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Based on the number and nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Governing Body. The hospital failed to have an effective governing body legally responsible for the conduct of the hospital as an institution. The Governing Body failed to provide effective oversight to ensure the quality of care and services provided by contractual agreements in the areas of environmental safety, food and dietary, laboratory services, radiological services, temporary nursing staff and acute renal dialysis. In addition, the Governing Body failed to ensure that the hospital had adequate corporate support, or individual hospital flexibility, to ensure that the hospital had appropriate medical record forms to comply with CMS regulations regarding discharge planning.

The facility failed to meet the following standards under the condition of Governing Body.

Tag A 0049 Medical Staff Accountability
The facility Governing Body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. The facility failed to ensure that all medical care, provided to patients by contract radiologists and pathologists, was provided by physicians who were credentialed, appointed to the medical staff and granted privileges by the Governing Body. The failure to exert direct oversight over these two categories of contract physicians created the potential for a negative patient outcome.

Tag A 0083 Contracted Services-Responsibility for Services
The facility Governing Body failed to be responsible for services furnished in the hospital whether or not they were furnished under contracts. The governing body failed to ensure that all contractors of services furnished them in a manner that permitted the hospital to comply with all applicable conditions of participation and standards for the contracted services.

Tag A 0084 Contracted Services-Provided in a Safe and Effective Manner
The facility Governing Body failed to ensure that services performed under contract were provided in a safe and effective manner. In addition, the facility's Quality Assurance/Performance Improvement (QAPI) activities and reports failed to include performance measures for contracted services, including radiology, laboratory, food and dietary and renal dialysis.

Based on the nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Quality Assurance/Performance Improvement (QAPI). The hospital failed to ensure that the hospital developed, implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital's Governing Body failed to ensure that the program involved all hospital departments and services, including those services furnished under contract or arrangement.

The facility failed to meet the following standard under the Condition of Participation of Quality Assurance/Performance Improvement (QAPI):

Tag A 0312 Executive Responsibilities
The facility failed to ensure each department, whether in-house or contracted, was thoroughly evaluated for quality assessment and performance improvement. The facility did not ensure that priorities for improved quality of care were addressed and implemented.

Tag A 0276 Identify Improvement Opportunities
The facility failed to systematically incorporate findings from the complaint/grievance process into quality assurance activities. The lack of a centralized and comprehensive tracking system created the potential for important investigative findings to be overlooked in facility quality improvement activities. There was no evidence that the facility was evaluating complaints/grievances with trend analysis and creating/implementing action plans to improve patient care delivery.

Based on staff interviews and review of the medical staff roster and bylaws, the Governing Body of the facility failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. The facility failed to ensure that all medical care, provided to patients by contract radiologists and pathologists, was provided by physicians who were credentialed, appointed to the medical staff and granted privileges by the Governing Body. The failure to exert direct oversight over these two categories of contract physicians created the potential for a negative patient outcome.

The findings were:

1. Review of the medical staff roster on 6/21/10 revealed that there were no radiologists or pathologists appointed to the medical staff, despite the fact that the facility had contracted radiology services and contracted laboratory services, as well as an in-house arterial blood gas laboratory certified by CMS/CLIA.

2. Review of the medical staff bylaws on 6/28/10 revealed the following, in pertinent parts:
"...Article IV MEDICAL STAFF MEMBERSHIP
...Section 2. Qualifications for Membership
...i. The Hospital is a long-term acute care hospital, specializing in medically complex patients. The Hospital is not a general acute care facility providing a full spectrum of surgical, medical and other health care services. All appointments to the Medical Staff must be consistent with the needs and objectives of the Hospital to establish a medical staff of specialty Members necessary to meet the needs of the Hospital's patients and consistent with the Hospital's goal to restrict membership to the extent necessary to those specific specialties required by the Hospital.
...Article V. CATEGORIES OF THE MEDICAL STAFF
...Section 5. Contract Physicians
The Hospital may contract with physicians for certain patient care services. The MEC (Medical Executive Committee) shall provide advice about the sources of clinical services that shall be provided through contractual arrangement. The services provided by Contract Physicians may be categorized three ways:
1. Services provided within the Hospital or under the control of the Hospital;
2. Services provided outside the Hospital but under the control of another Joint Commission-accredited organization; and
3. Services provided outside the Hospital and outside the Hospital's control by a non-Joint Commission accredited organization or individual physician.
All Contract Physicians shall comply with the qualifications, conditions, responsibilities and standards for membership set forth in Article IV (MEDICAL STAFF MEMBERSHIP). Ongoing professional practice evaluation of Contracted Physicians will take place per policy and the evaluation information gathered will be factored into the decision to maintain existing Privileges, to revise Privileges, or to revoke an existing Privilege prior to or at the time of reappointment. Contract Physicians shall automatically lose Medical Staff membership and all Privileges upon the termination of the contractual relationship between the Contract Physician's employer and the Contract Physician or the Hospital and the Contract Physician or Contract Physician's employer..."

3. Interview with the director of quality on 6/23/10 at approximately 1 p.m. revealed that the facility does not have an internal evaluation process for assessing the quality of radiology or laboratory services, since they are provided by contractual arrangement. The only evaluation for those services was the annual contract evaluation form filled out by the Chief Executive Officer (CEO) each year for a report to the Governing Body.

4. The facility's "ANNUAL CONTRACT SERVICE EVALUATION" was reviewed on 6/23/2010 at approximately 12:30 p.m., in the presence of the CEO (Chief Executive Officer). Annual review for 2010 was done by the CEO on 5/26/10 and 6/1/10. The evaluation for each contract consisted of three questions and then a score between one and five. The three questions were:
1) Provided services in a safe and effective manner
2) Meet quality of series expected by hospital
3) Meets expectation and terms of contract
After the CEO reviewed the contracts, s/he took them to the Governing Body meeting for final approval. When the CEO was asked how s/he formulated the ratings for each contract, s/he said that s/he attended all the meetings throughout the year and was aware of the happenings in the facility. When asked for further data supporting the evaluations, s/he could not provide any. The evaluations for all contracted services reviewed (including radiology and laboratory services) were rated at "4," which represented "above average," as opposed to the "5," which would have represented "excellent." The CEO had no internal or external reports or evaluations of quality to review prior to assigning the rating of "4."

Based on staff interviews, tours, observation and review of facility documents, the governing body of the facility failed to ensure that services furnished under contract complied with all applicable conditions of participation and standards for the contracted services. The failure created the potential for a negative patient outcome.

