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.

OCEANS BEHAVIORAL HOSPITAL OF SAN MARCOS 1106 N IH 35 SAN MARCOS, TX 78666 May 31, 2019
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the facility failed to maintain an effective, ongoing, hospital wide, data driven quality assessment performance improvement program. The facility has not had a Quality Assurance/Performance Improvement Committee Meeting since July 13, 2018, that includes the collection and aggregation of data from all hospital departments, so the hospital can monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement. This put all patients at risk for receiving unsafe care while in the hospital.

Findings:

In an interview on May 30, 2019, with the facility Director of Quality she stated, "We are aware that the Quality Program is lacking. I am new to the facility as of January and have been unable to find the QAPI meeting minutes. It has been a lot of turnover in positions and paperwork has been lost."

Quality Assessment and Performance Improvement Program Policy, Effective Date 4/1/2017 states in part, "...A hospital shall develop, implement, and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement program. The Quality Improvement Program shall:

Reflect the complexity of the hospital's organization
Involve all hospital departments and services
Specify the frequency and detail of the data collected
Focus on high-risk, high-volume, and problem prone areas in the hospital.

Procedure:

The hospital shall collect and aggregate all data to monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement. The data to be collected and aggregated shall be at least:

Sentinel events
Allegations of abuse and neglect as defined in Rule 134.6 of title 25.
Findings of abuse and neglect made by Texas Department of Health in accordance with Rule 134.64 of title 25
Violations of patients' rights described in Chapter 404, Subchapter E of title 25.
Nosocomial infections
Injuries of patients
Medication errors
Unauthorized departures of patients
Deaths of patients
Surveys of patients, patient's families, and LAR's regarding satisfaction with hospital services.
Complaints and grievances made by patients, and patients families, and LARs.
Psychoactive medications usage (see policy for QI of psychoactive medications).

All above data will be aggregated at least quarterly to assess need for performance improvement (PI). When a need for PI is identified the hospital will develop and implement an action plan. The action plan will be updated and outcomes determined. If the action plan is found not to be successful then it should be modified and reevaluated at a later date.

The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including the Texas Department of Health, The Centers for Medicare and Medicaid Services, and the Joint Commission..."

Cross Refer to Citations A0273, A0283, and A0308.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review, the facility failed to provide documentation that the hospital measures, analyzes, and tracks quality indicators, and other aspects of performance that assess processes of care, hospital service and operations.

Findings:

The facility was unable to provide any documentation of a QAPI program being maintained since July 13, 2018.

Quality Assessment and Performance Improvement Program Policy, Effective Date 4/1/2017 states in part, "...A hospital shall develop, implement, and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement program. The Quality Improvement Program shall:

Reflect the complexity of the hospital's organization
Involve all hospital departments and services
Specify the frequency and detail of the data collected
Focus on high-risk, high-volume, and problem prone areas in the hospital.

Procedure:

The hospital shall collect and aggregate all data to monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement, The data to be collected and aggregated shall be at least:

Sentinel events

Allegations of abuse and neglect as defined in Rule 134.6 of title 25.
Findings of abuse and neglect made by Texas Department of Health in accordance with Rule 134.64 of title 25
Violations of patients' rights described in Chapter 404, Subchapter E of title 25.
Nosocomial infections
Injuries of patients
Medication errors
Unauthorized departures of patients
Deaths of patients
Surveys of patients, patient's families, and LAR's regarding satisfaction with hospital services.
Complaints and grievances made by patients, and patients families, and LARs.
Psychoactive medications usage (see policy for QI of psychoactive medications).

All above data will be aggregated at least quarterly to assess need for performance improvement (PI). When a need for PI is identified the hospital will develop and implement an action plan. The action plan will be updated and outcomes determined. If the action plan is found not to be successful then it should be modified and reevaluated at a later date.

The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including the Texas Department of Health, The Centers for Medicare and Medicaid Services, and the Joint Commission..."
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review, the hospital failed to collect data from all hospital departments to use in the identification of opportunities for improvement and changes that will lead to improvements in care provided by the hospital.

Findings:

The facility was unable to provide any documentation of a QAPI program being maintained since July 13, 2018.

Quality Assessment and Performance Improvement Program Policy, Effective Date 4/1/2017 states in part, "...A hospital shall develop, implement, and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement program. The Quality Improvement Program shall:

Reflect the complexity of the hospital's organization
Involve all hospital departments and services
Specify the frequency and detail of the data collected
Focus on high-risk, high-volume, and problem prone areas in the hospital.

Procedure:

The hospital shall collect and aggregate all data to monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement, The data to be collected and aggregated shall be at least:

Sentinel events

Allegations of abuse and neglect as defined in Rule 134.6 of title 25.

Findings of abuse and neglect made by Texas Department of Health in accordance with Rule 134.64 of title 25

Violations of patients' rights described in Chapter 404, Subchapter E of title 25.

Nosocomial infections

Injuries of patients

Medication errors

Unauthorized departures of patients

Deaths of patients

Surveys of patients, patient's families, and LAR's regarding satisfaction with hospital services.

Complaints and grievances made by patients, and patients families, and LARs.

Psychoactive medications usage (see policy for QI of psychoactive medications).


All above data will be aggregated at least quarterly to assess need for performance improvement (PI). When a need for PI is identified the hospital will develop and implement an action plan. The action plan will be updated and outcomes determined. If the action plan is found not to be successful then it should be modified and reevaluated at a later date.

The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including the Texas Department of Health, The Centers for Medicare and Medicaid Services, and the Joint Commission..."
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record review, the hospital's governing body failed to ensure that the QAPI program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

Findings:

The facility was unable to provide any documentation of a QAPI program being maintained since July 13, 2018.

Quality Assessment and Performance Improvement Program Policy, Effective Date 4/1/2017 states in part, "...A hospital shall develop, implement, and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement program. The Quality Improvement Program shall:

Reflect the complexity of the hospital's organization

Involve all hospital departments and services

Specify the frequency and detail of the data collected

Focus on high-risk, high-volume, and problem prone areas in the hospital.


Procedure:

The hospital shall collect and aggregate all data to monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement, The data to be collected and aggregated shall be at least:


Sentinel events

Allegations of abuse and neglect as defined in Rule 134.6 of title 25.

Findings of abuse and neglect made by Texas Department of Health in accordance with Rule 134.64 of title 25

Violations of patients' rights described in Chapter 404, Subchapter E of title 25.

Nosocomial infections

Injuries of patients

Medication errors

Unauthorized departures of patients

Deaths of patients

Surveys of patients, patient's families, and LAR's regarding satisfaction with hospital services.

Complaints and grievances made by patients, and patients families, and LARs.

Psychoactive medications usage (see policy for QI of psychoactive medications).

All above data will be aggregated at least quarterly to assess need for performance improvement (PI). When a need for PI is identified the hospital will develop and implement an action plan. The action plan will be updated and outcomes determined. If the action plan is found not to be successful then it should be modified and reevaluated at a later date.

The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including the Texas Department of Health, The Centers for Medicare and Medicaid Services, and the Joint Commission..."