The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

FAIRMOUNT BEHAVIORAL HEALTH SYSTEM 561 FAIRTHORNE AVENUE PHILADELPHIA, PA March 11, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of facility documents, medical records (MR) and interview with staff (EMP) it was determined the facility failed to complete a face-to-face evaluation within one hour after the initiation of a physical hold for one of three medical records reviewed (MR10).

Findings include:

Review on March 9, 2015, of facility document "Holds and Restraints," reviewed February 2013, revealed "... Definitions: Physical Holds: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely [also named therapeutic hold, protective hold, or manual/physical restraint.] ... 5.0-Face to Face Evaluation-within one hour of the initiation of manual hold, the patient shall be evaluated in person by a physician or trained RN.

Review of MR10 physician's orders, "Physical Hold or Mechanical Restraint," revealed "Type and Length of Time of Restraint-12/16/14, at 8:17 PM-Physical Hold up to one hour ... Face to Face Assessment: time of assessment 11:40 PM."

Interview on March 10, 2015, at 10:00 AM, with EMP4 confirmed that a face-to-face evaluation was not completed, by a physician or trained RN, within one hour from the initiation of a physical hold on this patient.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure that capital expenditures were developed for at least a 3-year period.

Findings include:

Review on March 10, 2015, of "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed " ... Article V Duties and Responsibilities of the Board shall be to: 1. Be responsible for the planning, management and operational activities of the Facility ... 11. Take all reasonable steps to ensure that Facility conforms with all applicable Federal, State, and local laws and regulations and all applicable accreditation standards."

Review on March 11, 2015, of facility document "Fairmount Project List 2015," revealed a list of projects designated to be completed in 2015.

Interview on March 11, 2015, at 11:50 AM, with EMP1 confirmed the facility did not have a 3-year capital expenditures plan.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services was provided in a safe and effective manner.

Findings include:

Review on March 10, 2015, of facility policy "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed "Article IV Purpose of the Facility ... The Board shall be accountable for the safety and quality of care, treatment and services of the Facility ... Article V ... 5. Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Facility ... "

Review on March 11, 2015, of facility document "Governing Body Meeting Minutes, " dated February 10, 2015, revealed three clinical contracts for X-ray, Pharmacy and Lab services were reviewed for quality and approved.

Review on March 11, 2015, of facility document "Fairmount Behavioral Health Systems Contracts," revealed service contracts that included trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Further review of facility documents revealed no documented evidence that the facility evaluated the quality of these contracted services.

Interview on March 11, 2015, at 9:00 AM, with EMP3 confirmed that the facility's Quality Assurance Performance Improvement Program did not include the evaluation of quality for these contracted services: trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, review of facility documents, review of medical records (MR) and interview with staff (EMP) it was determined that the facility failed to protect and promote each patient's rights as evidence by: failing to maintain effective operation of the grievance process (A0119); failing to investigate and provide written resolution to patient grievances (A0123); failing to notify a minor's legal representative and obtain consent of the use of a physical restraint (A0131); failing to safeguard personal possessions, including personal information (A0142); failing to provide a safe and emotionally healthy enviornment (A0144); failing to complete a face-to-face evaluation within one hour after the initiation of a physical hold (A0178).

Cross Reference:
482.13(a)(2) Patient Rights
482.13.13(a)(2)(iii) Patient Rights
482.13(b)(2) Patient Rights
482.13(c) Patient Rights
482.13(c)(2) Patient Rights
482.13(e)(12) Patient Rights
482.41(a) Physical Environment
482.42(a)(1) Infection Control
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on review of facility documents, medical records (MR) and interview with staff (EMP) it was determined the hospital's governing body failed to maintain effective operation of the grievance process for four of four (MR25, MR26, MR27, and MR28).

Findings include:

Review on March 10, 2015, of facility document "Medical Staff Bylaws," approved February 10, 2015 revealed " ... Section 10-Ethics Committee A. Composition- the Ethics Committee is a standing committee of the Medical Staff and will consist of at least two physicians from the Active and Associate categories of the Medical Staff, one of whom will be Chair, the Chief Nursing Officer, the Patient advocate, and the Assistant Hospital Administrator for Operations ... B. Responsibilities, Duties and Authority, the responsibility, duties and authority of the Ethics Committee shall be to hear, investigate and attempt resolution of a patient grievances by: 1. conducting adhoc meetings to hear patient grievances referred by the patient advocate 2. to investigate and make a written decision within 48 hours to the patient and to place a copy on the medical record. C. Meetings-The Ethics Committee shall meet as often as necessary to accomplish its function ..."

Review on March 11, 2015, of facility policy "Patient and Family Grievances/The Role of the Patient Advocate," reviewed January 2013 revealed " ... Procedure: 3.0-The Board of Governors has designated the Ethics Committee, an ad hoc sub-committee of the Medical Executive Committee, as the body responsible for the effective operation of the grievance process and for the review and resolution of grievances, as well as a Patient Advocate, who will act as a liaison between the patient and the facility to facilitate problem-solving actions when necessary ... 4.0-the Board of Governors shall have final authority and responsibility in resolving grievances ... the Patient Ethics committee shall meet to review the grievance and render a decision in writing within 48 hours ... 5.7-The patient shall be given a copy of the complaint and final decision ... 10.0-In cases involving physician-related complaints, the President of the Medical Staff should be notified and should follow-up with the individual physician involved. ..."

Review on March 11, 2015, of facility document "Board of Governors Fourth Quarter 2014 and Annual Review 2014" revealed no documented evidence that the governing body was reviewing operations of the facility's grievance process.