The findings were:

Reference Tag A 0043 (Condition of Participation of Governing Body) and Tag A 0084 (Standard under Governing Body) for findings related to the Governing Body's failure to monitor the quality of services provided by contractual agreement, to ensure quality care and patient, visitor and staff safety.

Based on staff interviews and review of facility documents and meeting minutes, the Governing Body of the facility failed to ensure that services performed under contract were provided in a safe and effective manner. In addition, the facility's Quality Assurance/Performance Improvement (QAPI) activities and reports failed to include performance measures for contracted services, including radiology, laboratory, food and dietary and renal dialysis. The failure created the potential for a negative patient outcome.

The findings were:

1. The facility's "ANNUAL CONTRACT SERVICE EVALUATION" was reviewed on 6/23/2010 at approximately 12:30 p.m., in the presence of the CEO (Chief Executive Officer) Annual review for 2010 was done by the CEO on 5/26/10 and 6/1/10. The evaluation for each contract consisted of three questions and then a score between one and five. The three questions were:
1) Provided services in a safe and effective manner
2) Meet quality of series expected by hospital
3) Meets expectation and terms of contract
After the CEO reviewed the contracts, s/he took them to the Governing Body meeting for final approval. When the CEO was asked how s/he formulated the ratings for each contract, s/he said that s/he attended all the meetings throughout the year and was aware of the happenings in the facility. When asked for further data supporting the evaluations, s/he could not provide any. The evaluations for all contracted services reviewed were rated at "4," which represented "above average," as opposed to the "5," which would have represented "excellent." The CEO had no internal or external reports or evaluations of quality to review prior to assigning the rating of "4." The only contract with any supporting data was a contracted renal dialysis department that provided external quality review data complied by it's parent corporation.

2. Interview with the director of quality on 6/23/10 at approximately 1 p.m. revealed that the facility does not have an internal evaluation process for assessing the quality of radiology or laboratory services, since they are provided by contractual arrangement. The only evaluation for those services was the annual contract evaluation form filled out by the Chief Executive Officer (CEO) each year for a report to the Governing Body. S/he confirmed that the facility's Quality Assurance/Performance Improvement (QAPI) activities and reports did not include performance measures for contracted services, including radiology, laboratory, food and dietary and renal dialysis.

For additional finding related to failures to monitor contracted services, reference the following tags:

Tag A 0398 Supervision of Contracted Nursing Staff
The facility Governing Body failed to ensure that the facility maintained documentation in two of three agency staff files validating that they were actually oriented to the facility. The files contained no evidence that the agency staff had been oriented to emergency policies/procedures and policies/procedures relevant for them to provide safe patient care.

Tag A 0529 Scope of Radiologic Services
The facility Governing Body failed to have the necessary structural elements in place for the contracted service of radiology. Specifically, the facility failed to clearly identify the scope of radiologic services available to its patients, have clear policies/procedures regarding accessing radiologic services, and clearly evaluate the radiologic processes in regards to patient needs.

Tag A 0584 Written Description of Laboratory Services Provided
The facility Governing Body failed to have the necessary structural elements in place for the contracted service of laboratory. Specifically, the facility failed to clearly identify the scope of laboratory services available to its patients, have clear policies/procedures regarding accessing laboratory services, and clearly evaluate the laboratory processes and procedures.

Tag A 0714 Fire Safety-Fire Control Plans
The facility Governing Body failed to ensure that the fire extinguishers were being inspected monthly in accordance with their "Fire Safety Plan."

Tag A 0827 Discharge Planning Documentation
The facility Governing Body failed to ensure that the hospital had adequate corporate support, or individual hospital flexibility, to ensure that the hospital had appropriate medical record forms to comply with CMS regulations requiring documentation that choices for discharge referrals was offered to patients.

Based on review of facility documents, policies/procedures and staff interviews, the facility failed to maintain an organized grievance process program that ensure that all grievances were tracked and records of actions, investigation, contacts and resolution were maintained in a centralized filing system for each complaint/grievance case. In addition, the facility failed to ensure clear accountability was assigned for maintaining complete/accurate records of all grievances/complaints received and processed. The lack of a centralized and comprehensive tracking system created the potential for important investigative findings to be overlooked in facility quality improvement activities.
The failure created the potential for negative patient outcome.

The findings were:

1. On 6/22/10, review of the facility policy/procedure "Grievance and Complaints," revealed the following, in pertinent parts:
"...Policy
...3. The Triumph Hospital Chief executive Officer (CEO), Chief Clinical Officer (CCO) and the Quality Resource Manager (QRM or DQM) has been designated as a committee by the Governing Board to review and resolve all patient grievances.
...11. All Complaints and grievance reports and responses will be maintained in the Quality Resource Manager's/Director of Quality Management Office..."

2. Interview with the director of quality management on 6/22/10 at approximately 12:30 p.m., with additional clarification during a telephone interview on 6/30/10 at approximately 9:30 a.m., about the grievance process, revealed the following information:
S/he stated that the grievance committee did not meet or maintain separate minutes. S/he stated that a daily "Flash" meeting was held to discuss a variety of issues related to the facility. S/he stated that the members of the grievance committee stayed after the rest of the "Flash" meeting to discuss patient complaints. S/he presented a copy of the "Daily Flash Report" for 4/29/10, 5/18/10 and 5/21/10 for review, because they contained content related to family concerns.
On the 3 forms provided, there was very brief notations of family issues being discussed, but more from a clinical patient care plan modification standpoint than related to investigation of a complaint issue. There was no indication of policy review or administrative action taken. All of the notations were from the point of view of family involvement in care. There was no indication of notification to the board or quality assurance.

The director of quality management confirmed during the 6/30/10 telephone interview that those notations at the end of the "Flash" meeting were the only documentation of activity by the "Grievance Committee."

3. Review of grievance documentation related to one of the grievances mentioned on one of the provided "Flash" reports revealed that the documentation by the case managers, who according to the grievance policy/procedure were charged with responsibility for receiving and investigating and resolving grievances, contained no notations information on grievances. The notes of case manager progress notes were a part of the medical record and did not reflect family or patient contact dedicated to pursuing grievance issues. The notes documented patient/family contacts that were related to discharge planning and treatment planning activities, rather than investigation or resolution of a defined grievance or complaint.

