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.

Based on review of hospital policies and procedures, documents, medical records, and staff interviews, it was determined the administrator failed to provide orientation to agency personnel according to facility policy. This deficiency posed a high potential risk to a patient's health and safety if the facility cannot confirm that personnel are orientated to their job. (BHT # 7)

Findings include:

A review of policy/procedure 'New Employee Orientation' revealed: "...[Haven] provides general orientation to all newly hired orient the employee to key elements of [Haven], and to comply with applicable regulatory standards, which require that new employees are oriented to [Haven], their departments and their positions. SCOPE: All [Haven] employees, agency and contract workers...All full-time, part-time and PRN employees must attend a New Employee Orientation session offered by Human Resources and the department(s). Employees are paid while attending the orientation...All new hire employees, regardless of employee status type, are required to perform the initial training for the Compliance and Ethics (C&E) Program and HIPAA Compliance before they begin working at Haven...The mandatory C&E training requirements apply to all employees, agency, contract workers, and medical staff members regardless of whether they are employees or independent contractors...Departmental New Employee Orientation is critical, and must be done in a conscientious and consistent manner with all new employees. Departmental orientations should include any additional issues that are specific to the department such as training, safety, and security...The employee and applicable supervisor(s) shall complete a Department Orientation Checklist for each employee and place a copy of the form in the employee's personnel file...."

A copy of BHT # 7's Department Orientation Checklist was requested from Human Resources. RN # 3 informed surveyor that there was none.

Telephone interview with agency BHT # 7 (BHT) revealed that the BHT has worked at [Haven] four (4) times through his/her agency. BHT relayed that s/he arrived on the unit and was assigned a patient and provided a clipboard with instructions to chart on the patient every 15 minutes. The BHT confirmed that s/he was never oriented, provided direction or training, or informed of the facility policies.

RN # 2 relayed during interview on 4/18/18 at 14:10 that agency RNs are provided a mini orientation which includes a tour by the house supervisor for keys, access to the Pyxis, and patient charts. BHTs are provided a tour by the Lead BHT, and provided a badge and keys.

RN # 8 relayed during interview on 4/18/18 at 14:40 that there is a huddle at the start of a shift which includes full-time and agency personnel. Registry remains behind approximately 15 additional minutes and the BHTs are provided information as to what is expected of them during the shift. The BHTs are given a patient assignment and the name of a float BHT they can utilize for reference.

RN(s) # 2, # 3 and # 8 confirmed during interview that BHT employees hiring on full-time with [Haven] receive a full 6 days of BHT orientation. The first day is spent on Health Stream, a computerized training program. The BHT is then given 5 days on the floor with a mentor. The goal is that the BHT will be able to take their own patient assignment by completion of the 5th day with the mentor. Orientation will be extended for the new BHT if needed, wherein the facility will customize the orientation to that individual.

RN(s) # 2, # 3 and # 8 acknowledged during interview that the facility is not following their policy regarding providing agency personnel with orientation.