Review of "Ethics Committee Meeting Minutes," from September 2014 and January 2015, revealed no documented evidence that grievances were discussed or presented to the Ethics Committee for review and resolution.

Review on March 11, 2015, of facility document "Grievance Log," dated September 2014 thru January 2015, revealed patient grievances filed for MR25, MR26, MR27, and MR28. Further review revealed MR25, MR27 and MR28 patient grievances were assigned to EMP20 for investigation and resolution; and that MR26 patient grievance was assigned to EMP21 for investigation and resolution.

Review of MR25, MR26, MR27, and MR28 patient grievances revealed no documented evidence that the grievances were reviewed by the Ethics Committee and/or the President of the Medical Staff. Further review of MR25, MR26, MR27 and MR28 revealed no documented evidence that each grievance was investigated and that each patient was provided with a written resolution, in accordance with facility policy.

Interview on March 11, 2015, at 10:00 AM, with EMP3 confirmed the grievance procedure was not followed for MR25, MR26, MR27, and MR28. EMP3 confirmed grievances are not presented and/or reviewed during Ethics Committee meetings. The hospital's governing body failed to maintain effective operation and oversight over the grievance process.

Cross Reference:
482.13(a)(2)(iii) Patient Rights
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of facility documents, medical records (MR), and interview with staff (EMP) it was determined the facility failed to investigate and provide written resolution of patient grievances for four of four medical records reviewed (MR25, MR26, MR27, and MR28).

Findings include:

Review on March 10, 2015, of facility document "Medical Staff Bylaws," approved February 10, 2015, revealed " ... Section 10-Ethics Committee ... B. Responsibilities, Duties and Authority- the responsibility, duties and authority of the Ethics Committee shall be to hear, investigate and attempt resolution of a patient grievances by: 1. conducting adhoc meetings to hear patient grievances referred by the patient advocate, 2. to investigate and make a written decision within 48 hours to the patient and to place a copy on the medical record ..."

Review on March 11, 2015, of facility policy "Patient and Family Grievances/The Role of the Patient Advocate" reviewed January 2013" revealed " ... Procedure: 3.0-The Board of Governors has designated the Ethics Committee, an ad hoc sub-committee of the Medical Executive Committee, as the body responsible for the effective operation of the grievance process and for the review and resolution of grievances, as well as a Patient Advocate, who will act as a liaison between the patient and the facility to facilitate problem-solving actions when necessary ... 4.0-the Board of Governors shall have final authority and responsibility in resolving grievances ... the Patient Ethics committee shall meet to review the grievance and render a decision in writing within 48 hours ... 5.7-The patient shall be given a copy of the complaint and final decision ... 10.0-In cases involving physician-related complaints, the President of the Medical Staff should be notified and should follow-up with the individual physician involved. ..."

Review of "Ethics Committee Meeting Minutes," from September 2014 and January 2015, revealed no documented evidence that grievances were discussed or presented to the Ethics Committee for review and resolution.

Review on March 11, 2015, of facility document "Grievance Log," dated September 2014 thru January 2015, revealed patient grievances filed for MR25, MR26, MR27, and MR28. Further review revealed MR25, MR27 and MR28 patient grievances were assigned to EMP20 for investigation and resolution; and that MR26 patient grievance was assigned to EMP21 for investigation and resolution.

Review of MR25, MR26, MR27, and MR28 patient grievances revealed no documented evidence that the grievances were reviewed by the Ethics Committee and/or the President of the Medical Staff. Further review of MR25, MR26, MR27 and MR28 revealed no documented evidence that each grievance was investigated and that each patient was provided with a written resolution, in accordance with facility policy.

Interview on March 11, 2015, at 10:00 AM, with EMP3 confirmed the grievance procedure was not followed for MR25, MR26, MR27, and MR28. EMP3 confirmed grievances are not presented and/or reviewed during Ethics Committee meetings.


Cross Reference:
482.13(a)(2) Patient Rights
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on review of facility policy, credential files (CF) and interview with staff (EMP) it was determined the facility failed to receive all required documentation for credentialing for two of 12 credential files reviewed (CF4 and CF6).

Findings include:

Review on March 12, 2015, of "Fairmount Behavioral Health System Policy/Procedure - Commonwealth of Pennsylvania Child Protective Services Law," dated August 2010, revealed " ... Policy: It is the policy of the Hospital to require Criminal History and Child Abuse History Clearances at the time of hire. The Hospital may require employees to submit Child Abuse History Clearances on a bi-annual basis thereafter. ... "

Review on March 11, 2015, of CF4 and CF6 failed to contain documentation of the Federal Bureau of Investigation (FBI) background check.

Interview on March 12, 2015, at 12:30 PM, with EMP11 confirmed that CF4 and CF6 were required to have the FBI background check. EMP11 confirmed that there was no documented evidence that the FBI background checks were completed for CF4 and CF6.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, review of facility policy and interview with staff (EMP), it was determined that the Food Service Director failed to ensure that sanitary conditions were maintained in food storage and service areas.

Findings include:

Review of facility policy "Subject: Sanitation," dated August 21, 2013, revealed "Policy: It will be the responsibility of the Food Service Director to see that sanitary conditions are maintained in food storage, preparation and food service areas. Procedure: 1. Cleaning schedules will be planned which contain all areas of equipment and food service. The cleaning duties will be performed as scheduled. Cleaning inspection checklist will be used to monitor compliance. 2. The kitchen will be cleaned by food service personnel. ... 8. Waste will be disposed of after every meal. Trash will be placed in trash can lined with plastic bag. Trash will be emptied into a dumpster which is covered and emptied periodically by the contract sanitation service. ..."
Review of facility policy "Refrigerator Cleaning," dated September 2014, revealed "Policy: All refrigerators will be kept clean and have temperatures checked daily. ... Procedure: ... 2. The night staff will clean the patient food and drink refrigerator on a weekly basis. ... 6. ... Food is to be discarded if it is not labeled with the patient ' s name, date and time ... "
Observation on March 9, 2015, at 10:00 AM, of the Children and Adolescent food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Observation on March 9, 2015, at 10:10 AM, of the Children and Adolescent food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:15 AM, of the Adult food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:20 AM, of the Adult food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Interview on March 9, 2015, at 10:20 AM, with EMP27 confirmed that there was thick unknown film substances and multiple food particles located in the Children and Adolescent food services line and dining areas; and in the Adult food service lines and dining areas.