4. An interview was conducted with the case manager on 6/22/10 at approximately 12:45 p.m. S/he stated that the case managers provided a utilization review, social work and discharge planning functions, as well as being responsible for complaints and grievances. S/he stated that all of the case managers received and worked on complaints and grievances. S/he stated that no individual was responsible for maintaining the records. S/he stated that grievance documentation would be contained in the medical record in the case management progress notes. S/he stated that neither the complaint/grievance function nor individual complaint/grievance cases were assigned to one person for the purpose of accountability.

5. Interview with the director of quality management on 6/21/10
at approximately 12:30 p.m., with additional clarification during a telephone interview on 6/30/10 at approximately 9:30 a.m., about the grievance process, revealed the following information: S/he stated that some complaints/grievances and records were maintained by him/her in a grievance notebook, some records were kept by the CEO, in cases in which s/he was involved, and some records were kept by the case managers in the medical record. S/he stated that complaints were initially documented on a complaint/grievance sheet completed by the person who received the complaint. Any additional investigation or contacts with patients/families to attempt to resolve complaints/grievance was not centralized. No individual was responsible for overseeing the grievance function to ensure that individual cases did not get lost or overlooked before they could be investigated and/or resolved or referred to an outside entity (such as the State Health Department or CMS) for further action or appeal.

In summary, the facility had a system in place that relied on numerous staff conducting grievances activities, which were documented in multiple locations. No centralized and comprehensive tracking system was in place to ensure that all complaints/grievances were thoroughly investigated and resolved or referred to outside entities. In addition, the lack of a centralized and comprehensive tracking system created the potential for important investigative findings to be overlooked in facility quality improvement activities.

Based on review of medical records and policies/procedures, the facility failed to ensure that there was a physician order in place for each instance of restraint use, in accordance with facility policy/procedure and CMS regulations, for Sample Patients #8 and #23. The failure created the potential for negative patient outcome.

The findings were:

1. Review of sample patient #8's medical record was conducted on 6/22/10. The patient was an adult admitted to the facility on 2/22/10 and diagnosed with respiratory failure, chronic obstructive pulmonary disease and cerebral vascular accident. Documentation reflected that the patient was restrained on 2/22/10, 2/28/10 and 3/3/10 without a corresponding order in the patient record.

2. Review of sample patient #23's medical record was conducted on 6/23/10. The patient was an adult admitted to the facility on 6/2/10 and diagnosed with acute renal failure and a subarachnoid hemorrhage. Documentation reflected that the patient was restrained on 6/2/10 and 6/3/10 without a corresponding order in the patient record.

3. Review of the policy/procedure "Restraint Use," on 6/22/10 revealed the following findings, in pertinent parts:
"...PROCEDURE:
Restraint for Acute Medical and Surgical Care (Non-Behavioral):
...3) A physician must order restraints. This order must be:
a) Time limited. Restraint orders must be ordered daily. If the restraint is removed for a trial period of time a new order must be obtained to re-apply the restraint. [PRN restraints ...are not used in Triumph Hospitals.]..."
NOTE: Attached to the policy/procedure was the form titled "Non-Behavioral Restraint Order & Assessment," which was the form on which physician orders for restraint use were to be written, in accordance with the "Restraint Use" policy/procedure.

Based on medical record, policy/procedure review, and staff interview it was determined the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. Seven (#s 4, 7, 9, 10, 14, 20 & 24) of thirty medical records revealed incomplete nursing documentation on the Interdisciplinary Plan of Care, which was not in compliance with the facility's policies. This created the potential for negative patient outcome.

The findings were:

On 6/22/10 the facility's policy titled "Plan of Care, Interdisciplinary" was reviewed. It stated the following, in pertinent part:
PURPOSE: "The purpose of this policy is to define the process for development and documentation of the individualized treatment plan. The individualized treatment plan is prepared and/or carried out by an interdisciplinary team of healthcare professionals, including physicians. It is integrated and ongoing as required to meet the patient's needs and to maintain the continuity and Coordination of care, treatment and services."
POLICY: "The Interdisciplinary Plan of Care (IPC) is individualized to meet the patient's unique needs and circumstances. Initial needs are assessed and care is planned by a registered nurse (RN) from information gathered on the Admission Data base/Assessment. The IPC will be initiated from this assessment and revised or maintained using an interdisciplinary approach based on the patient's response to the care, treatment, and services provided. Each discipline as warranted will contribute to the IPC and will involve the patient and/or family to the extent possible."
PROCEDURE: "1) The assigned RN will be responsible for assessing the initial needs of the patient and initiating the IPC within 24 hours of admission, based on data obtained from the Admission Date Base/Assessment... 13) The Plan of Care should be reviewed at least weekly and updated as appropriate to the patient's condition."

On 6/22/10 the facility's policy titled "Multidisciplinary Care Management Committee", was reviewed. It stated the following, in pertinent part:
Policy: "...The multidisciplinary team will review the Interdisciplinary Plan of Care (IPC) on a weekly basis and revise as needed to meet the patient's needs. Updates may occur more frequently if necessary..."

On 6/22/10 review of the medical records were completed and revealed the following:

Sample record #4 was an inpatient from 1/21/10 to 1/28/10. The eight "Nursing" sections of the "Interdisciplinary Plan of Care" (IPC) did not contain any documentation.

Sample record #7 was admitted on 2/16/10 and expired on 3/4/10. The nursing sections in the ICP were initially completed on 2/21/10, but no further documentation (such updates) existed whereas the physical therapy and pharmacy sections contained three entries and occupational therapy, respiratory therapy, and dietician sections contained two entires. In contrast, the case management section had zero entries.

Sample record #9 was an inpatient from 3/5/10 to 3/24/10. The nursing sections of the ICP contained initial documentation on 3/7/10 and follow-up documentation on 3/23/10. There was no evidence why one week of documentation was absent.

Sample record #10 was admitted on 3/11/10 and discharged on 3/23/10. An initial entry was made by nursing on the ICP but no consistent follow-up documentation existed.

Sample record #14 was admitted on 4/30/10 and expired on 6/6/10. Two entries were documented in the nursing sections on the ICP as well as in the case management sections, the last for both were dated 5/10/10. No further entries existed for the patient's 27 following hospitalization days.

Sample record #20 was admitted on 5/25/10 and discharged on 6/10/10. The case management and nursing sections of the ICP were blank and without any initial or follow-up documentation evidencing the patient issues and needs.

Sample record #24 was admitted on 6/3/10 and discharged on 6/6/10. The dietician, case management, and nursing sections were all blank and without any initial or follow-up documentation.

