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.

OPTIONS BEHAVIORAL HEALTH SYSTEM 5602 CAITO DRIVE INDIANAPOLIS, IN 46226 March 6, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, interview, and observation, the facility failed to provide shower temperatures per guidelines in 10 of 69 instances.

Findings include:

1. Review of a facility document titled Daily water temperature 2019 indicated the Tem [temperature] range: 110f [degrees Fahrenheit] - 120f. Further review indicated the following:

Jan {January} 31 no temperature recorded
Feb {February} 19 109f
[DATE] 108f
Mar {March} 1 106f

2. In interview on 03-06-2019 at 12:30 pm, employee #A1, Director of Risk, confirmed all the above and no other documentation was provided prior to exit.

3. On 03-06-2019 at 10:55 am, in the presence of employees #A1, Director of Risk, #A2, Director of Plant Operations, and #A3, Maintenance, at a first floor nursing station, it was observed a temperature thermometer provided by the facility was calibrated by placing the thermometer in a cup with water and ice. The calibrated thermometer reading was observed to be 33 degrees F.

4. On 03-06-2019 at 11:05 am in the presence of employees #A1, #A2 and #A3, the following was observed in patient Room 512:
- patient shower head water temperature 105 degrees F.

5. On 03-06-2019 at 11:20 am in the presence of employees #A1,# A2 and #A3, the following was observed in patient Room 507:
- patient shower head hot water temperature 105 degrees F.

6. On 03-06-2019 at 11:30 am in the presence of employees #A1, #A2 and #A3, the following was observed in patient Room 511:
- patient shower head water temperature 104 degrees F.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document review and interview, the facility lacked documentation that discharged patient rooms were cleaned in 1 instance.

Findings include:

1. On 03-06-2019 at 12 noon, employee #A1, Director of Risk, was requested to provide documentation of a policy to clean patient rooms after discharge and also to provide documentation that patient rooms were cleaned after discharge.

2. Review of a facility document titled PATIENT ROOMS - DISCHARGE ISOLATION ROOM CLEANING, approval date unknown, indicated after a patient was discharged , various actions to be taken regarding waste receptacles, bedding and spoiled linen, cleaning mattress and pillow covers, replace pillow covers and remake the bed, damp dust all surfaces of the over-the-bed table and bedside stand, and clean the inside as well as the outside surfaces.

3. In interview on 03-06-2019 at 12:20 pm, employee #A1 confirmed the above policy was followed for all discharges and also indicated there was no documentation of cleaning of patient rooms at discharge. No other documentation was provided prior to exit.