Observation on March 9, 2015, at 10:30 AM, of the Kitchen's Dry Storage Room revealed a thick unknown film substance located on the shelving units.

Interview on March 9, 2015, at 10:30 AM, with EMP27 confirmed that there was thick unknown film substance located on the shelving units.

Observation on March 9, 2015, at 10:45 AM, of the Kitchen's storage racks revealed on the bottom of three of the storage racks metal trays, pots, and pans were being stored, where the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Interview on March 9, 2015, at 10:45 AM, with EMP27 confirmed that the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Observation on March 9, 2015, at 10:50 AM, of the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

Interview on March 9, 2015, at 10:50 AM, with EMP27 confirmed the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

Observation on March 9, 2015, at 11:15 AM, of the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.

Interview on March 9, 2015, at 11:15 AM, with EMP15 confirmed the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.
Observation on March 9, 2015, at 11:00 AM, of D Pod nourishment room revealed the following: a black substance along the baseboards, under the refrigerator and around the base of the trash can, an unlabeled and uncovered salad and an unlabeled Styrofoam container of food in the refrigerator, a towel with a large orange stain on the bottom shelf of the refrigerator, and an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers. The cabinet under the sink had a broken handle and no laminate noted on the edges of the cabinet door.
Interview on March 9, 2015, at 11:30 AM, with EMP2 confirmed the above findings.
Observation on March 9, 2015, at 11:35 AM, of E Pod nourishment room revealed the following: an unlabeled Styrofoam container of food, an unlabeled and uncovered bowl of cereal on the counter, a black substance around the bottom of the ice/water dispenser, an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers, and a trash can with a broken lid and dried substances located on the outside of the trash can.

Interview on March 9, 2015, at 11:35 AM, with EMP2 confirmed the above findings.

Observation on March 9, 2015, at approximately 11:45 AM of D and E Pod's dining area revealed a black substance around the bottom of the milk dispenser, a black substance along the baseboards and along the bottom of all doors and black substance around a broken drain located below the serving line.

Interview on March 9, 2015, at 11:45 AM, with EMP2 confirmed the above findings.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of facility policy and interview with staff (EMP), it was determined that the facility failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

Review of facility policy "Cleaning Baseboards," dated January 2013, revealed "Policy: The Support Services Department will clean the baseboards on a regular basis. ... "

Review of facility policy "Cleaning Waste Container," dated January 2013, revealed "Policy: The Support Services Department will clean waste container on a regular basis. ... "

Review of facility policy "Cleaning Water Fountains," dated January 2013, revealed "Policy: The Support Services Department will clean water fountains on a daily basis. ... 3. Wipe all surfaces including the fountain head, jet guard ... "

Review of facility policy "Cleaning Common Areas" dated January 2013, revealed "Policy: The Support Services Department personnel will clean all common areas at FBHS ... "

Review of facility policy "Cleaning Patient Room - Occupied, " dated January 2013, revealed "... All patient rooms will be cleaned on a daily basis. ... Damp dust ... with a hospital approved germicidal solution ... "

Review of facility policy "Support Services," dated January 2013, revealed "The Support Services Department will clean all patient rooms as per the following procedure when a patient has been discharged or transferred ...Damp dust over ...cabinets ...Mop floor using a hospital approved germicidal solution according to procedure ... "

Review of facility policy "Wet Mopping," dated January 2013, revealed "Policy: It is the policy of Fairmount Behavioral Health System to have all the floors cleaned on a regular basis. ... "

Review of facility policy "Subject: Pest Control," dated August 21, 2013, revealed "Policy: A program for the eradication and prevention of infestation by rodents and insects will be carried, including a contract to treat the kitchen ... Procedure ... 4. Rodents (Rats and Mice) ... a) Eliminate any holes in structure where they can enter. ..."

Review of facility document "Battery-Powered Egress Lighting & Emergency Power Supply-Systems Minimum Required Testing & Explanatory Materials," no date, revealed " ... Battery-powered Egress Lighting, Emergency Generators and Automated Transfer Switches must be tested to meet the minimum requirements ... These minimum requirements are as follows: ... EP.5 - The monthly for diesel-powered generators are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer's recommended prime movers ' exhaust gas temperature. ... If your diesel-powered generator* is unable to meet the 30% rule during any monthly test, you have two options: .... b. Test once every 12 months using supplemental (dynamic or static) loads ..."

1. N1 Patient Care Unit
Observation on March 9, 2015, at 10:00 AM, of N1 Patient Care unit revealed the entrance hallway was splattered with a dried substance. The hallway located between patient rooms 200 and 232 had a heavy layer of a dark gray substance along the floor baseboard. The flooring of the hallway was splattered with a dried light brown-gray substance throughout the unit.
In patient rooms the following was observed: Room 200- bathroom with a malodor and no hand soap,Room 201- bathroom flooring has a light gray haze and a heavy build-up of brown/white debris around base of toilet, Room 203- the bed frame had a shiny dried substance on the two side panels of the bed, Room 204- there was splatters of a dried red substance observed on the hallway wall outside of the room, Room 205- there was a broken bathroom tile and the bedroom wall had peeling paint and scratch marks, Room 206- plumbing fixture is heavily soiled with a white/reddish brown substance, Room 232- the floor had a light gray haze between the bathroom door and the bedroom entry door.