Based on review of personnel files for contracted nursing staff and staff interview it was determined that two of three agency staff did not have documentation of their orientation to the facility in their files. There was no evidence that the agency staff had been oriented to emergency policies/procedures and policies/procedures relevant for them to provide safe patient care. This failure created the potential for negative patient outcome. The findings were:

On 6/22/10 personnel files were reviewed. Two of three agency staff (sample #3 and #4) revealed no documented evidence of orientation to the facility.

On 6/23/10 interview with the CCO revealed he/she was unable to find those documents.

Based on medical record, policy/procedure review and staff interview it was determined the facility failed to follow their policy regarding consents for blood transfusions. There was no evidence that a blood consent was obtained for one, (sample #8), of thirty patients. This failure created the potential for negative patient outcome. The findings were:

On 6/21/10 through 6/23/10 a sample of thirty medical records were reviewed. Sample #8 had been transfused with two units of Packed Red Blood Cells (PRBCs) on 3/7/10. Review of the blood administration forms for sample #8, indicated that all the blood slips were filled in correctly. However, there was no consent form for blood administration in the patient's record.

On 6/23/10 at approximately 11:00 a.m., the Chief Clinical Officer (CCO) was interviewed regarding the lack of a blood consent. The CCO was unable to provide evidence that a blood consent had been signed by the patient.

On 6/23/10 the facility policy titled "Blood & Blood Products: Transfusion" was reviewed. The policy, in pertinent, part stated: "PROCEDURE: Preparing to administer blood: 1. Obtain the transfusion consent before a Type and Crossmatch is performed. Only one transfusion consent is needed for each hospitalization."

Based on medical record review and staff interview, the facility failed to ensure that all patient medical record entries were timed in 14 (Sample records #4, 8, 9, 10, 13, 14, 15, 17, 18, 20, 21, 22, 23, 24) of 30 records. This failure created the potential for negative patient outcomes.

The findings were:

Patient medical records were reviewed from 6/21/2010-6/23/2010. In 14 (Sample records #4, 8, 9, 10, 13, 14, 15, 17, 18, 20, 21, 22, 23, 24) of 30 records, times were absent on physician progress notes. In two (Sample records #13 & #20) of 30 records, times were absent on physician orders.

An interview was conducted with the Director of Quality Management on 6/23/2010 at approximately 10:00 AM. S/he stated that the facility has noted that some providers do not time entries. S/he stated that it has been an ongoing effort to ensure the timing of all entries.

Based on review of facility internal documents, policies/procedures, and staff interviews, the facility failed to have the necessary structural elements in place for the contracted service of radiology. Specifically, the facility failed to clearly identify the scope of radiologic services available to its patients, have clear policies/procedures regarding accessing radiologic services, and clearly evaluate the radiologic processes in regards to patient needs. This failure created the potential for negative patient outcomes.

The findings were:

The facility's policies and procedures were reviewed on 6/21/2010. The facility only had two policies that related to radiology which were titled "Chest X-ray Protocol" and "Ultrasound." The Purpose portion of the Chest X-ray policy stated the following, in pertinent part:
"To outline the responsibilities of the Nursing Department and Respiratory Therapy Department when assessing a patient for the need of a stat chest x-ray. This policy will allow the Charge nurse, in conjunction with the Respiratory Therapist, to determine need for a stat chest x-ray based on criteria outlined below..."

In an interview with the facility's Director of Quality Management (DQM) on 6/21/2010 at approximately 3:45 p.m., s/he revealed that the facility did not have a formal scope of service for radiology. The facility provided the unit secretary's desk resource book for review. This book had typed instructions and tips for ordering radiology procedures, along with information about many secretarial duties. The location the test could be performed or the provider that could perform the radiology procedure could be found within the instructions, however it was not always clear. The radiology procedures mentioned in the instructions include CT, MRI, X-ray, ultrasound, PICC lines, and IR. A unit secretary is scheduled 24 hours a day, so an agency nurse could use the secretary as a resource. However, there was no clear way in which staff, agency or permanent, could independently access the radiology scope of services available.

The facility's "ANNUAL CONTRACT SERVICE EVALUATION" was reviewed on 6/23/2010 at approximately 12:30 p.m. Annual review for 2010 was done by the CEO (Chief Executive Officer) on 5/26/10 and 6/1/10. The evaluation for each contract consisted of three questions and then a score between one and five. The three questions were:
1) Provided services in a safe and effective manner
2) Meet quality of series expected by hospital
3) Meets expectation and terms of contract
After the CEO reviewed the contracts, s/he took them to the Governing Body meeting for final approval. When the CEO was asked how s/he formulated the ratings for each contract, s/he said that s/he attended all the meetings throughout the year and was aware of the happenings in the facility. When asked for further data supporting the evaluations, s/he could not provide any.

Based on review of facility internal documents, policies/procedures, and staff interviews, the facility failed to have the necessary structural elements in place for the contracted service of laboratory. Specifically, the facility failed to clearly identify the scope of laboratory services available to its patients, have clear policies/procedures regarding accessing laboratory services, and clearly evaluate the laboratory processes and procedures. This failure created the potential for negative patient outcomes.

The findings were:

The facility's policies and procedures (P&P) were reviewed on 6/21/2010. The P&Ps that related to laboratory processes were titled the following:
Plan: Bloodborne Pathogens Exposure Control
Lab Quality Assurance Plan (CLIA)
SureStepPro, and SureStepFlexx Whole Blood Glucose Testing
Lab Director
Blood and Blood Products: Transfusion

In an interview with the facility's Director of Quality Management (DQM) on 6/21/2010 at approximately 3:45 p.m., s/he revealed that the facility had no formal scope of service for laboratory despite the fact that the facility had contracted laboratory services, as well as an in-house arterial blood gas laboratory certified by CMS/CLIA.

A "LABORATORY REQUISITION" form was provided by the facility upon request of the surveyor. The form is filled out when a lab is ordered by a physician and a copy is sent with the courier and lab sample (blood or otherwise) to the facility that performs the lab tests. When the DQM was asked if the requisition included all tests that the facility could have done, s/he stated that it did not and other tests could also be ordered. However, the facility did not have a list, formal or otherwise, of those lab tests. The facility provided the unit secretary's desk resource book for review. It described other tests (Hemoccult Stool, Type and Cross) that are not on the checklist requisition and would necessitate an entry in the "Misc. Tests" section. A unit secretary is scheduled 24 hours a day, so an agency nurse could use the secretary as a resource. However, there was no clear way in which staff, agency or permanent, could independently access the laboratory scope of services available.

