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.

BRYAN W. WHITFIELD MEMORIAL HOSPITAL 105 HIGHWAY 80 EAST DEMOPOLIS, AL 36732 March 23, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility Services Agreement, policies, medical records, complaint documentation, Self - Recovery Group Session for March 20, 2018, Medical Staff Bylaws, Rules and Regulations, Credential and quality file, Employee personnel file, observations and interviews, it was determined the Governing Body failed to ensure:

1. The Self Recovery Unit (SRU) (contracted service) provided group and individual counseling to patients admitted to the SRU.

2. All areas of the hospital, including the SRU participated in the Quality Assurance Performance Improvement activities.

3. The SRU followed their policy related to discharge for rules violation.

4. All patient complaints / concerns with care provided at this facility were investigated.

5. Psychosocial assessments were completed within 24 hours of admission for patients admitted to the SRU.

6. Biopsychosocial assessments were completed within five (5) days of admission to the SRU.

7. Individualized treatment plans were developed and implemented for patients admitted to the SRU.

8. The medical staff failed to follow it's rules and regulations regarding:

a. Enforcement of completion of medical records.

b. Investigation of incidents of improper conduct or violation of the Medical Staff bylaws.

9. All medical staff completed a History & Physical (H & P) within 24 hours of admission for all patients admitted to this facility and physician progress notes were documented.

10. SRU staff were qualified and oriented to the duties to be performed.

11. Patient medical records were accurately and completely documented with all events and activities, including:

a. Group therapy sessions, including the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

b. All group therapy sessions conducted by Volunteers or other Self Recovery Unit (SRU) staff members.

c. Counselor's discharge summary.

12. A discharge planning evaluation was completed for patients admitted to the SRU.

13. A discharge plan was implemented for patients admitted to the SRU.

These deficient practices affected 7 of 8 medical records reviewed, including Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, PI # 7 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Refer to A083, A084, A117, A122, A130, A273, A347, A358, A397, A438, A806 and A820 for individual findings.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility Services Agreement, policies, medical records, Self - Recovery Group Session for March 20, 2018, observations and interviews, it was determined the facility failed to ensure the Self Recovery Unit (SRU) (contracted service) provided group and individual counseling to patients admitted to the SRU.

This affected 4 of 5 records reviewed of patients admitted to the SRU, including Patient Identifier (PI) # 4, PI # 5, PI # 6, PI # 7 and had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Services Agreement between Tombigbee Healthcare Authority (Hospital) and Self Recovery, L.L.C. (Self Recovery)

... 1. Term. This agreement shall remain in effect for a term of one year beginning 6/30/10 the ("Effective Date") and ending 6/30/11, unless sooner terminated as provided herein. Thereafter, the Agreement shall automatically renew for successive one (1) year periods, unless sooner terminated as provided herein...

e. Compliance with Terms of Agreement. In providing services on behalf of Self Recovery under this Agreement, Self Recovery's Staff shall comply with all applicable provisions of the Agreement...

7. Duties of Self Recovery. In accordance with the Program Description and Concept set forth in Exhibit "A", Self Recovery shall furnish the Programs with the following...

Exhibit "A"

Program Description and Concept...

All treatment will be provided by Self Recovery and Self Recovery's Staff in accordance with appropriate and accepted medical and clinical guidelines and applicable federal, state and local laws...

******
Policy
Self-Recovery, L.L.C.
Group Therapy
Administrative Policy No. 7

Purpose:

1. To provide patients with an objective understanding of the disease of addiction and a constructive means of dealing with the disease.

2. To provide cognitive stimuli in treatment, in an attempt to maximize the use of reaming cognitive abilities, thus allowing the patient to maintain greater degree of independence.

3. To provide a means through ventilation is allowed and encouraged.

5. To maintain and support the individuality, dignity and self-esteem of the patient.

Procedure:

Group Therapy will be conducted on a daily basis by the counselors and/or the treatment team of the Self-Recovery program. Patients will be required to attend all meetings / sessions unless otherwise informed by the counselor and/or Treatment Team.

Reality orientation / therapy will be a continuous (24-hour/day) and the ongoing responsibility of all the staff members on the unit...

******
Policy
Self-Recovery, L.L.C.
Job Description
Certified Alcoholism / Drug Addiction Counselor
Administrative Policy No. 8

... XXVI. Major Functions

... b. Provide individual counseling...

f. Lead group therapy and other sessions provided in treatment modalities in subjects such as alcoholism / chemical dependency, mental and physical hygiene and support groups such as Alcoholics Anonymous...

1. PI # 4 was admitted on [DATE] for Medical Detoxification and discharged on [DATE].

Review of the medical record revealed no documentation of Group Therapy sessions for 3/16/18, 3/17/18 and 3/20/18. There was no documentation of individual counseling sessions.

An interview was conducted on 3/21/18 at 3:00 PM with Employee Identifier (EI) # 6, SRU Counselor who verified the above.

2. PI # 5 was admitted on [DATE] for Medical Detoxification.

Review of the medical record revealed no documentation of Group Therapy sessions for 3/20/18. There was no documentation of individual counseling sessions.

3. PI # 6 was admitted on [DATE] for Medical Detoxification.

Review of the medical record revealed no documentation of Group Therapy sessions for 3/20/18.

4. PI # 7 was admitted on [DATE] requesting Detox (detoxification).

The patient was observed on 3/21/18 at 9:10 AM, but was preparing to be discharged home. The surveyor reviewed the patient's medical record on 3/21/18 after the patient had been discharged .

Review of the medical record revealed no documentation of Group Therapy sessions for 3/16/18, 3/17/18 and 3/20/18. There was no documentation of individual counseling sessions.

A tour of the SRU was conducted on 3/20/18 at 10:30 AM Employee Identifier (EI) # 2, SRU Nurse Manager. During this tour, the surveyor observed no patients were visible in the dining / meeting room or hallways. According to EI # 2, all four (4) patients were in their rooms.