Observation of the N1 medication room revealed the floor and counter work space was heavily cluttered with books and non-clinical supplies. Floor is heavily soiled with splatters of unidentified substances. Medication cart cassettes are heavily soiled with a gray substance and covered with tape.
Observation of the Mechanical room revealed three metal shelving units with linen stored on the shelves and four large gray laundry bins. Further observation revealed a ceiling access panel that was open and an attached ladder that extended from the floor to the opening in the ceiling. The ladder was blocked with the four laundry bins.
Interview on March 9, 2015, 10:25 PM, with EMP4 confirmed the mechanical room is also the storage room for the laundry.
Interview on March 9, 2015, at 10:45 AM, with EMP9 confirmed housekeeping is on the unit daily performing housekeeping duties.

2. A and B Pod Nursing Care Units

Observation on March 9 and 10, 2015, of A Pod, revealed that in Room 1, 2 and 3 there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Observation on March 9 and 10, 2015, of B Pod revealed that in Room 2, 4 and 5, there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Interview on March 10, 2015, at 9:30 AM, with EMP15 confirmed that the dust and paper debris was present. Further interview at 10:52 AM, with EMP15 confirmed that to adequately clean the areas that the beds would need to be unfastened from the wall and caulk applied in the joint between the bed and wall and there was no documentation that proved that had been done.

3. D Pod Nursing Care Unit

Observation on March 9, 2015, at 11:15 AM, of room number 190, revealed a black substance on the floors, especially along the baseboards.

Observation March 9, 2015, at 11:20 AM, of the seclusion/quiet room revealed a two inch hole in the mattress and dust on the floor. A broken lock was noted on the door to the seclusion room as well.

Observation on March 9, 2015, at 11:25 AM, of the D Pod patient laundry room revealed loose dust on the floor between the washer and dryer.

Observation on March 9, 2015, at 11:30 AM, of the D Pod hallway revealed a water fountain with a white/green substance build up noted around the base of the water dispenser.

Interview on March 9, 2015 at 11:30 AM, with EMP2 confirmed the above findings.

Interview on March 10, 2015, at approximately 2:00 PM, with EMP28 indicated that the laundry area was cleaned daily.

4. N2 Patient Care Unit

Observations on March 9, 2015, at 11:30 AM, of N2 Patient Care Unit revealed Rooms 154 through 157 included black marks on the floors in the bedrooms and bathrooms, paint chips with exposed wallboard, soap dispensers were empty, sharp wood was exposed on doors and the shower entrance was black at corners. Observation of Rooms 186 through 188 included blackened areas on the floor and entrance to shower at the corners.

Interview on March 9, 2015, at 12:00 PM, with EMP4 confirmed the above findings.

5. N5 Patient Care Unit

Observation on March 9, 2015, at 12:30 PM, of N5 Patient Care Unit revealed Room 122, 123, 125, 127, 129, 131, 133 included blackened ares on the bedroom and bathroom floors and shower entrance, mildew on shower curtains, water puddles on BR floors, paint chippings along doorways. Room 133 was observed to have orange tinged areas in the ADA shower.

Observation on March 9, 2015, at 12:30 PM, revealed rooms 124, 126, 128, 130 included light black residue on shower curtains, around the sink faucets, and the base of the toilets.

Interview on March 9, 2015, at 1:00 PM, with EMP17 revealed that Room 133 had been cleaned and mopped.

Further observation of Room 133, after EMP17 confirmed the room was cleaned, revealed dirt and debris remained around the bedside table next to the bed where a patient was sleeping.

Observation of the N5 Housekeeping closet revealed that there was a ceiling tile not intact near the vent. The floor sink was heavily soiled with a thick black substance. Further observation revealed the shelving in the area was covered in a heavy accumulation of dust.

Observation of the N5 patient hallway revealed black scuff marks along the entire baseboard on both sides of the hallway between rooms 125 and 127 and that there was a black substance surrounding the individual tiles and where the tile meets baseboard.

Interview on March 9, 2015, at 12:50 PM, with EMP4 confirmed the above findings.

6. N3 Patient Care Unit

Observation on March 11, 2015, at 9:30 AM, of the N3 Psychiatric Nursing Unit's room 183, revealed a thick black buildup of unknown substances around the baseboards of the room.

Interview on March 11, 2015, at 9:30 AM, with EMP5 confirmed room 183 had a thick black buildup of unknown substances around the baseboards of the room.

7. N1 Patient Care Unit

Observation on March 11, 2015, at 10:00 AM, of the N1 Psychiatric Nursing Unit's Laundry Storage room revealed an approximate 18 inch by 12 inch hole in the wall.

Interview on March 11, 2015, at 10:00 AM, with EMP5 confirmed the Laundry Storage room had an approximate 18 inch by 12 inch hole in the wall.

8. N5 Nursing Care Unit
Observation on March 11, 2015, of room 133B revealed the bottom shelf of a cabinet contained dust. The floor had visible loose dirt and debris. The perimeter of the baseboards had an accumulation of dirt and there was a black/brown substance in the corners of room.
Interview on March 10, 2015, at 2:, with EMP26 confirmed the patient was discharged from 133B and the room was cleaned. EMP26 confirmed that above findings and that the room was not properly cleaned.