The facility's "ANNUAL CONTRACT SERVICE EVALUATION" was reviewed on 6/23/2010 at approximately 12:30 p.m. Annual review for 2010 was done by the CEO (Chief Executive Officer) on 5/26/10 and 6/1/10. The evaluation for each contract consisted of three questions and then a score between one and five. The three questions were:
1) Provided services in a safe and effective manner
2) Meet quality of series expected by hospital
3) Meets expectation and terms of contract
After the CEO reviewed the contracts, s/he took them to the Governing Body meeting for final approval. When the CEO was asked how s/he formulated the ratings for each contract, s/he said that s/he attended all the meetings throughout the year and was aware of the happenings in the facility. When asked for further data supporting the evaluations, s/he could not provide any.

Based on tours and observations, staff interviews and review of policies and procedures, the facility failed to ensure that the fire extinguishers were being inspected monthly in accordance with their "Fire Safety Plan." The failure created the potential for a negative outcome for patients, visitors and staff.

The findings were:

1. Tour of the facility on 6/21/10 at approximately 9:30 a.m., the facility revealed that all fire extinguishers had last been checked on 5/4/10.

2. Review of the facility policy and procedure "Fire Safety Plan," on 6/22/10 revealed the following, in pertinent parts:
"...Objectives: ...L. Fire extinguishers are inspected monthly and maintained annually, are positioned to be in visible locations, and are selected based on the hazards of the area in which they are
installed..."

3. Interview with the "lead" plant operations manager for the building, an employee of the "host" hospital, revealed that the "host" hospital was responsible for inspecting the fire extinguishers for the facility. S/he stated that the "host" hospital utilized another outside contractor to inspect the fire extinguishers and conduct tests on them. When asked why the fire extinguishers had not been inspected for almost two months, the manager stated that there was a gap in service because the "host" hospital was in the process of transitioning to a new contractor for fire extinguisher inspections. S/he stated that the new contractor would begin inspecting fire extinguishers in the next few weeks.

4. At the time of exit from the survey on 6/23/10 at approximately 3 p.m., the quality assurance director confirmed that the fire extinguishers had not been checked. S/he added that the plant operation "lead" in the building for the "host" hospital stated that the fire extinguishers could be inspected that day, if needed, by "host" hospital plant operations employees, until the contractor began regular inspections.

Based on staff interview, medical record review, and review of the hospital's Policies and Procedures the hospital failed to document in the patient's medical record the discharge planning evaluation for use in formulating appropriate discharge plans and updates in nine (Sample patients #7, 8, 9, 14, 17, 20, 21, 22 & 25) of 30 records. This failure had the potential to lead to increased length of hospitalization.

The findings were:

Medical records were reviewed from 6/21/2010 through 6/23/2010.

Sample patient #7 was admitted to the hospital 2/16/2010 with a diagnosis chronic obstructive pulmonary disease, methicillin resistant staphylococcus aureus, and end-stage renal disease and expired on 3/4/2010. A document in the record titled "Interdisciplinary Plan of Care" was found to have no documentation in the section for Case Management to document weekly progress towards goals. There was no documentation on the form that Case Management was involved in the interdisciplinary plan of care meetings for the patient. A document titled "Case Management Evaluation and Orientation" was dated 2/18/2010 and signed by the Case Manager. The form was completed on one side, but was left blank on the back page except for a projected discharge plan that stated, "Home with HHC and Change O2 Company". There was no indication in the documentation how the discharge plan was formulated or evidence of a complete assessment of patient/family needs.

Sample patient #8 was admitted to the hospital 2/22/2010 with a diagnosis of respiratory failure, chronic obstructive pulmonary disease, and central vascular accident and expired on 3/10/2010. A document in the record titled "Interdisciplinary Plan of Care" was found to have no documentation in the section for Case Management to document weekly progress towards goals. There was no documentation on the form that Case Management was involved in the interdisciplinary plan of care meetings for the patient. A document titled "Case Management Evaluation and Orientation" was dated 2/25/2010 and signed by the Case Manager. The form was completed on one side, but was left blank on the back page where a projected discharge plan was required. A document in the record titled "Discharge Planning Evaluation" was dated 2/25/2010 and signed by the case manager. The sections titled "Community Referrals, Identified Problems Relative to Discharge Planning, Other Agency/Community Services Used in Past and/or Needed for Post Discharge, and Goals Related to Discharge Plan" were all blank although the first side of the document indicated that a case manager identified the patient would need assistance with total care, transfer/mobility, dressing and/or bathing, toileting, meal prep/feeding, and activities of daily living.

Sample patient #9 was admitted 3/5/2010 with a diagnosis of pneumonia and was transferred to rehabilitation hospital on 3/24/2010. The "Interdisciplinary Plan of Care" document in the record stated on the top of each of the pages "Initiated on Admission. Updated every week and as needed". The section for Case Management had entries only on 3/8/2010 and on 3/23/2010, leaving no evidence of documentation from Case Management for 14 consecutive days.

Sample patient #14 was admitted 4/30/2010 with a diagnosis of a stage IV pressure ulcer and expired on 6/6/2010. A document in the record titled "Interdisciplinary Plan of Care" stated on the top of each of the pages "Initiated on Admission. Updated every week and as needed". The section for Case Management had entries on 5/3/2010 and on 5/10/2010, leaving no evidence of documentation from Case Management for 26 consecutive days.

Sample patient #17 was admitted 5/6/2010 with a diagnosis of chronic obstructive pulmonary disease and colonic ileus and discharged home with home health on 5/25/2010. A document in the record titled "Interdisciplinary Plan of Care" stated on the top of each of the pages "Initiated on Admission. Updated every week and as needed". The section for Case Management had only one entry which was on 5/10/2010, leaving no evidence of documentation from Case Management for 14 consecutive days. A document titled: "Case Management Evaluation and Orientation" was dated 5/10/2010 and signed by the Case Manager. The section titled projected discharge plan was left blank, but it was indicated in the section titled "Are there additional educational needs by patient or family?" that home oxygen was anticipated. A document titled "Discharge Planning Evaluation" was dated 5/10/2010 and signed by the Case Manager. There was no indication of any community referrals or details of any discharge plans although the first page of the document indicated the patient would need assistance with dressing and/or bathing and activities of daily living. The patient was discharged home with a home health agency providing home care.

