HospitalInspections.org

Based on record review, observations and interview, the facility failed to ensure it was primarily engaged in providing to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons. This had the potential to affect all of the facility's 184 active outpatients and 109 active inpatients. The average inpatient census this year is 110.

Findings include:

1. On 11/02/17 at 2:27 PM, Staff B was interviewed. Staff B reported:

The facility is a "specialty hospital for drug and alcohol treatment. We have physicians, physician assistants, nurse practitioners, registered nurses 24 hours a day and a pharmacist". The facility is part of Hospital A, affiliated with Hospital B. The facility "provides all levels of care for adults with addiction problems, medical Detox, inpatient, partial hospitalization, and extended care". The facility "safely gets people off drugs and helps them learn to stay off. Many patients have a dual diagnosis and are treated by our psychiatrists at this facility. We provide EKG (electrocardiogram) services, lab draws, and CLIA (Clinical Laboratory Improvement Amendments) tests". The facility has inpatient beds of which "33 are dedicated Detox" beds.

2. Staff B was interviewed on 11/01/17 at 4:00 PM. Staff B reported the facility had 64 on campus partial inpatient beds" plus "114 inpatient beds". When asked Staff B stated in email on 12/27/17 at 1:52 PM "we do not have "partial inpatient beds" but do provide therapeutic overnight for patients who meet criteria for partial hospitalization. Partial hospitalization is a level of care that traditionally provides 6 to 8 hours of treatment per day. Patients who do not meet medical necessity criteria for inpatient care according to their insurance carrier but who are not stable emotionally and or physically are permitted to remain at Glenbeigh in a non-hospital bed. We do this to provide the patient with a safe drug free environment where they can develop the emotional stability and coping skills in order to safely return home and maintain long term recovery from drug addiction."

3. The facility's active inpatient census and active outpatient census were reviewed. The review revealed the facility had 184 active outpatients and 109 active inpatients. Staff B stated in email on 12/27/17 at 1:52 PM "through Nov. 30, 2017 the average inpatient length of stay is 12.5 days. The average inpatient census this year is 110."

4. The facility's contracts were reviewed. The facility contracts with Hospital A to send patients to Hospital A for Emergency Services and inpatient care. The contract stated the following:

The facility "maintains a hospital in Rock Creek, Ohio, for the treatment of chemically dependent persons, and WHEREAS, the facility serves the Ashtabula County community as well as many other communities; and WHEREAS, the parties hereto are desirous of developing a close working relationship WHEREBY patients serviced by the facility can obtain, when necessary, the acute inpatient and emergency care afforded by "Hospital A", and WHEREBY individuals serviced by "Hospital A" can obtain, when necessary, treatment afforded by GLENBEIGH;"

4. Hospital A "will agree to provide on a routine basis, laboratory, radiological, surgical, EKG, psychiatric and needed services to the facility's patients". "Coordination for the provision of those services will be developed by the appropriate Hospital personnel and" the facility's "Director of Medical Affairs; a bona fide medical director licensed and in good standing in the State of Ohio." 6. The facility, "licensed and certified, "as a hospital by JCAHO" (Joint Commission Accreditation Health Care Organization), "agrees to maintain accreditation by the Joint Commission Accreditation Health Care Organization during the term of this agreement and any renewals thereof". The facility contracts with Facility A for laboratory services.

5. The facility's Mission Statement was reviewed. The Mission Statement stated the following:

"Chemical Dependency is an illness that results in the progressive physical, emotional, psychological, social and spiritual deterioration of individuals and their families, if left untreated. With treatment, chemically dependent individuals and their families have the capacity to lead full, meaningful and productive lives. We believe that successful treatment of chemical dependency requires an abstinence-based, 12-step model of recovery, utilizing a holistic approach. Social, medical and/or psychiatric conditions may complicate treatment and must be addressed to ensure ongoing recovery. Since 1981," the facility "has provided comprehensive, individualized chemical dependency treatment in caring and compassionate environment."