9. Patient Care Coordinator (PCC) Office

Observation on March 9, 2015,at 1:00 PM, of the Patient Care Coordinator Office [supervisor office used by multiple staff], located near the cafeteria, revealed an office that was cluttered; there was one mouse trap in a corner of the room near the door, patient inventory was stored in a file cabinet; there were numerous boxes stored on top of each other that contained shift to shift reports, a box of patient valuables was noted on the floor that included discharged patients bagged inventory that was left behind and that the facility was storing.

Interview on March 9, 2015, at 1:15 PM, with EMP4 confirmed the above findings in the PCC Office.

10. Basement area

Observation on March 11, 2015, at 10:30 AM, of the Hospital's basement storage room revealed approximately 20 cardboard boxes that were stored on the floor.

Interview on March 11, 2015, at 10:30 AM, with EMP5 confirmed the cardboard boxes should not be directly stored on the floor.

11. Emergency Power

Review of the facility's "Emergency Power System," binder revealed the facility's last generator annual load test occurred on April 23, 2013.

Interview on March 11, 2015, at 12:00 PM, with EMP5 confirmed the facility's diesel-powered generator is unable to meet the 30% rule during monthly tests and that the generator is to be tested every 12 months using supplemental (dynamic or static) loads. EMP5 confirmed the diesel-powered generator's annual load test was last tested [DATE], which was greater than 12 months from the present date.



Cross Reference:
482.13(c)(2) Patient Rights
482.42 Infection Control
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, review of facility policy and interview with staff (EMP), it was determined the Infection Control Officer failed to implement a comprehensive hospital-wide infection prevention and control program in order to ensure a sanitary environment.
Findings include:
Review of facility policy "Support Services Policy and Procedure," dated January 2013, revealed, "The Support Services Department will clean all patient rooms as per the following procedure when a patient has been discharged or transferred ...Damp dust over ...cabinets ...Mop floor using a hospital approved germicidal solution according to procedure ... "
1. Dinning and Kitchen Areas
Observation on March 9, 2015, at 10:00 AM, of the Children and Adolescent food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Observation on March 9, 2015, at 10:10 AM, of the Children and Adolescent food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:15 AM, of the Adult food dining area revealed a thick unknown film substance and multiple food particles located underneath the beverage station.

Observation on March 9, 2015, at 10:20 AM, of the Adult food service line revealed a thick unknown film substance and multiple food particles located underneath the food service line.

Interview on March 9, 2015, at 10:20 AM, with EMP27 confirmed that there was thick unknown film substances and multiple food particles located in the Children and Adolescent food services line and dining areas; and in the Adult food service lines and dining areas.

Observation on March 9, 2015, at 10:30 AM, of the Kitchen's Dry Storage Room revealed a thick unknown film substance located on the shelving units.

Interview on March 9, 2015, at 10:30 AM, with EMP27 confirmed that there was thick unknown film substance located on the shelving units.

Observation on March 9, 2015, at 10:45 AM, of the Kitchen's storage racks revealed on the bottom of three of the storage racks metal trays, pots, and pans were being stored, where the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Interview on March 9, 2015, at 10:45 AM, with EMP27 confirmed that the bottom of racks were open shelves, which allowed for contamination when wet mopping.

Observation on March 9, 2015, at 10:50 AM, of the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

Interview on March 9, 2015, at 10:50 AM, with EMP27 confirmed the Kitchen's loading dock revealed various amounts of food related items, unknown packages, and garbage located around the dumpsters.

2. N4 Patient Care Unit

Observation on March 9, 2015, at 11:15 AM, of the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.

Interview on March 9, 2015, at 11:15 AM, with EMP15 confirmed the N4 Psychiatric Unit's patient refrigerators revealed a thick unknown film substance located on the refrigerator shelving units.
3. D and E Pod Nursing Care Unit
Observation on March 9, 2015, at 11:00 AM, of D Pod nourishment room revealed the following: a black substance along the baseboards, under the refrigerator and around the base of the trash can, an unlabeled and uncovered salad and an unlabeled Styrofoam container of food in the refrigerator, a towel with a large orange stain on the bottom shelf of the refrigerator, and an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers. The cabinet under the sink had a broken handle and no laminate noted on the edges of the cabinet door.
Interview on March 9, 2015, at 11:30 AM, with EMP2 confirmed the above findings.
Observation on March 9, 2015, at 11:35 AM, of E Pod nourishment room revealed the following: an unlabeled Styrofoam container of food, an unlabeled and uncovered bowl of cereal on the counter, a black substance around the bottom of the ice/water dispenser, an orange sticky substance on the bottom shelf of the refrigerator, as well as in the bottom drawers, and a trash can with a broken lid and dried substances located on the outside of the trash can.

Interview on March 9, 2015, at 11:35 AM, with EMP2 confirmed the above findings.

Observation on March 9, 2015, at approximately 11:45 AM of D and E Pod's dining area revealed a black substance around the bottom of the milk dispenser, a black substance along the baseboards and along the bottom of all doors and black substance around a broken drain located below the serving line.

Interview on March 9, 2015, at 11:45 AM, with EMP2 confirmed the above findings.