Sample patient #20 was admitted 5/25/2010 with a diagnosis of acute osteomyelitis and a decubitus ulcer of the toe and was discharged home with home health care on 6/10/2010. A document in the record titled "Interdisciplinary Plan of Care" was found to have no documentation in the section for Case Management to document weekly progress towards goals. There was no documentation on the form that Case Management was involved in the interdisciplinary plan of care meetings for the patient.

Sample patient #21 was admitted 5/26/2010 with a diagnosis of sepsis and respiratory insufficiency and was discharged to a skilled nursing facility on 6/10/2010. A document in the record titled "Interdisciplinary Plan of Care" was found to have no documentation in the section for Case Management to document weekly progress towards goals. There was no documentation on the form that evidenced Case Management was involved in the interdisciplinary plan of care meetings for the patient.

Sample patient #22 was admitted 5/28/2010 with a diagnosis of sepsis, urinary tract infection and meningitis versus ventriculitis and transferred to a hospital for chemotherapy on 6/1/2010. A document in the record titled "Interdisciplinary Plan of Care" was found to have no documentation in the section for Case Management to document weekly progress towards goals. There was no documentation on the form that Case Management was involved in the interdisciplinary plan of care meetings for the patient. There was also no documentation by case management on any form of discharge planning occurring during the patient's stay.

Sample patient #25 was admitted 4/1/2010 with renal failure and was discharged home on 4/16/2010. A document in the record titled "Interdisciplinary Plan of Care" stated on the top of each of the pages "Initiated on Admission. Updated every week and as needed". The section for Case Management had only one entry which was on 4/2/2010, leaving no evidence of documentation from Case Management for 14 consecutive days.

The hospital's Policies and Procedures were reviewed on 6/22/2010.

A hospital policy titled: "Work Flow: Case Management" stated in pertinent parts:
"Admission
Within 72 hours of admission (goal of 24 hours on weekday admissions)...
...d. Meet with each patient and family.
e. Complete the Case Management admission form
f. Discuss:
a. initial treatment plan including anticipated length of stay,
b. potential discharge plans and target D/C date,
c. the need for alternate options for discharge plan...
...Weekly Functions
a. Review and discuss Plan of Care, discharge plan and target D/C date w/ interdisciplinary team, patient and family. Do not allow one plan for discharge to fail before considering an alternative. Alternate plans for discharge must be considered and at least two plans should be in the works at all times. Coordinate patient and family education. Ensure education is complete and documented appropriately by each service...
...d. Document in the progress notes, at least weekly patient's progress toward goals and information regarding patient/family conferences, D/C planning arrangements, barriers to discharge and communication w/ all health disciplines...
...Discharge Planning
a. The Case Manager is the coordinator of discharge planning:
i. Discharge planning should begin upon admission..."

A hospital policy titled: "Discharge Planning and Evaluation" stated in pertinent parts:
"...Case Management is responsible for appropriate discharge planning for all patients. The Case Manager assigned to the individual patient case completes a Discharge Planning Evaluation within 72 hours of admission.
1. Discharge planning services and goals are established and begun upon admission into the facility. Services are designed through concerted efforts of the interdisciplinary team, medical staff, patient and supportive others..."

An interview was conducted with a Case Manager on 6/22/2010 at approximately 12:45 PM. S/he stated that discharge planning usually begins on the first day of admission and that goals are discussed at that time with the patient and/or the patient's family. S/he stated that a Case Manager participates in the interdisciplinary care planning meetings weekly and updates the patient or patient's family on anticipated needs such as skilled nursing facility placement, physical/occupational therapy, or home healthcare. S/he stated that initial goals would be documented upon admission on the Interdisciplinary Plan of Care (IPC) form, but the ICP may not have weekly updates documented. S/he stated that, in the case of Sample patient #22, the IPC form "should have been filled out" in the Case Manager section. S/he then looked at the record and stated that she did not see any documentation in the chart by case management. S/he stated that discharge planning was documented on multiple different forms and was inconsistent at times since there are many places to document similar information. S/he stated that forms could not be changed by the hospital to adapt to the hospital's needs as the forms are controlled by the corporation that owns the hospital. S/he stated that some staff may not fill out the same forms and that there is a progress note that is sometimes utilized for updates and discharge planning.

In summary, the hospital failed to ensure documentation of discharge planning and weekly updates (as required by hospital policies) were present in nine (Sample patients #7, 8, 9, 14, 17, 20, 21, 22 & 25) of 30 patient medical records.

Based upon staff interview and a review of the hospital's Policies and Procedures the hospital failed to reassess the hospital's discharge planning process on periodically including reviewing discharge plans to ensure that the plans were responsive to the patient's discharge needs.

The findings were:

A hospital policy titled: "Case Management Organization" stated in pertinent parts:
"...6. Performance Improvement
The quality and appropriateness of case management services provided to patient will be reviewed regularly and evaluated by established quality control mechanisms...
...The Director of Quality Management/Case Management (or designee) will be responsible for assuring that a review and evaluation of the appropriateness and effectiveness of case management services is accomplished in a timely manner. The review and evaluation will be performed at least four times each year, and will involve the use of the medical record and other pre-established criteria. Such criteria will relate at least to the indications for providing case management services and to the effectiveness of the transfer of patients to long-term facilities and to home placement with supportive services, and to crisis intervention in the emergency services...Results of evaluations will be used in departmental planning to continually improve the case management process."

On 6/23/2010, at approximately 1:45 PM, an interview with the Director of Quality Management revealed that the review of Case Management did not include a review of appropriate and required documentation. S/he stated that the hospital has studied early and late discharges and had identified factors that contributed to these variations in discharge expectations. S/he stated that full reviews of discharge planning documentation would be implemented.

Based on review of facility documents and meeting minutes, the facility failed to systematically incorporate findings from the complaint/grievance process into quality assurance activities. The facility had a system in place that relied on numerous staff conducting grievances activities, which were documented in multiple locations. No centralized and comprehensive tracking system was in place to ensure that all complaints/grievances were thoroughly investigated and resolved, or referred to outside entities. The lack of a centralized and comprehensive tracking system created the potential for important investigative findings to be overlooked in facility quality improvement activities. There was no evidence that the facility was evaluating complaints/grievances with trend analysis and creating/implementing action plans to improve patient care delivery. The failure created the potential for negative patient outcomes.