When questioned about group therapy, EI # 2 stated the SRU Counselors are responsible for group therapy. The surveyor asked about the counselors, EI # 4 stated both of the counselors were at an inservice in another city for 3/20/18 and 3/21/18.

On 3/21/18 at 7:40 AM, the surveyor returned to the SRU and observed 2 male patients sitting in the dining / meeting room watching TV while eating breakfast and 1 male patient standing in the doorway to the dining / meeting room.

On 3/21/18 at 9:45 AM, the surveyor conducted a confidential interview with PI # 5. The surveyor asked about group therapy for 3/20/18. PI # 5 stated that some guy (unable to recall name) came in the afternoon and showed a video.

On 3/21/18 at 10:05 AM, the surveyor conducted a confidential interview with PI # 6. The surveyor asked PI # 6 how he/she occupied his/her time while admitted to the hospital. PI # 6 stated, "mostly sleeps or watches TV. PI # 6 stated he/she usually talks with the counselor 2 times a day." The surveyor asked about group therapy for 3/20/18. PI # 6 stated that some guy (unable to recall name) came in around 9 or 10 in the morning on 3/20/18 and showed the film.

On 3/21/18 at 11:00 AM, the surveyor asked EI # 1, Director of Professional Standards to find out who the "guy" was that came a showed the patients a video in the SRU on 3/20/18. EI # 1 left the room and a short while later, came in with a sticky note with a gentleman's name and, "... Volunteer who comes up every Tuesday morning and has been coming for 3 weeks..." and his phone number.

On 3/21/18 at 1:48 PM, a document entitled, "Self - Recovery Group Session for March 20, 2018" was observed sitting on the table in which the surveyor had been reviewing medical record documentation.

A review of the documented Self - Recovery Group Session for March 20, 2018 revealed, "... Group Topic: Coping Skills... (PI # 5) attended group therapy session, the session was on coping skills... (PI # 7) attended group therapy session, the session was on coping skills... (PI # 6) attended group therapy session, the session was on coping skills... (EI # 5, SRU Manager)..."

An interview was conducted on 3/22/18 at 2:27 PM with EI # 5 in regards to the above document, "Self - Recovery Group Session for March 20, 2018". EI # 5 stated she typed it up because she held a group on 3/20/18. When questioned about the time, EI # 5 stated, "yesterday afternoon." The surveyor asked if this document was a part of the patient's medical record, EI # 5 stated, "No, she just typed it up for the surveyor."
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on review of facility Services Agreement, policies and interviews, it was determined the facility failed to ensure all areas of the hospital, including the Self Recovery Unit (SRU) participated in the Quality Assurance Performance Improvement activities. This had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Services Agreement between Tombigbee Healthcare Authority (Hospital) and Self Recovery, L.L.C. (Self Recovery)

... 1. Term. This agreement shall remain in effect for a term of one year beginning 6/30/10 the ("Effective Date") and ending 6/30/11, unless sooner terminated as provided herein. Thereafter, the Agreement shall automatically renew for successive one (1) year periods, unless sooner terminated as provided herein...

e. Compliance with Terms of Agreement. In providing services on behalf of Self Recovery under this Agreement, Self Recovery's Staff shall comply with all applicable provisions of the Agreement...

7. Duties of Self Recovery. In accordance with the Program Description and Concept set forth in Exhibit "A", Self Recovery shall furnish the Programs with the following...

Exhibit "A"

Program Description and Concept...

All treatment will be provided by Self Recovery and Self Recovery's Staff in accordance with appropriate and accepted medical and clinical guidelines and applicable federal, state and local laws...

******
Policy
Self Recovery, L.L.C.
Quality Assurance Indicators
Administrative Policy No. 15

Purpose:

Quality Assurance (QA) indicators are designed to provide comprehensive, objective, timely information on all aspects of patient care. They fairly, and equally, monitor the care all practitioners (Physician and Non-Physician) and Departments. The QA indicators are criteria based.

Procedure:

Patient charts are reviewed on a concurrent basis to determine if an event has occurred which is a result of health care management and not to be the disease process.

Physician-approved screening criteria will be used in screening each chart. Data on each adverse even (event) is aggregated so that trends and patterns can be reported to the Hospital Quality Assurance Committee.

1. The greater of 10 charts or 10% of charts per month are reviewed by random selection.

2. review is concurrent and retrospective.

3. Reviews are based on objective physician-approved criteria...

******
Policy:
Self Recovery. L.L.C.
Quality Assurance Form
Administrative Policy No. 16

Aspects of care and treatment to be monitored:

Primary Counselor...
Case Number...
Reviewer's Name...

Please check one of the following for the questions listed below. (Yes/No questions)

1. Was the primary contact made the primary counselor within 24 hours of admission?

... 4. Was the Master treatment Plan completed within 72 hours of admission?

... 6. Were individual sessions conducted as indicated in the program description?

7. Were aftercare plans completed and copies filed in the chart?

8. Were the required documents for discharge completed and filed in the chart?

... Reviewer's Comments...

Action Taken...

On 3/21/18 at 10:45 AM, the surveyor requested to review the QA documentation for the SRU.

An interview was conducted on 3/21/18 at 2:15 PM with Employee Identifier # 1, Director of Professional Standards, who stated there was no documentation of QA reviews by the SRU.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, medical records and interviews, it was determined the facility failed to follow their policy related to discharge for rules violation. This affected 1 of 1 patient discharged for rules violation, including Patient Identifier (PI) # 3 and had the potential to negatively affect all patients admitted to the Self Recovery Unit (SRU).

Findings include:

Policy
Self Recovery

If a patient is found to be in violation of the rules set forth by Self Recovery the Self Recovery staff should be notified.

