October 2, 2019.

Interview with EMP5 on November 5, 2019, at approximately 2:30 PM confirmed dietary staff did not check and document the temperature of milk prior to serving and the dates listed above.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Quality Improvement monitoring was performed for all facility departments which included Dietary/Nutrition, Social Services, Utilization Review and Infection Control and contracted service which included laundry.

Findings include:

Review on November 6, 2019, of the facility's "2019 Quality Improvement Plan," revealed "Executive Summary ... The quality and patient safety infrastructure supports Endless Mountains Health Systems' commitment to safety, quality, evidence-based medicine, and continuous learning is an effort to provide the highest level of care to the communities we serve. The committees and councils within the structure are multidisciplinary and include representatives from impacted entities to include providers, staff, community members, and outpatient care area representatives where appropriate. ... Purpose The purpose of the Quality Plan supports the systematic organization -wide approach to design, measure, analyze, and improve organizational performance. Initiatives are designed to: Attain optimal patient outcomes and patient and family experience Support an engaged and safe workforce Enhance appropriate utilization Minimize risks and hazards of care Develop and share best practices ... Guiding Principles Provide safe and quality clinical services and demonstrate superior patient outcomes Assess performance with objective and relevant measures ... Identify and focus on functions that are important to our customers and implement changes which will increase satisfaction. ... Authority and Accountability: ... The Quality Improvement Committee This committee is a multidisciplinary group, which will meet quarterly, and more frequently as circumstances dictate. The QI Committee will be responsible for the directing, monitoring and reviewing of all QI activities at Endless Mountain Health Systems. ... The QI Committee will review the care provided by the medical staff, nursing and all ancillary services to include all health care practitioners employed or contracted by EMHS ..."

Review on November 6, 2019, of the facility's Quality Improvement Committee meeting minutes for 2018 and 2019 revealed no documentation Dietary/Nutrition, Social Services, Utilization Review and Infection Control reported Quality Improvement activities for the 2018 and 2019 calendar years.

Interview with EMP1 on November 6, 2019, at approximately 2:30 PM confirmed Dietary / Nutrition, Social Services, Utilization Review and Infection Control did not report Quality Improvement activities for the 2018 and 2019 calendar years.

Review on November 6, 2019, of the facility's contract list, identified by EMP1 as active facility contracts, revealed contracts for patient care services which included laundry.

Review on November 6, 2019, of the facility's Quality Improvement Committee meeting minutes for 2018 and 2019 revealed no documentation the contracted service of laundry reported Quality Improvement activities for the 2018 and 2019 calendar years.

Interview with EMP1 on November 6, 2019, at approximately 2:30 PM confirmed the contracted service of laundry did not report Quality Improvement activities for the 2018 and 2019 calendar years.

Repeat deficiency
April 5, 2017

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to document activities were offered to swing bed program patients and the facility failed to document the swing bed patients' refusal of the activity for three of six swing bed patient medical records reviewed (MR37, MR38 and MR39).

Findings include:

Review on November 7, 2019, of the facility's "Swing Bed Activities" policy, last approved September 5, 2012, revealed "Policy - A program of planned activities is provided to patients occupying swing beds by way of the EMHS Activities Program The facility will provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each patient in the swing bed unit. ... Objective - The intent of the program is to provide activities appropriate to the needs, interests, and potential of each patient, to encourage resumption of normal activities and to reach and maintain an optimal level of psychosocial functioning. Procedure - 1. The program activities personnel of the Swing Bed Program are responsible for the development and management of activities planned for each patient in a swing bed setting. The activities plan is an integral part of the multi-disciplinary care review. 2. Activities shall be designed to promote the physical, social, and mental well-being of the patients. 3. Appropriate documentation shall be maintained in the medical record by the activity provider. 4. EMSH employed Occupational Therapist will oversee the activities program. a quarterly review will be completed, with more frequent consultation performed as needed."

Review of MR37 on November 7, 2019, revealed the facility assessed this swing bed patient's activity interests in knitting or crocheting, reminiscing, television, visitation, cooking and canning. There was no documentation in MR37 indicating the facility offered this patient knitting or crocheting, reminiscing, television or visitation or that MR37 refused to accept knitting or crocheting, reminiscing, television or visitation during the stay in swing bed.

Interview with EMP8 on November 7, 2019, at approximately 2:00 PM confirmed MR37 was a swing bed patient. EMP8 confirmed MR37's activity interest included knitting or crocheting, reminiscing, television, visitation, cooking and canning and there was no documentation indicating the facility offered this patient knitting or crocheting, reminiscing or television, visitation or that MR37 refused to accept these activities during the stay in swing bed.

Review of MR38 on November 7, 2019, revealed the facility assessed this swing bed patient's activity interests in reminiscing, television, visitation and large print magazines. There was no documentation in MR38 indicating the facility offered this patient reminiscing, television, visitation or large print magazines or that MR38 refused to accept reminiscing, television, visitation or large print magazines during the stay in swing bed.

Interview with EMP8 on November 7, 2019, at approximately 2:00 PM confirmed MR38 was a swing bed patient. EMP8 confirmed MR38's activity interest included reminiscing, television, visitation and large print magazines and there was no documentation indicating the facility offered this patient reminiscing, television, visitation or large print magazines or that MR38 refused to accept these activities during the stay in swing bed.

Review of MR39 on November 7, 2019, revealed the facility assessed this swing bed patient's activity interests in reminiscing, television, visitation, crafts and library books. There was no documentation in MR39 indicating the facility offered this patient reminiscing, television, visitation crafts or library books or that MR39 refused to accept reminiscing, television, visitation, crafts or library books during the stay in swing bed.

Interview with EMP8 on November 7, 2019, at approximately 2:00 PM confirmed MR39 was a swing bed patient. EMP8 confirmed MR39 ' s activity interest included reminiscing, television, visitation, crafts and library books and there was no documentation indicating the facility offered this patient reminiscing, television, visitation, crafts or library books or that MR39 refused to accept these activities during the stay in swing bed.