4. N1 Patient Care Unit
Observation on March 9, 2015, at 10:00 AM, of N1 Patient Care unit revealed the entrance hallway was splattered with a dried substance. The hallway located between patient rooms 200 and 232 had a heavy layer of a dark gray substance along the floor baseboard. The flooring of the hallway was splattered with a dried light brown-gray substance throughout the unit.
In patient rooms the following was observed: Room 200- bathroom with a malodor and no hand soap,Room 201- bathroom flooring has a light gray haze and a heavy build-up of brown/white debris around base of toilet, Room 203- the bed frame had a shiny dried substance on the two side panels of the bed, Room 204- there was splatters of a dried red substance observed on the hallway wall outside of the room, Room 205- there was a broken bathroom tile and the bedroom wall had peeling paint and scratch marks, Room 206- plumbing fixture is heavily soiled with a white/reddish brown substance, Room 232- the floor had a light gray haze between the bathroom door and the bedroom entry door.
Observation of the N1 medication room revealed the floor and counter work space was heavily cluttered with books and non-clinical supplies. Floor is heavily soiled with splatters of unidentified substances. Medication cart cassettes are heavily soiled with a gray substance and covered with tape.
Observation of the Mechanical room revealed three metal shelving units with linen stored on the shelves and four large gray laundry bins. Further observation revealed a ceiling access panel that was open and an attached ladder that extended from the floor to the opening in the ceiling. The ladder was blocked with the four laundry bins.
Interview on March 9, 2015, 10:25 PM, with EMP4 confirmed the mechanical room is also the storage room for the laundry.
Interview on March 9, 2015, at 10:45 AM, with EMP9 confirmed housekeeping is on the unit daily performing housekeeping duties.

5. A and B Pod Nursing Care Units

Observation on March 9 and 10, 2015, of A Pod, revealed that in Room 1, 2 and 3 there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Observation on March 9 and 10, 2015, of B Pod revealed that in Room 2, 4 and 5, there was large amounts of grey dust and paper debris between the headboard and wall of the beds.

Interview on March 10, 2015, at 9:30 AM, with EMP15 confirmed that the dust and paper debris was present. Further interview at 10:52 AM, with EMP15 confirmed that to adequately clean the areas that the beds would need to be unfastened from the wall and caulk applied in the joint between the bed and wall and there was no documentation that proved that had been done.

6. D Pod Nursing Care Unit

Observation on March 9, 2015, at 11:15 AM, of room number 190, revealed a black substance on the floors, especially along the baseboards.

Observation March 9, 2015, at 11:20 AM, of the seclusion/quiet room revealed a two inch hole in the mattress and dust on the floor. A broken lock was noted on the door to the seclusion room as well.

Observation on March 9, 2015, at 11:25 AM, of the D Pod patient laundry room revealed loose dust on the floor between the washer and dryer.

Observation on March 9, 2015, at 11:30 AM, of the D Pod hallway revealed a water fountain with a white/green substance build up noted around the base of the water dispenser.

Interview on March 9, 2015 at 11:30 AM, with EMP2 confirmed the above findings.

Interview on March 10, 2015, at approximately 2:00 PM, with EMP28 indicated that the laundry area was cleaned daily.

7. N2 Patient Care Unit

Observations on March 9, 2015, at 11:30 AM, of N2 Patient Care Unit revealed Rooms 154 through 157 included black marks on the floors in the bedrooms and bathrooms, paint chips with exposed wallboard, soap dispensers were empty, sharp wood was exposed on doors and the shower entrance was black at corners. Observation of Rooms 186 through 188 included blackened areas on the floor and entrance to shower at the corners.

Interview on March 9, 2015, at 12:00 PM, with EMP4 confirmed the above findings.

8. N5 Patient Care Unit

Observation on March 9, 2015, at 12:30 PM, of N5 Patient Care Unit revealed Room 122, 123, 125, 127, 129, 131, 133 included blackened ares on the bedroom and bathroom floors and shower entrance, mildew on shower curtains, water puddles on BR floors, paint chippings along doorways. Room 133 was observed to have orange tinged areas in the ADA shower.

Observation on March 9, 2015, at 12:30 PM, revealed rooms 124, 126, 128, 130 included light black residue on shower curtains, around the sink faucets, and the base of the toilets.

Interview on March 9, 2015, at 1:00 PM, with EMP17 revealed that Room 133 had been cleaned and mopped.

Further observation of Room 133, after EMP17 confirmed the room was cleaned, revealed dirt and debris remained around the bedside table next to the bed where a patient was sleeping.

Observation of the N5 Housekeeping closet revealed that there was a ceiling tile not intact near the vent. The floor sink was heavily soiled with a thick black substance. Further observation revealed the shelving in the area was covered in a heavy accumulation of dust.

Observation of the N5 patient hallway revealed black scuff marks along the entire baseboard on both sides of the hallway between rooms 125 and 127 and that there was a black substance surrounding the individual tiles and where the tile meets baseboard.

Interview on March 9, 2015, at 12:50 PM, with EMP4 confirmed the above findings.

9. N3 Patient Care Unit

Observation on March 11, 2015, at 9:30 AM, of the N3 Psychiatric Nursing Unit's room 183, revealed a thick black buildup of unknown substances around the baseboards of the room.

Interview on March 11, 2015, at 9:30 AM, with EMP5 confirmed room 183 had a thick black buildup of unknown substances around the baseboards of the room.

10. N5 Nursing Care Unit

Observation on March 11, 2015, of room 133B revealed the bottom shelf of a cabinet contained dust. The floor had visible loose dirt and debris. The perimeter of the baseboards had an accumulation of dirt and there was a black/brown substance in the corners of room.
Interview on March 10, 2015, at 2:, with EMP26 confirmed the patient was discharged from 133B and the room was cleaned. EMP26 confirmed that above findings and that the room was not properly cleaned.

Interview on March 10, 2015, at 11:00AM, with EMP25 revealed that EMP25 only worked in the facility approximately 20 hours a week; and does not participate in environmental rounds. There was no evidence that EMP25 implemented or maintained a hospital-wide infection prevention and control program in order to reduce the risk of infection and ensure a sanitary environment.
Cross Reference:
482.28(a)(1) Food and Dietetic Services
482.41(a) Physical Environment
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of facility policies, medical records (MR), and interview with staff (EMP) it was determined that the facility failed to notify a minor patient's legal representative of the use of a physical restraint for one of one medical record reviewed (MR4).