6. The facility's marketing brochure was reviewed. The marketing brochure revealed a full complement of services to address the needs of patients across the continuum of care including:

Comprehensive evaluation

Detoxification

Inpatient Rehabilitation

Partial Hospitalization

Intensive outpatient treatment

Extended care recovery residences

Family services

Continuing care

Community referrals

The facility's marketing brochure stated the following:

"For more than a century, we have helped thousands of individuals into recovery from alcohol and drug addiction. As a specialty hospital, we encourage our patients to grow personally and support their efforts by providing an environment that is secure, challenging, enjoyable and conducive to recovery."

"Our experienced team of caring trusted professionals includes physicians, nurses, counselors, psychiatrists, psychologists, social workers, and clergy."

The facility's marketing brochure did not state it was primarily engaged in providing to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

The facility's website, http://www.glenbeigh.com/inpatient-treatment, was reviewed. The website stated:

The facility "is a nationally recognized drug and alcohol treatment center. Located in the northeast corner of Ohio on 80 acres of rural serenity, our landscaped grounds provide patients the opportunity to enjoy beauty and tranquility during the recovery process. Our expansive treatment center in Rock Creek, Ohio provides a spacious, modern environment for learning, healing and taking the necessary steps toward recovery.

We understand that the journey of drug and alcohol rehabilitation sometimes requires an intensive level of care. For these instances," the facility "offers an Inpatient Drug and Alcohol Rehab Program. It's about nurturing our patients and offering them the courage to help re-discover a life free from alcohol and drugs.

Primary Inpatient Treatment at "the facility" is a multi-disciplinary program utilizing an abstinence-based, disease-concept model of treatment, with the length of stay based on individual need. For some patients with a history of extensive alcohol or opioid use, treatment may include the use of non-addictive medication. Our programs treat the whole person: medically, psychologically, spiritually and emotionally.

The facility offers a full compliment of services to address the needs of patients across the continuum of care including:
Diagnostic Evaluation
Detoxification
Inpatient Rehabilitation
Partial Hospitalization
Extended Residential Care
A Complimentary Family Program
Continuing Care
Community Referrals

We at "the facility" firmly believe that all individuals suffering from drug and alcohol addiction can fully recover and begin new, meaningful lives, without the need for alcohol and drugs. Based upon this belief, our commitment is to provide treatment in a truly positive and therapeutic environment. Recognizing that all patients' needs are different, we offer Specialized Treatment to address those individuals' needs."

7. The medical records of 30 active patients were reviewed. The record reviews revealed 30 of the 30 patients were admitted to the facility with primary and/or secondary diagnosis of mental health diagnosis versus medical diagnosis (according to the facility's EMR (electronic medical records) classification system). Examples of the patient's primary and secondary diagnosis include alcohol use disorder, opioid use disorder, cocaine use disorder, opioid withdrawal, cigarette nicotine dependence, and sedative, hypnotic or anxiolytic dependence. M.D. admission orders note that "patient is admitted to detox". A random sample was conducted with all charts containing this order.

8. The facility has certification from the Ohio Department of Mental Health and Addiction Services for the "hospital" and outpatient centers which expires 11/18/19. The certification is to operate an alcohol and drug addiction program.

9. The facility was accredited by The Joint Commission on 11/18/16 as meeting the requirements for a Behavioral Health Care Accreditation Program. The facility was not contracted as a hospital, as required per the facility's contract with Facility A.

10. On 10/31/17 at 3:09 PM, Staff C was interviewed. Staff C reported a "doctor is available 24 hours a day, but not on-site 24 hours a day". A registered nurse is present 24 hours a day.

11. On 10/31/17 at approximately 11:50 am, observations were conducted of 10 patients receiving medications from nurses.

Based on record review, observation and staff interview, the facility failed to ensure outdated medications were not available for patient use. This affected two of two Blue Emergency Bags inspected.