The findings were:

1. Review of the meeting minutes on 6/22/10 for the quality assurance committee and on 6/30/10 for examples of the daily "flash" report meetings revealed no evidence that complaints/grievances were being investigated in an attempt to determine if personnel, training, policy/procedure or others system problems contributed to the complaint/grievance. There was no evidence of routine review of complaints/grievances in quality assurance meeting minutes.

2. Refer to Tag A 0119 for additional findings related to the operation of the grievance process.

Based on review of meeting minutes/agendas, facility internal documents, and staff interviews, the facility failed to ensure each department, whether in-house or contracted, was thoroughly evaluated for quality assessment and performance improvement. This facility did not ensure that priorities for improved quality of care were addressed and implemented, which created the potential for a negative patient outcome.

The findings were:

On 6/23/2010 the facility's policy titled "Responsibilities: Department Services Directors/Qualities of the Manager" was reviewed. The "Procedure" portion of the policy stated the following, in pertinent part:
"Department, Managers, Coordinators and/or Supervisors, in accordance with an approved organization chart and criteria based job descriptions and performance evaluations shall be responsible for managing their areas. This includes but is not limited to the following:
...Ongoing performance improvement activities including quality control to facilitate improved outcomes and meeting for exceeding customer expectations.
Provision of department-specific orientation and education..."

1. The facility's "ANNUAL CONTRACT SERVICE EVALUATION" was reviewed on 6/23/2010 at approximately 12:30 p.m., in the presence of the CEO (Chief Executive Officer) Annual review for 2010 was done by the CEO on 5/26/10 and 6/1/10. The evaluation for each contract consisted of three questions and then a score between one and five. The three questions were:
1) Provided services in a safe and effective manner
2) Meet quality of series expected by hospital
3) Meets expectation and terms of contract
After the CEO reviewed the contracts, s/he took them to the Governing Body meeting for final approval. When the CEO was asked how s/he formulated the ratings for each contract, s/he said that s/he attended all the meetings throughout the year and was aware of the happenings in the facility. When asked for further data supporting the evaluations, s/he could not provide any. The evaluations for all contracted services reviewed were rated at "4," which represented "above average," as opposed to the "5," which would have represented "excellent." The CEO had no internal or external reports or evaluations of quality to review prior to assigning the rating of "4." The only contract with any supporting data was a contracted renal dialysis department that provided external quality review data complied by it's parent corporation.

2. The Rehabilitation (Rehab) Department's staff meeting minute/agenda records were provided by the Director of Rehab and reviewed on 6/23/2010. The Rehab Department had one meeting in 2010, dated February 25. The department had three meetings in 2009 and three in 2008. Each meeting record had a list of topics, which was not greater than five, and a portion where each staff member would initial. Meeting minutes were not kept for any of the meetings.

3. The Nursing Supervisor meeting minute/agenda records for 2010 were provided by the Chief Clinical Officer and reviewed on 6/23/2010. The meetings for 2010 were held on the following dates: January 20, February 17, May 19, and June 16. The meeting record contained a list of members and two meetings also had a list of guests. There was no portion in which the members and/or guests signed in, so the attendance of the meetings was unclear. The "Members" were listed and included the Nursing Supervisors, Chief Clinical Officer, Chief Executive Officer, and Human Resources Director, but not staff nurses. The record contained a detailed agenda, but meeting minutes were not kept for the first three meetings of the year. An email sent to the Director of Quality Management from the Chief Executive Officer, with an original date of June 20, was provided. It contained detailed meeting minutes for the June 16 meeting which addressed all the topics listed on the agenda.

4. In an interview with the Director of Quality Management (DQM) on 6/23/2010 at approximately 1:50 p.m., s/he stated that the facility holds meetings every other week on pay day. S/he stated that attendance is voluntary but open to all staff from all departments of the facility, including Environmental Services, Nursing, Respiratory, and Rehab. The DQM directed these meetings and stated that most of the time there has been a good turnout of about 16-20 people. During this meeting, education on facility changes and updates have been provided. The DQM did not have any record of attendance to these meetings, agendas, or meeting minutes.

5. An interview with the Director of Respiratory was conducted on 6/22/2010 at approximately 1:30 p.m. When asked about department meetings, s/he stated "Most of my meetings are informal or one on one... I don't have records of my meeting dates, but I try to have them every couple months... I communicate a lot by my communication book..." Review of the respiratory department's meeting records revealed only one staff meeting for 2010, dated January 7. The record was a hand written agenda and without meeting minutes but had an attached sign-in for record of staff attendance. Further meeting record review revealed several disorganized handwritten agendas, several typed agendas, and sign-in forms. It was unclear how many meetings were held in 2009 as dates of the agendas and sign-ins were not consistent. Review of the Director of Respiratory's communication book revealed numerous entries over the past few years. Entries were not consistently signed, therefore it is unclear if the entries were all made by the director or by other staff. Each entry was initialed by the other staff members in the department, signifying that they had been read. The entries were handwritten and often contained personal opinions and emotional reactions instead of constructive comments and legible educational updates as would be expected within a professional department of a hospital.

In summary, the facility failed to evaluate each department and contract for quality assessment and performance improvement in accordance with its own policy. Contract evaluation done by the CEO did not contain details regarding quality control evaluation in order to facilitate improved outcomes. In addition, the facility's own departments of Rehabilitation Services, Respiratory Care, and Nursing Services did not evaluate polices, processes, and equipment and maintain records of such evaluations and further changes and implementation. This failure did not facilitate effective and prompt review of each service provided to patients.

Based on staff interviews and facility tour and review of the hospital's Policies and Procedures, the hospital failed to ensure that unauthorized individuals could not gain access to or alter patient records. This failure created the potential for breaches of patient confidentiality and a potential lack of medical record authenticity integrity.

The findings were:

An interview was conducted on 6/21/2010 at approximately 2:00 PM with the Medical Records Manager. S/he stated that the medical records for discharged patients are stored in the medical records office as well as in a storage closet on the unit where the hospital is located. S/he also stated that records are kept in a storage area in the basement of the building. S/he stated that the medical records office is secured with a keypad entry and that the code is known to only three people: the CEO, the Medical Records Manager, and another employee (an Occupational Therapist) that works in the medical records department. S/he stated that the code for the door is changed every six to nine months. S/he stated that the record storage closet on the floor the hospital occupies has only two keys and that the keys are held by the Medical Records Manager and the Materials Manager.