Once they are notified they will make the decision as to whether to have the patient discharged or not.

The Self Recovery staff will discuss the situation with the MD (Medical Doctor) and if they agree on the discharge the MD will give the nurse a discharge order.

The nurse will then discharge the patient as per usual procedure...

The Self Recovery Staff will do the following for the patient:Notify a family member and allow the patient to call to get a ride home from their family or a friend. If the patient decides not to call someone to come get them or asks to walk we will allow them to under the following conditions:

1) If they have had any of our meds (medications), we will notify the local police of the situation.

2) If they have not had any meds, we will notify hospital security and have them escorted off of BWWMH (Bryan W. Whitfield Memorial Hospital) premises.

Also, we occasionally will provide transportation home for rule violation if available...

1. PI # 3 was admitted to the facility on [DATE] with diagnosis of Medical Detoxification.

Review of the medical record revealed Self Recovery Consent for Treatment and Release form signed and dated 8/21/17. Review of this document revealed, "... I fully understand that violent behavior and self-inflicted injuries are inherent possibilities in all persons suffering from alcohol or any drug dependency... I fully understand that a negative attitude and failure to cooperate are cause for immediate discharge..."

Review of the Patient Notes dated 8/23/17 at 5:06 PM revealed the nurse documented, "Patient in tech (technician) office at this time using abusive language because (he/she) could not use the phone. Pt (patient) informed of phone time. Pt began cursing and yelling at staff at this time because (he/she) needed to use the phone as early as this morning. Security called at this time. Pt went to (his/her) room and eventually calms down. Pt will be allowed to use the phone at next available time..."

Review of the Patient Notes dated 8/23/17 at 5:35 PM and amended at 6:00 PM revealed the nurse documented, "Original Note: Patient in tech (technician) office using phone and informed (him/her) phone time was up by tech. After phone call, pt (patient) proceeds to throw phone at tech. (EI # 5, SRU Manager) called and notified. Pt to be discharged for rules violation... 5:25 PM Patient informed of why (he/she did not receive medications this afternoon. Patient informed... did not have any medications scheduled at that time and that (he/she) was resting in bed with eyes closed. Patient informed that had (he/she) been awake and asked for as needed medication, this nurse would have given (him/her) what (he/she) needed. Patient voiced... understanding..."

Review of the Patient Notes dated 8/23/17 at 6:07 PM revealed the nurse documented, "... Patient discharged at this time for rules violation and for violent behavior towards staff. Patient escorted off unit with Self Recovery driver at this time..."

There was no documentation the physician was notified of the patient's behavior and rules violation to determine if the patient needed to be discharged . There was no documentation the patient's family was notified of the patient's discharge, nor was there documentation the patient was allowed to make a phone call to the family in regards to being discharged from the facility.

A interview was conducted on 3/21/18 at 2:15 PM with Employee Indentifer # 1, Director of Professional Standards, who verified the above.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of facility policy, complaint documentation and interview, it was determined the facility failed to investigate patient concerns with care provided at this facility. This affected Patient Identifier (PI) # 3 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Facility Policy
Chapter Thirteen
Patient Satisfaction / Patient Advocacy Program

131.00 Patient Complaint / Grievance Policy

THA (Tombigbee Healthcare Authority) and its Board of Directors as part of their total commitment to providing quality, professional patient care, believes in the patients and their representatives right to courteous, prompt and complete response to their communications with the hospital. Information and response provided by THA will be consistent in the presentation of facts and statement of policies. When appropriate or necessary, follow-up action and/or patient contacts will be completed. This policy applies to all patients receiving care provided by THA...

THA will investigate complaints including grievances... Administration manages all complaints and grievances directed to THA...

Definitions:

Complaint: A "complaint" is defined as an expression of dissatisfaction brought to the attention of THA personnel. A complaint is not initially considered to be a grievance.

Grievance: A formal complaint "grievance" is defined as a written or verbal complaint that is made to THA by a patient, or the patient's representative, regarding the patient's care (when the concern is not resolved at the time of the complaint by staff present)... issues related to the hospital's compliance with the CMS (Centers for Medicare & Medicaid) Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint...

The CEO (Chief Executive Officer)/ Administrator or designee, will assign each grievance to a THA staff member. The THA staff member will collaborate with the appropriate leaders of the disciplines/departments involved. The leader (e.g. nurse manager, department manager) assigned to provide feedback will investigate the grievance, address and return a response to the Administrator. The Administrator will either respond directly to the complainant or designate a manager or leader to respond via written or phone response.

A review of the complaint documentation provided to the surveyor revealed email messages related to complaints regarding the care provided to PI # 3. Review of this complaint documentation revealed no documentation the grievance was investigated, resolved or that the complainant was notified of the results of the investigation.

An interview was conducted on 3/21/18 at 10:45 AM with Employee Identifier # 1, Director of Professional Standards, who verified the above findings.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical records and interviews, it was determined the facility failed to ensure:

1. Psychosocial assessments were completed within 24 hours of admission

2. Biopsychosocial assessments were completed within five (5) days of admission to the Self Recovery Unit (SRU).

3. Individualized treatment plans were developed and implemented for patients admitted to the SRU.

These failures prevented patients from participating in the care planning process.

This affected 5 of 5 records reviewed of patients who had been admitted to the SRU, including Patient Identifier (PI) # 3, PI # 4, PI # 5, PI # 6, PI # 7 and had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Policy
Self Recovery, L.L.C.
Standards of Care
Administrative Policy No. 11

The patient can expect:

... 3. To have a comprehensive assessment of the biopsychosocial needs and spiritual orientation initiated with 24 hours of admission and the complete biopsychosocial assessment complete within five (5) days of admission...