Findings include:

Facility policy Nursing Department Medical Equipment for Emergencies was reviewed. Per policy, "all of these supplies are inspected at designated frequencies by nursing staff to ensure that items are stocked and not expired."

Observation of the Blue Emergency Bag in the Main Nursing Office was conducted on 11/02/17 at 9:41 AM with Staff A, Director of Quality. Two of two glucagon emergency kits for low blood sugar expired in October of 2017. One of six narcan nasal spray (4 mg) expired in April 2017. One of two glucose oral gel (15 ml) expired on 10/20/17. Staff A confirmed these findings at the time of the observation.

Observation of the Blue Emergency Bag in Medication Room 3 was conducted on 11/02/17 at 10:10 AM with Staff A. Two of two glucagon emergency emergency kits for for low blood sugar expired in October of 2017. One box of ammonia inhalant expired in November 2016. Staff A confirmed these findings at the time of the observation.

Per Staff A the Blue Emergency Bags and Emergency Cart are inspected on a nightly basis by a nurse. Review of the check sheets revealed both bags were last inspected on 11/01/17.

Based on observation, interview, and documentation review the facility failed to ensure the building smoke barriers, construction type, hazardous area walls, and fire drills complied with NFPA 101, exit sprinkler system instillation complied with NFPA 13, generator testing, and generator remote annunciator panel instillation were complied with NFPA 99 and NFPA 110, warning devices, door hold open devices, duct detectors and smoke detector testing/inspections complied with NFPA 72 and NFPA 101, and exit discharges complied with Survey and Certification Letter 05-38. This has the potential to affect all patients in the facility. (A710)

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients in the facility.

Findings include:

Building 1 of 6

1. Please see K131 for the facility failing to ensure the fire rated occupancy separation was free of penetrations.

2. Please see K291 for findings related to the facility failing to ensure battery backup emergency light testing was documented for each emergency light.

3. Please see K321 for findings related to the facility failing to ensure there were no penetrations in the walls of hazardous areas and doors with self closing devices were kept in a closed position.

4. Please see K345 for findings related to the facility failing to ensure duct detectors, smoke detectors, strobes, horns, and magnetic door releasing devices were tested.

5. Please see K916 for findings related to the facility failing to ensure a remote annunciator panel was located in a regular work station.

6. Please see K918 for findings related to the facility failing to ensure generators were tested monthly for 30 minutes at 30% name plate rating and the 3 year 4 hour load testing was completed.

Building 4 of 6

1. Please see K271 for findings related to the facility failing to ensure exits are of a hard packed all-weather travel surface.

2. Please see K321 for findings related to the facility failing to ensure there were no penetrations in the walls and ceiling of hazardous areas.

3. Please see K351 for findings related to the facility failing to ensure the entire facility was sprinklered including the attic space.

4. Please see K918 for findings related to the facility failing to ensure generators were tested monthly for 30 minutes at 30% name plate rating and the 3 year 4 hour load testing was completed.

Building 5 of 6

1. Please see K271 for findings related to the facility failing to ensure exits are of a hard packed all-weather travel surface.

2. Please see K321 for findings related to the facility failing to ensure there were no penetrations in the walls and ceiling of hazardous areas.

3. Please see K351 for findings related to the facility failing to ensure the entire facility was sprinklered including the attic space.

4. Please see K916 for findings related to the facility failing to ensure a remote annunciator panel was located in a regular work station.

5. Please see K918 for findings related to the facility failing to ensure generators were tested monthly for 30 minutes at 30% name plate rating and the 3 year 4 hour load testing was completed.

Building 6 of 6

1. Please see K161 for findings related to the facility failing to meet the construction type requirement for NFPA.

2. Please see K271 for findings related to the facility failing to ensure exits are of a hard packed all-weather travel surface.

3. Please see K321 for findings related to the facility failing to ensure there were no penetrations in the walls and ceiling of hazardous areas.

4. Please see K371 for findings related to the facility failing to ensure the facility was divided into at least 2 smoke compartments.