An interview was conducted on 6/21/2010 at approximately 2:20 PM with staff member sample #1. It was revealed that patient records from 2007 and 2008 were stored in a locked room in the basement of the facility. S/he stated that keys to that room were in the possession of the hospital's CEO, Medical Records Manager, and the Head of Environmental Services for the Hospital. The staff member also stated that several other personnel from the building's owner also had keys to the storage area in the basement.

An interview was conducted on 6/21/2010 at approximately 3:15 PM with staff member sample #5. It was revealed that the staff member was aware that personnel from the building's owner had keys to the medical records storage in the basement of the building. S/he stated that they had a key so that they would have access for plumbing of the building should an emergency arise. An additional interview was conducted on 6/21/2010 at approximately 3:45 PM with staff member sample #5. It was revealed that the building's owner's personnel had keys to "everything" on the unit where the hospital was located "except pharmacy". S/he stated, "I cannot say about medical records, but they (the building's owner) were adamant about having a key to that (the basement storage) room."

An interview was conducted on 6/21/2010 at approximately 4:00 PM with staff member sample #6. The staff member stated that the building's owner and the personnel of the building's owner did not have keys to the medical record storage room.

An interview was conducted on 6/22/2010 at approximately 3:45 PM with staff member sample #6. The staff member stated that the hospital's Head of Environmental Services installed the door lock to the medical record storage area and that there were only 3 keys to the door. S/he stated that the keys were in the possession of the hospital's CEO, Medical Records Manager and the Head of Environmental Services and that there were no other keys.

A review of the hospital's policies was conducted. A policy titled "Security of Records/Confidential Information/HIM Dept Key Control" stated in pertinent parts:
"Medical records shall be housed in secure areas at all times or in attendance of an authorized employee.
The medical record department will be locked at all times when not occupied and restricted to authorized employees only.
Keys to the medical record department will be restricted to
- HIM employees
- Director of Plant Engineering and Security Personnel
- Security Guard on Duty
- Administrator
- Director of Clinical Services"

Further interviews revealed:

An interview was conducted on 6/23/2010 at approximately 8:05 AM with staff member sample #1. It was revealed that s/he was sure that multiple unauthorized personnel continued to have access to the medical record storage area in the building's basement. S/he also stated that she was made aware that while the basement storage room that contained medical records was being cleaned and organized the previous day, a set of keys was discovered that contained keys that "opened all the doors" of the hospital and the building.

An interview was conducted on 6/23/2010 at approximately 8:50 AM with staff member sample #2. It was revealed that there was a key box located in the Materials Manager's office that contained keys to all of the hospital's doors (including two keys to the Medical Records department). S/he stated that keys to the key box were held by the hospital's CEO and Materials Manager.

A tour of the medical record storage room in the building's basement was conducted on three separate occasions.

On 6/21/2010, at approximately 2:55 PM, a tour of the medical record storage room in the building's basement was conducted. The room served as a storage room for multiple departments of the hospital as well as storage for facility documents and the medical records for 2007 and 2008. Some of the items contained in the room were old cabinets, bulletin boards, paint cans, fans, physical therapy equipment, scales, carpet remnants, linen carts, cleaning chemicals, maintenance tools, parking targets, bed supplies, a knife, IV poles, Christmas decorations, cardiac monitors, garbage bags, a refrigerator, a ladder and firewood. Facility documents and binders were in boxes on the floor that contained pharmacy policies, data, meeting minutes and protocols. Boxes containing medical records were on shelves with patients' full names and discharge dates facing out. There were no extra security measures or cabinets that secured the records other than the single exterior door to the storage room.

On 6/22/2010, at approximately 3:45 PM, a tour of the same storage room was conducted. The hospital's Chief Executive Officer (CEO) stated that the room had been cleaned and organized that day. It was revealed that there were more policies and facility documents in an area not accessible on the previous tour due to the items that were present at that time. The records remained stored on the shelving as noted previously with no added security measures. A tour was conducted of an additional storage room in the building's basement which was proposed as a future record storage area. The room contained a small inner room that had a separate lock. The main room contained many of the supplies and equipment that were viewed in the original medical record storage room the previous day. The inner room was equipped with shelving, but contained no records. The CEO stated that the plan was to leave records in the original room since the new proposed storage room's inner room was limited in space and would make it difficult to maneuver with the records added.

On 6/23/2010, at approximately 10:55 AM, a tour of the building's plant operation's department and interview with the building's Lead for Plant Operations (an employee of the building's owner) was conducted. At approximately 11:17 AM, the Lead for Plant Operations accompanied the surveyors to the medical record storage room in the building's basement and was readily able to open the door with a key on his/her key ring.

On 6/23/2010, at approximately 2:00 PM, the CEO of the hospital was interviewed. S/he stated that the keys previously possessed by the building's personnel were collected and now in the possession of the hospital's CEO. S/he also stated that there were no plans to replace the lock or any additional measures to secure the room to allow only hospital personnel access. S/he also stated that the keys to the medical record department were removed from the key box in the Material Manager's office.

In summary, the hospital failed to ensure that access to patient records was limited to only personnel that were authorized access. These failures lead to a potential breach of patient confidentiality and the integrity of medical record authenticity.

Based on Medical Record review, staff interview, and review of the hospital's Policies and Procedures the hospital failed to document in the patient's medical record that a list of available home health agencies was presented to the patient or the individual acting on the patient's behalf in one (Sample patient #20) of 30 records.

The findings were:

On 6/22/2010 review of the medical record of sample #20 revealed that the case manager had arranged home health for wound care upon discharge. There was no documentation in the record that a list of all qualified, available home health agencies was presented to the patient or the individual acting on the patient's behalf.

On 6/23/2010, at approximately 1:30 PM, an interview was conducted with a case manager. S/he stated that a list was provided to the patient's family. S/he confirmed that there was no documentation in the chart that the list was provided. S/he stated that the facility was not able to create a form documenting a list of choices, because the hospital's parent corporation generated all medical record forms. S/he stated that the individual hospital did not have the authority to create such a form to assist with documentation that choice was offered to a patient. S/he stated that the case managers would have to start utilizing their progress notes to document that choice was offered to patients, as required.

A hospital policy titled "Discharge Planning and Evaluation" revealed in pertinent parts:
"...5. In all cases, (except cases in which patients request otherwise), the Case Manager contacts the patient and/or family members regarding their choice of services and may also provide them with a list of services offered in his/her community. The patient and/or family preferences for follow-up services (i.e., home health, DME provider, or outpatient clinics) will be given to the Case Manager to make the appropriate arrangements..."