******
Policy
Self Recovery, L.L.C.
Master Treatment Plan
Administrative Policy No. 13

Purpose:
To develop a written, individual treatment plan based on each patient's case assessment of his/her clinical needs. An individualized treatment plan will be developed for each patient, reflecting the staff belief in individualized treatment. Such treatment plans will integrate the interventions used as a normal part of our recovery program with individual interventions specifically designed to meet patient problems and needs. The treatment plan used at Self-Recovery should be multidisciplinary and fully integrated that is, all practitioners regardless of discipline will use it.

Procedure:
Assignment
The overall development and coordination of the development of the individualized treatment plan will be the responsibility of the primary counselor.

Development

A. Assessments:

a. Treatment plans should be developed as soon as the clinical information becomes available.

b. Upon admission, the clinical Director will imitate (initiate) the treatment plan indicating the type of addiction and if detoxification is required...

d. Within the first 24 hours, if patient is physically able, the clinical Director will complete the psychosocial assessment on each new patient. Such information will be integrated into the master Treatment Plan.

e. During the session in which the counselor has the initial contact, he/she will assign the Self-Assessment for completion by the patient. Such information will be integrated into the Master Treatment Plan...

B. The Treatment Plan:

From the Bio/Psycho/Social Assessment, the primary counselor will formulate the treatment plan... The treatment plan will contain the following information:

a. The description of each identified problem to be dealt with in treatment, derived from the Bio/Psycho/Social...

d. The intervention(s) planned by the treatment team to address the specific problem, and the frequency thereof.

e. Specific objectives, written in measurable terms related to the goals for the identified problem...

g. The target date for completion of every intervention will be annotated...

i. The signature of the counselor.

j. The signature of the patient.

k. Approval and significant (signature?) of the Clinical Director...

1. PI # 3 was admitted on [DATE] for Medical Detoxification and discharged on [DATE] at 6:07 PM.

There was no documentation a psychosocial assessment was completed within 24 hours of admission and no documentation of a Treatment Plan for PI # 3.

An interview was conducted on 3/21/18 at 2:15 PM with Employee Identifier (EI) # 1, Director of Professional Standards, who verified the above findings.

2. PI # 4 was admitted on [DATE] for Medical Detoxification and discharged on [DATE].

There was no documentation of a Treatment Plan for PI # 4.

3. PI # 5 was admitted on [DATE] for Medical Detoxification.

Review of the medical record revealed the Psychosocial Assessment was not completed until 3/21/18, which was greater than 24 hours after admission.

There was no documentation of a Treatment Plan for PI # 5.

4. PI # 6 was admitted on [DATE] for Medical Detoxification.

There was no documentation of a Treatment Plan for PI # 6.

5. PI # 7 was admitted on [DATE] requesting Detox (detoxification).

The patient was a observed on 3/21/18 at 9:10 AM, but was preparing to be discharged home. The surveyor reviewed the patient's medical record on 3/21/18 after the patient had been discharged .

There was no documentation a psychosocial assessment was completed within 24 hours of admission and no documentation a Biopsychosocial assessment was completed within five (5) days of admission.

There was no documentation of a Treatment Plan for PI # 7.

An interview was conducted on 3/21/18 at 3:00 PM with EI # 6, SRU Counselor, who verified the above medical record findings. EI # 6 stated she only completes the (UNCOPE Assessment - Screening Instrument for Substance Abuse) Biopsychosocial Assessment if a patient is wanting to continue with further treatment after being discharged from the SRU.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of facility policies and interviews, it was determined the facility failed to ensure all areas of the hospital, including the Self Recovery Unit (SRU) participated in the Quality Assurance Performance Improvement activities. This had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Self Recovery, L.L.C.
Quality Assurance Indicators
Administrative Policy No. 15

Purpose:

Quality Assurance (QA) indicators are designed to provide comprehensive, objective, timely information on all aspects of patient care. They fairly, and equally, monitor the care all practitioners (Physician and Non-Physician) and Departments. The QA indicators are criteria based.

Procedure:

Patient charts are reviewed on a concurrent basis to determine if an event has occurred which is a result of health care management and not to be the disease process.

Physician-approved screening criteria will be used in screening each chart. Data on each adverse even (event) is aggregated so that trends and patterns can be reported to the Hospital Quality Assurance Committee.

1. The greater of 10 charts or 10% of charts per month are reviewed by random selection.

2. review is concurrent and retrospective.

3. Reviews are based on objective physician-approved criteria...

******
Self Recovery. L.L.C.
Quality Assurance Form
Administrative Policy No. 16

Aspects of care and treatment to be monitored:

Primary Counselor...
Case Number...
Reviewer's Name...

Please check one of the following for the questions listed below. (Yes/No questions)

1. Was the primary contact made the primary counselor within 24 hours of admission?

... 4. Was the Master treatment Plan completed within 72 hours of admission?

... 6. Were individual sessions conducted as indicated in the program description?

7. Were aftercare plans completed and copies filed in the chart?

8. Were the required documents for discharge completed and filed in the chart?

... Reviewer's Comments...

Action Taken...

On 3/21/18 at 10:45 AM, the surveyor requested to review the QA documentation for the SRU.

A interview was conducted on 3/21/18 at 2:15 PM with Employee Identifier # 1, Director of Professional Standards, who stated there was no documentation of QA reviews by the SRU.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on review of Medical Staff Bylaws, Rules and Regulations, Credential and quality file and interview, it was determined the medical staff failed to follow it's rules and regulations regarding:

1. Enforcement of completion of medical records.

2. Investigation of incidents of improper conduct or violation of the Medical Staff bylaws.

This affected 2 of 2 records reviewed of patients with complaints/concerns regarding Employee Identifier (EI) # 3, Physician, including Patient Identifier (PI) # 1, PI # 3 and had the potential to negatively affect the care provided at this facility.