Findings include:

Review on March 10, 2015, of facility policy "Informed Consent," reviewed January 2013, revealed "Policy: It is the policy of Fairmount Behavioral Health System to consider and respect patient rights and need for relevant information through informed consent. ..."

Review on March 10, 2015, of facility document "Holds and Restraints," reviewed February 2013 revealed "... 6.0 Notification of the Patient's Family, 6.1 With any hold/restraint episode for a patient that is under the age of 14 years of age, unless they are emancipated minor, shall require notification of the parent, guardian, family member, or conservator ... 6.3 The date and time of the notification of the family member/guardian will be noted on the Physical Hold/Restraint Record. ..."

Review on March 10, 2015, of MR4 revealed a [AGE] year old patient was admitted to the facility on on [DATE], and discharged [DATE]. Further review of MR4 revealed that the patient was identified as having a legal representative.

Review of MR4 nursing documentation revealed that the patient was placed in a physical hold. Further review of MR4 "Physical Hold/Restraint Record," dated January 6, 2015, revealed no documented evidence that the patient's designated representative was informed or consented to the use of a physical restraint.

Interview on March 10, 2015, at 11:45 AM, with EMP4 confirmed there is no documented evidence the minor's legal representative was notified or consented to the use of physical restraints.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation, review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to safeguard personal possessions, some containing personal information; and failed to ensure patient valuables were returned to the patient at the time of discharge for three of three medical records reviewed (MR21,MR22, MR24).

Findings include:

Review of the facility "Patient Handbook," revised March 2006, revealed " ... Patient Rules and Guidelines ... Valuables/Patient Belongings Fairmount cannot be responsible for any lost or missing item that is not placed in the hospital's safe. We request that no valuables, such as credit cards, checks, cash or jewelry, be brought to the hospital. Please send these items home with your family or staff will lock them in the hospital safe. Only the patient signing his or her valuables into the safe will be allowed to sign them out. ... Patient Bill of Rights ... 3. You have the right to keep and use personal possessions, unless it has been determined that specific personal property is contraband. The reasons for imposing any limitation and its scope must be clearly defined, recorded and explained to you. ... "

Review of facility policy and procedure, "Admission Procedure," dated February 10, 2015, revealed, " ... 6. For inpatients ... suitcases, purses, pockets, and hidden areas are to be check for contraband and secured and returned to patients after discharge as clinically appropriate with a physician's order ... "

Review of facility document "Patient Valuables," revealed a form for patients to list valuables to be stored during admission. Further review of the form revealed check boxes where the valuables are to be deposited, which included the "Admission Safe, Nursing Supervisor Safe or Drop Safe." Also noted was a patient signature line at the bottom of the form to acknowledge repossession of valuables.

Observation on March 9, 2015, at 1:00 PM, of the Patient Care Coordinator's Office (PCC), located near the cafeteria, revealed a locked supervisor's office with a box stored on the floor. The box contained clear plastic bags with patient identification labels on the outside of the plastic bags. The bags contained valuables from previously discharged patients.

Review of MR21 "Patient Valuables," dated February 14, 2013, revealed the following items: identification cards, a wallet with money and transportation tokens. Further review of the form revealed no documentation as to why the patients belongings were removed from the patient, where the patient's belongings were deposited nor was there documentation of the patient's signature acknowledging receipt of repossession of valuables at the time of discharge.

Observation on March 9, 2015, at 1:15 PM, of the PCC Office revealed MR21's belongings were never returned to the patient and still remained at the facility.

Review of MR22 "Patient Valuables," dated July 13, 2014 revealed the following items: one wallet, ID, a medical card, phone, ear phones, a lighter and set of keys. Further review of the form revealed no documentation as to why the patients belongings were removed from the patient, where the patient's belongings were deposited nor was there documention of the patient's signature acknowledging receipt of repossession of valuables at the time of discharge.

Observation on March 9, 2015, at 1:10 PM, of the PCC Office revealed a plastic bag, labeled with MR22's information. However, the bag contained an inhaler and did not match the items that were documented on the MR22's "Patient Valuable" form.

Review of MR24 "Patient Valuable," dated February 28, 2014, revealed no documentation of patient valuables.

Observation on March 9, 2015, at 1:15 PM, of the PCC Office revealed a plastic bag labeled with MR24's information. The bag contained a health card and various personal items.

Interview on March 9, 2015, at 1:15 PM, with EMP4 confirmed that patient belongings are to be returned to the patient at the time of discharge.

Interview on March 11, 2015, at 10:00 AM, with EMP3 confirmed the facility does not attempt to contact patients after discharge to return valuables nor does the facility have a policy regarding disposition of patient belongings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, review of facility documents and interview with staff (EMP), it was determined that the facility failed to provide a safe environment and emotionally healthy environment.

Findings include:

Review of the facility "Environmental / Hazard Surveillance Surveys," for January 16, 2014, May 27, 2014, July 25, 2014, and November 12, 2014, revealed no documented evidence that the patient rooms that had holes on the desks countertops were identified as a potential tie-off points for a ligature device.

Observation of N3 and N4 Psychiatric Nursing Unit revealed in each patient room there was a desk countertop that was approximately 30 inches off the ground. Each desk had a hole on the countertop which could be used as a tie off point for a ligature device.

Interview on March 9, 2015, at 1:15 PM, with EMP5 confirmed the desks countertops could be a potential tie-off point for a ligature device. EMP5 stated that it was a facility oversight that the holes in the desks countertops were not identified as a tie-off point for a ligature device, where a patient could cause harm to self.