Findings include:

Medical Staff Bylaws, Rules and Regulations

Section IV. Miscellaneous Rules and Regulations

1. The Medical Staff discussions at it's monthly meetings shall constitute a thorough review and analysis of the clinical work done in the Hospital, including consideration of deaths, unimproved cases, infections, complications... and results of treatment, from among significant cases in the Hospital at the time of the meeting, an analysis of clinical reports from each department and reports of committees of the Active Medical Staff...

13. The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include identification data; complaint... history of present illness... progress notes; final diagnosis; condition on discharge; summary of discharge note... No medical record shall be filed until it is complete, except on order of the Medical Records Committee. Physicians shall be notified of all records incomplete fourteen (14) days after discharge. The physician will have fourteen (14) days from this notice to complete the records. In the event these records have not been completed within this 14 day window, admission privileges shall be suspended. If after an additional 7 day period, records have still not cleared, ALL Medical Staff privileges shall be suspended.

14. A complete history and physical examination shall in all cases be documented in the medical record within twenty-four (24) hours after admission of the patient...

28. Procedure for disciplinary action:

A. A full investigation shall be conducted of all incidents regarding alleged improper conduct of violation of the Medical Staff bylaws, rules and regulations by members of the medical or Hospital staff.

B. Complaints regarding alleged improper conduct shall be submitted in writing to the CEO (Chief Executive Officer) / Administrator or their designate and shall be held in strict confidence.

C. Investigation of alleged improper conduct shall be made by the CEO/Administrator of their designate and a report shall be submitted in writing to the individual making the complaint...

E. After review by the appropriate committee, the committee shall make recommendations to the full Medical Staff regarding action to be taken. The final action shall be reviewed and determined by the Board of Director or a committee appointed by the Board of Directors...

Review of the Credential File for EI # 3, Physician revealed the physician was approved for reappointment through 10/1/18.

A review of EI # 3's Quality File revealed two (2) documents as follows:

1. "Chart Summary" by EI # 7, Physician dated 3/29/16 related to PI # 1. This document was a summary the patient's care and events during the patient's hospitalization . Review of this document revealed, "...Conclusion of admission day: Patient was admitted , declined, treated with an intubation but not seen by EI # 3. No notes, No H & P (History & Physical) on chart throughout hospital stay until death 80 hours later. Sunday March 27, 2016 (Easter Day) Someone told me that (EI # 3) came in at 08:15 AM before church, but this can not be verified)... Monday March 28, 2016 Someone told me (EI # 3) came at 8:15 AM before going on Hospital van to remote locations)... 8:20 PM Patient declining. (EI # 3) notified and requested ABG's (arterial blood gasses). Patient died during ABG attempt per (EI # 4, Physician) attendance..."

2. Copy of a letter dated 8/30/17 from PI # 3 with complaints of the care received in the Self Recovery Unit (SRU) and the care provided by EI # 3. There was no documentation of an investigation or resolution of the patient's concerns.

There was no documentation the above concerns were discussed with EI # 3 to improve the care provided at this Hospital.

An interview was conducted on 3/20/18 at 1:15 PM with EI # 1, Director of Professional Standards, who verified the above.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Medical Staff Bylaws, Rules and Regulations, medical record and interviews, it was determined the hospital failed to ensure the medical staff completed a History & Physical (H & P) within 24 hours of admission for all patients admitted to this facility and physician progress notes were documented. This affected 3 of 8 records reviewed, including Patient Identifier (PI) # 1, PI # 2, PI # 3 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Medical Staff Bylaws, Rules and Regulations
Reviewed and Revised May 2011
Reviewed and Revised August 2016
Reviewed and Revised February 2017
Reviewed and Revised February 2017

... Section IV. Miscellaneous Rules and Regulations

... 13. The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include identification data; complaint; personal history... progress notes; final diagnosis; condition on discharge; summary of discharge note... Physicians shall be notified of all records incomplete fourteen (14) days after discharge. The physician will have fourteen (14) days from this notice to complete the records...

14. A complete history and physical examination shall in all cases be documented in the medical record within twenty-four (24) hours after admission of the patient...

1. PI # 1 was admitted to the facility on [DATE] with Pneumonia and expired on [DATE] at 10:45 PM.

Review of the medical record revealed the H & P was dictated on 5/1/16 at 6:17 PM, transcribed on 5/1/16 at 8:39 PM and signed by the physician on 5/4/16 at 2:21 PM, which was greater than 24 hours after admission.

Review of the medical record revealed no documentation of a physician's progress note for 3/27/16.

Review of the Patient Notes dated 3/28/16 at 9:19 PM for 7:45 PM, the nurse documented, "... Vent (ventilator) alarm noted going off... Resp (respiratory) Therapy suction pt (patient) moderate amount of mucous returned... 8:00 PM... HR (heart rate) 163, BP (blood pressure) 96/77... 8:12 PM called resp due to vent alarming again about high pressure... pt sats (saturation) starting to drop down in the 50's. Called (Employee Identifier (EI) # 3, Attending Physician) and she ordered ABG (arterial blood gas). Informed Resp therapy. While attempting to get ABG, the pt's HR started decreasing down into the 50's noted that pt had very faint pulse. Code Blue called. See Code Blue sheet for medications and people assisting with code. Code called by (EI # 4, Physician) at 8:45 PM..."

Review of the Progress Note dated 3/28/16 at 8:45 PM, EI # 4 documented, "... Pt coded - without response. Declared at 8:45 PM. Family in attendance and informed..."

Review of the medical record revealed the Discharge Summary was dictated on 5/1/16 at 6:19 PM, transcribed on 5/1/16 at 9:59 PM and signed by the physician on 5/4/16 at 2:21 PM, which was greater than 28 days after discharge.

Review of the above Discharge Summary revealed EI # 3 dictated and signed the following, "... (patient) comes in with shortness of breath and altered mental status. We recently, in the last couple of weeks found that (he/she) had lung cancer... (Patient) has refused all treatment and elected to be a DNR (Do not resuscitate) and did pass quietly in (his/her) sleep..."

An interview was conducted on 3/21/18 at 2:05 PM with EI # 1, Director of Professional Services who verified the above findings.

2. PI # 2 was admitted to the facility on [DATE] with Pneumonia.

Review of the medical record revealed the H & P was dictated on 4/14/16 at 7:47 PM, transcribed on 4/15/16 at 4:50 AM and signed by the physician on 4/15/16 at 7:59 AM, which was greater than 24 hours after admission.

Review of the medical record revealed no documentation of a physician's progress notes for 2/22/16, 2/23/16 and 2/24/17.

Review of the medical record revealed the Discharge Summary was dictated on 4/14/16 at 7:47 PM, transcribed on 4/14/16 at 9:04 PM and signed by the physician on 4/15/16 at 7:59 AM, which was greater than 28 days after discharge.

An interview was conducted on 3/21/18 at 2:00 PM with EI # 1, who verified the above findings.

3. PI # 3 was admitted to the facility on [DATE] with diagnosis of Medical Detoxification and discharged on [DATE] at 6:07 PM for "rules violation."

Review of the medical record revealed no documentation of a physician's progress note for 8/22/17 or 8/23/17.

An interview was conducted on 3/21/18 at 2:15 PM with EI # 1, who verified the above findings.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of the Services Agreement, policy, employee personnel file and interview, it was determined the facility failed to ensure Self Recovery Unit (SRU) staff were qualified and oriented to the duties to be performed. This had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Services Agreement between Tombigbee Healthcare Authority (Hospital) and Self Recovery, L.L.C. (Self Recovery)

... 1. Term. This agreement shall remain in effect for a term of one year beginning 6/30/10 the ("Effective Date") and ending 6/30/11, unless sooner terminated as provided herein. Thereafter, the Agreement shall automatically renew for successive one (1) year periods, unless sooner terminated as provided herein...

e. Compliance with Terms of Agreement. In providing services on behalf of Self Recovery under this Agreement, Self Recovery's Staff shall comply with all applicable provisions of the Agreement...

6. Duties of Self Recovery. In accordance with the Program Description and Concept set forth in Exhibit "A", Self Recovery shall furnish the Programs with the following...

b. A Program Director, Counselors and Consultants adequate to provide an intensive alcohol and drug treatment program, as more fully described in Exhibit A... Self Recovery will provide the Hospital with the job descriptions, responsibilities, education, training, and appropriate credentialing of the Program Director, Counselors and Consultants. Self Recovery agrees that it's Programs Director, Counselors and Consultants will comply with all requirement as may be set forth by the Hospital as it relates to human resources/educational issues and shall meet all state, federal, and Joint Commission on Accreditation of Healthcare Organizations...

12. Self Recovery's Employees. Hospital shall have the right to review the personnel records and all files containing credentialing information of Self-Recovery's Staff assigned to the Program, with a copy provided to the Hospital for its credential files... Records shall be maintained in a fashion / consistent with Joint Commission and Alabama Department of Public Health Standards...

******
Policy
Self-Recovery, L.L.C.
Job Description
Assistant Counselor / Addiction Technician
Administrative Policy No. 9

... XXX. Qualification

Education: High School graduate or GED (General Equivalency Diploma)

Abilities: Have a working knowledge of the 12-Step Program. If recovering, must have a minimum of six (6) months in recovery and be active in a recovery group. Must have a valid Alabama driver's license and a good driving record.

XXXI. Summary of Responsibilities

Assist Primary Counselors with groups, paperwork (psychosocials, daily activity sheets, etc.) transport patient to outside activities, help patients obtain personal items, transport patients from/to bus station and towns in local areas, and other duties as needed.

XXXII. Major Functions

a. Relate to the patients in a constructive manner and treat patients with dignity and respect.

b. Transport patients to/from support group meetings, recreational activities, to/from bus stations or towns in local area, and assist patients in obtaining personal items for their well being (i.e. clothes, money wired from family members, cigarettes, etc.)

c. Assist Primary Counselors in group therapy and other sessions provided in treatment modalities.

d. Make observations and report directly to Primary Counselors and/or Clinical Director / Nursing Staff.

e. Help patients with their paperwork if needed.

f. Make sure patient attend all activities and report to Primary Counselors any problems / concerns.

g. All other duties as assigned by General Manager.

XXXIV. Hazardous Work Environment

Exposure to chemical and to contagious disease.
Inappropriate or aggressive behavior may arise occasionally from patients...

Review of the personnel file of Employee Identifier (EI) # 8, SRU Technician was conducted on 3/22/18.

Located in EI # 8's personnel file were the following documents:
(1) Job Description - Assistant Counselor / Addiction Technician - Administrative Policy No. 9, which was not signed by EI # 8.
(2) TB (tuberculin) Skin Test Verification dated 8/31/17
(3) Urine drug screen dated 10/28/15 (all results negative)
(4) Performance Appraisal dated and signed by EI # 8 and EI # 5, SRU Manager on 1/5/18

There was no documentation EI # 8 was a High School graduate or GED or had training and had a working knowledge of the 12-Step Program. There was no documentation of orientation to the SRU; including duties, responsibilities, group therapy or other sessions provided in treatment modalities, observations which should be reported to the primary counselor, SRU paperwork or therapeutic communication with patients who may exhibit inappropriate or aggressive behaviors.

An interview was conducted on 3/22/18 at 1:45 PM with EI # 5 related to orientation of EI # 8. EI # 5 stated everything was in a different file that was in storage. The surveyor requested EI # 5 to email EI # 8's orientation documentation by 3/23/18 at 8:00 AM. None was provided.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies, medical records, observations and interviews, it was determined the facility failed to ensure patient medical records were accurately and completely documented with all events and activities, including:

1. Group therapy sessions, including the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

2. All group therapy sessions conducted by Volunteers or other Self Recovery Unit (SRU) staff members.

3. Counselor's discharge summary.

This affected 5 of 5 records reviewed of patients admitted to the SRU, including Patient Identifier (PI) # 3, PI # 4, PI # 5, PI # 6, PI # 7 and had the potential to affect all patients admitted to the SRU.