Observation of N1 Psychiatric Nursing Unit revealed each patient room bathroom was equipped with sink, toilet and shower plumbing that would provide as a tie off point for a ligature device.

Interview on March 9, 2015, at 10:30 AM, with EMP4 confirmed the plumbing was classified as anti-ligature plumbing but could be used as a potential tie off point for a ligature device.

Cross Reference:
482.41(a) Physical Environment
482.42(a)(1) Infection Control
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to measure, analyze, and track a quality indicator, hand-washing, in order to monitor for the effectiveness, safety of services and quality of care.
Findings include:
Review of the "Medical Executive Meeting Minutes," January 2015, revealed that hand-washing was a quality initiative focus for 2014. Review of the "2014 Annual Report," revealed the following outcomes: "After touching patient" Quarter (Q) 3 - 49% compliant (C) and Q4 - 83% C; "After taking off gloves" Q3 - 52% C and Q4 - 50% C; "After touching something dirty" Q3 - 52% C and Q4 -50% C; "Before starting medication pass" Q3 - 45% C and Q4 - 100% C.
Review of "Infection Control Hand Washing Data Collection," revealed no hand washing data was collected in September, October and December 2014. Further review revealed that in November only 20 staff were observed with an 80% compliance rate on A-B-C Pods. EMP25 was unable to provide any hand-washing data collection for Pod N1, N2/3, N4, D-E and C-D.
Review of August collection data revealed that only 20 staff were observed Pod N1 with 75% compliance rate and only 20 staff were observed in Pod N4 with a 70% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N2/3, N4, D-E and C-D.
Review of July collection data revealed that only 20 staff were observed on Pod C-D with a 60% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N1, N2/3, N4, and D-E.
Interview on March 10, 2015, at 10:30 AM, with EMP26 revealed that they did not collect any the hand-washing data for their pod.
Interview on March 11, 2015, at 9:30 AM, with EMP3 revealed that the facility should have observed at least 50 personnel monthly in order to determine compliance with the quality indicator, hand-washing.
Cross Reference:
482.42(b) Infection Control
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services was provided in a safe and effective manner and that services provided complied with Conditions of Participation.

Findings include:

Review on March 10, 2015, of facility policy "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed "Article IV Purpose of the Facility ... The Board shall be accountable for the safety and quality of care, treatment and services of the Facility ... Article V ... 5. Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Facility ... "

Review on March 11, 2015, of facility document "Governing Body Meeting Minutes, " dated February 10, 2015, revealed three clinical contracts for X-ray, Pharmacy and Lab services were reviewed for quality and approved.

Review on March 11, 2015, of facility document "Fairmount Behavioral Health Systems Contracts," revealed service contracts that included trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Further review of facility documents revealed no documented evidence that the facility evaluated the quality of these contracted services.

Interview on March 11, 2015, at 9:00 AM, with EMP3 confirmed that the facility's Quality Assurance Performance Improvement Program did not include the evaluation of quality for these contracted services: trash, laundry services, pest control, preventative maintenance, bio hazardous waste management and language services.

Cross reference:
482.12(e)(1) Governing Body
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0756
Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure the adequate implementation of a hospital-wide quality assessment and performance improvement programs targeted to track hand-washing compliance throughout the facility; and failed to implement a corrective action plan to address and reduce incidences of hand-washing non-compliance, in order to improve quality outcomes.

Findings include:

Review on March 10, 2015, of facility "Amended and Restated Bylaws of the Board of Governors of Fairmount Behavioral Health System," approved February 10, 2015, revealed "Article IV Purpose of the Facility ... The Board shall be accountable for the safety and quality of care, treatment and services of the Facility ... Article V 5. Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Facility ... "

Review of the "Medical Executive Meeting Minutes," January 2015, revealed that handwashing was a quality initiative focus for 2014. Review of the "2014 Annual Report," revealed the following outcomes: "After touching patient" Quarter (Q) 3 - 49% compliant (C) and Q4 - 83% C; "After taking off gloves" Q3 - 52% C and Q4 - 50% C; "After touching something dirty" Q3 - 52% C and Q4 -50% C; "Before starting medication pass" Q3 - 45% C and Q4 - 100% C.
Review of "Infection Control Hand Washing Data Collection," revealed no hand washing data was collected in September, October and December 2014. Further review revealed that in November only 20 staff were observed with an 80% compliance rate on A-B-C Pods. EMP25 was unable to provide any hand-washing data collection for Pod N1, N2/3, N4, D-E and C-D.
Review of August collection data revealed that only 20 staff were observed Pod N1 with 75% compliance rate and only 20 staff were observed in Pod N4 with a 70% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N2/3, N4, D-E and C-D.
Review of July collection data revealed that only 20 staff were observed on Pod C-D with a 60% compliance rate. EMP25 was unable to provide hand-washing data collection for Pod N1, N2/3, N4, and D-E.
Interview on March 10, 2015, at 10:30 AM, with EMP26 revealed that they did not collect any the hand-washing data for their pod.
Interview on March 11, 2015, at 9:30 AM, with EMP3 revealed that the facility should have observed at least 50 personnel monthly in order to determine compliance with the quality indicator, hand-washing.

Review of facility documentation revealed no documented evidence that the facility addressed the issue of limited participation of units responsible for tracking and monitoring hand-washing non-compliance; nor was there evidence that the facility implemented a corrective action plan to address and reduce identified incidences of hand-washing non-compliance in order to improve quality outcomes.

Cross Reference:
482.21(a),(b)(1),(b)(2)(i),(b)(3) Qapi