Findings include:

PolicySelf-Recovery, L.L.C.
Charting
Administrative Policy No. 24

Purpose:
1. To provide standardized methods for documenting and maintaining chart forms which meet medico-legal requirements that will be all-inclusive, easily understood, and will eliminate error, omission or misrepresentation.

2. To provide a system for continuous assessment of patient care and records through Quality Assurance Committee and the Medical Records Committee...

Charting by Counselors is completed on the multidisciplinary Progress Notes. Charting will be done in accordance with procedures outlines in Attachment "A" hereto...

******
Policy
Self-Recovery, L.L.C.
Attachment "A"
Counselor Progress Notes Procedure
Administrative Policy No. 25

Counselors should maintain comprehensive documentation on each patient in treatment in the form of Progress Notes which related to the patient's Master Problems and Needs List and their Treatment Plan.

Purpose:
3. To insure that treatment is progressing in accordance with the stated goals, interventions, and objective of the Treatment Plan.

4. To provide a means to communicate the progress of treatment among the treatment team.

5. Within the confines of confidentiality, to provide a means to report individual patient progress to their party payer or referral sources.

6. To insure proper provision of continuity of care.

7. To produce a logical and progressive medical record.

Procedure:
1. Counselors should use the DAP (Data, Assessment Plan) or SOAP (Subjective, Objective, Assessment Plan) method of charting.

2. All entries in the Multidisciplinary Notes shall be cross referenced to the master Treatment Plan.

3. At least one individual session per week shall be documented...

5. Relevant discharge/aftercare planning shall be documented.

******
Self-Recovery, L.L.C.
Group Therapy
Administrative Policy No. 27

Purpose:
1. To provide patients with an objective understanding of the disease of addiction and a constructive means of dealing with the disease...

Procedure:
Group Therapy will be conducted on a daily basis by the counselors and/or the treatment team of the Self-Recovery program. Patients will be required to attend all meetings/sessions unless otherwise informed by the counselor and/or Treatment Team.

Reality orientation / therapy will be a continuous (24-hour/day) and the ongoing responsibility of all the staff members on the unit.

Chart:

Pertinent documentation is to be charted in the patient's Medical Record by the members of the Treatment Team:

1. Attendance
2. Participation
3. Orientation Status
4. Specific Needs / Problems
5. Education Provided
6. Reaction

******
Self-Recovery, L.L.C.
Discharge / Transfer Summary
Administrative Policy No. 33

Purpose:
To document treatment course and discharge planning.

Procedure:
A counselor's discharge summary will be completed and placed in the patient's chart within five days following discharge.

A written Continuing Care Plan... will be developed with the participation of the patient prior to discharge. The Continuing Care Plan will document that reasonable assurance of continued care has been developed.

The Continuing Care Plan will describe and facilitate the transfer of the patient and of the responsibility of his/her continuing care to another phase or modality of the program, to other programs, agencies or individuals, and/or to the patient and his/her personal support system...

1. PI # 3 was admitted to the facility on [DATE] with diagnosis of Medical Detoxification.

Review of the medical record revealed the following documentation related to Group Therapy:

8/22/17 at 11:33 AM: " Ct (Client) attended and participated in the morning 12 step session."
8/23/17 at 11:57 AM: "Ct attended and participated in group therapy session."
8/23/17 at 2:05 PM: "Ct attended and participated in 12 step group therapy session."

There was no documentation of the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

The patient was discharged on [DATE] at 6:07 PM for rules violation. There was no documentation the counselor completed a discharge summary.

An interview was conducted on 3/21/18 at 2:15 PM with Employee Identifier (EI) # 1, Director of Professional Standards, who verified the above.

2. PI # 4 was admitted on [DATE] for Medical Detoxification.

Review of the medical record revealed the following documentation related to Group Therapy:

3/15/18 at 1:51 PM: "Ct attended and participated in 12 step group therapy session."
3/18/18 at 1:31 PM: "Ct attended and participated in 12 step group therapy activity."
3/19/18 at 11:29 AM: "Ct attended and participated in 12 step group therapy session."

There was no documentation of the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

An interview was conducted on 3/21/18 at 3:00 PM with EI # 6, SRU Counselor, who verified the above.

3. PI # 5 was admitted on [DATE] for Medical Detoxification.

Review of the medical record revealed the following documentation related to Group Therapy:

3/21/18 at 10:52 AM: "Ct is currently attended group therapy session with (EI # 5, SRU Manager)."
3/21/18 at 3:40 PM: "Ct attended and participated in 12 step group therapy session - "Why can we not stop using?" the disease concept of addiction."
3/22/18 at 10:47 AM: "Ct attended and participated in the morning twelve step group session."

There was no documentation of the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

4. PI # 6 was admitted on [DATE] for Medical Detoxification.

Review of the medical record revealed the following documentation related to Group Therapy:

3/18/18 at 1:29 PM: "Ct attended and participated in 12 step group therapy activity."
3/19/18 at 11:30 AM: "Ct attended and participated in 12 step group therapy session."
3/21/18 at 12:49 PM: "Ct attended group therapy session this morning with (EI # 5)."
3/21/18 at 3:42 PM: "Ct attended and participated in 12 step group therapy session - "Why can we not stop using?" the disease concept of addiction."
3/22/18 at 10:48 AM: "Ct attended and participated in the morning twelve step group session."

There was no documentation of the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

5. PI # 7 was admitted on [DATE] requesting Detox (detoxification).

The patient was observed on 3/21/18 at 9:10 AM, but was preparing to be discharged home. The surveyor reviewed the patient's medical record on 3/21/18 after the patient had been discharged .

Review of the medical record revealed the following documentation related to Group Therapy:

3/18/18 at 1:30 PM: "Ct attended and participated in 12 step group therapy activity."
3/19/18 at 11:30 AM: "Ct attended and participated in 12 step group therapy session."

There was no documentation of the patient's orientation status, reaction or if there were any specific needs or problems identified during the group therapy sessions.

A tour of the SRU was conducted on 3/20/18 at 10:30 AM Employee Identifier (EI) # 2, SRU Nurse Manager. During this tour, the surveyor observed no patients were visible in the dining / meeting room or hallways. According to EI # 2, all four (4) patients were in their rooms.

When questioned about group therapy, EI # 2 stated the SRU Counselors are responsible for group therapy. The surveyor asked about the counselors, EI # 2 stated both of the counselors were at an inservice in another city for 3/30/18 and 3/21/18.

On 3/21/18 at 7:40 AM, the surveyor returned to the SRU and observed 2 male patients sitting in the dining / meeting room watching TV while eating breakfast and 1 male patient standing in the doorway to the dining / meeting room.

On 3/21/18 at 9:45 AM, the surveyor conducted a confidential interview with PI # 5. The surveyor asked about group therapy for 3/20/18. PI # 5 stated that some guy (unable to recall name) came in the afternoon and showed a video.

On 3/21/18 at 10:05 AM, the surveyor conducted a confidential interview with PI # 6. The surveyor asked PI # 6 how he/she occupied his/her time while admitted to the hospital. PI # 6 stated, "mostly sleeps or watches TV. PI # 6 stated he/she usually talks with the counselor 2 times a day." The surveyor asked about group therapy for 3/20/18. PI # 6 stated that some guy (unable to recall name) came in around 9 or 10 in the morning on 3/20/18 and showed the film.

On 3/21/18 at 11:00 AM, the surveyor asked EI # 1, Director of Professional Standards to find out who the "guy" was that came a showed the patients a video in the SRU on 3/20/18. EI # 1 left the room and a short while later, came in with a sticky note with a gentleman's name and, "Volunteer who comes up every Tuesday morning and has been coming for 3 weeks..." and his phone number.

There was no documentation of the above mentioned group therapy which was conducted by the "Volunteer".

On 3/21/18 at 1:48 PM, a document entitled, "Self - Recovery Group Session for March 20, 2018" was observed sitting on the table in which the surveyor had been reviewing medical record documentation.

A review of the documented Self - Recovery Group Session for March 20, 2018 revealed, "... Group Topic: Coping Skills... (PI # 5) attended group therapy session, the session was on coping skills... (PI # 7) attended group therapy session, the session was on coping skills... (PI # 6) attended group therapy session, the session was on coping skills... " This document had EI # 5, SRU Manager's name and and title "Unit Manager".

An interview was conducted on 3/22/18 at 2:27 PM with EI # 5 in regards to the above document, "Self - Recovery Group Session for March 20, 2018". EI # 5 stated she typed it up because she held a group on 3/20/18. When questioned about the time, EI # 5 stated, "yesterday afternoon." The surveyor asked if this document was a part of the patient's medical record, EI # 5 stated, "No, she just typed it up for the surveyor."
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical records and interviews, it was determined the facility failed to ensure a discharge planning evaluation was completed for patients admitted to the Self Recovery Unit (SRU). This affected 2 of 5 patient records reviewed, including Patient Identifier (PI) # 3, PI # 4 and had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Policy
Self Recovery, L.L.C.
Standards of Care
Administrative Policy No. 11

The patient can expect:

... 11. Individualized discharge planning to be initiated on admission and updated and revised throughout the patient's stay. A copy of discharge plan will be given to patient at time of discharge.

12. To be referred, either during or after treatment, to appropriate agencies according to problems/needs identified in discharge plan...

1. PI # 3 was admitted to the facility on [DATE] with diagnosis of Medical Detoxification.

Review of the medical record revealed no documentation a discharge planning evaluation was completed for PI # 3.

An interview was conducted on 3/21/18 at 2:15 PM with EI # 1, Director of Professional Standards, who verified the above findings.

2. PI # 4 was admitted to the facility on [DATE] with diagnosis of Medical Detoxification.

Review of the medical record revealed no documentation a discharge planning evaluation was completed for PI # 4.

An interview was conducted on 3/21/18 at 3:00 PM with EI # 6, SRU Counselor who verified the above findings.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical records and interviews, it was determined the facility failed to ensure a discharge plan was implemented for patients admitted to the Self Recovery Unit (SRU). This affected 1 of 5 patient records reviewed, including Patient Identifier (PI) # 3 and had the potential to negatively affect all patients admitted to the SRU.

Findings include:

Self Recovery, L.L.C.
Standards of Care
Administrative Policy No. 11

The patient can expect:

... 11. Individualized discharge planning to be initiated on admission and updated and revised throughout the patient's stay. A copy of discharge plan will be given to patient at time of discharge.

12. To be referred, either during or after treatment, to appropriate agencies according to problems/needs identified in discharge plan...

1. PI # 3 was admitted to the facility on [DATE] with diagnosis of Medical Detoxification.

Review of the medical record revealed no documentation a discharge plan was implemented for PI # 3.

Review of the Patient Notes dated 8/23/17 at 6:07 PM revealed the nurse documented, "... Patient discharged at this time for rules violation and for violent behavior towards staff. Patient escorted off unit with Self Recovery driver at this time..."

There was no documentation discharge instructions were provided to the patient for follow up care post discharge from the facility.

An interview was conducted on 3/21/18 at 2:15 PM with EI # 1, Director of Professional Standards, who verified the above findings.