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 Aug. 21, 2019
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document review, observation and interview, the facility failed to maintain a clean environment in one facility.

Findings include:

1. Review of facility policy, OFFICES, indicated the following. Daily: Empty waste receptacle... Weekly: Vacuum traffic patterns of carpeted floors.

2. Review of facility policy, DAY AREAS, GROUP ROOMS AND CORRIDORS IN PATIENT AREAS, indicated the following. Daily: ... Spot clean walls, doors, door facings, columns, and other building surfaces to remove handprints, smudges, and other obvious soil... Damp mop non-carpeted floors... WEEKLY: Dust ceiling vents and diffusers.

3. Review of facility policy, NURSES' STATION, indicated the following. DAILY: ... Spot clean walls, doors, door facings, columns, and other building surfaces to remove handprints, smudges, and other obvious soil... Damp mop non-carpeted floors...

4. Review of facility policy, PATIENT REST ROOMS, indicated the following. Daily: ... Clean toilets.

5. On observation of 8/21/2019, between approximately 9:03 am, and 10:59 am, with N1 (Director of Risk) the following was observed. Group room second floor main hall had approximately 12 dust balls about the size of a thumb and many smaller ones on the floor. Vent in ceiling coated in dust (brown fuzzy material). Nursing station for unit 1 and 2 had many brown and green crusty areas on floor. Brown dry drips on upper walls. Medication room had a full Pepsi bottle and a personal drink container on a cabinet. Under the sink was a Steak and Shake box containing what appeared to be a dried out pancake and syrup. Unit 2 patient items storage had clothes on the floor. Unit 2 Galley Kitchen had approximately 24 splattered areas (approximately the size of a fifty cent piece to smaller than a dime) covered in dirt. Unit 2 day room floor generally dirty with areas of sticky drips. Unit 2 hall had crusty dirty brown spots on wall. Dust and dirt on both sides of hallway floor for the entire length of the hall. Therapist office Unit 2 trash can was overflowing with multiple bottles sticking out of the top. 7 pieces of trash (paper) on the floor around the trash can. Dust and debris in corner of office (triangle of dust about 11 inches long on one side). Dust and debris all over the floor. Patient with therapist on our arrival. Patient room 207 brownish looking dried drips on toilet seat. Brownish streaks on toilet paper holder. Unit 3 Nursing station had approximately 36 crusty brown spots on the floor (approximate size of a quarter to 1/4 the size of a dime). The floor had lots of debris, dust and dirt and sticky areas. Discharge planning office on Unit 3 had debris all over carpet. Thick dust on top of cabinets. Group room Unit 3 had approximately 24 dust balls approximately the size of pinky finger. Paper was scattered over the floor.

6. On interview of 8/21/2019, at approximately 10:59 am, with N1 (Director of Risk) confirmed the items found above on observation from 9:03 am, through 10:59 am.

7. Review of facility personnel files indicated S1 (Housekeeper) presently trained and working as housekeeper. S2 (Cook) hired 6/17/2019, is functioning as a housekeeper, lacked documentation of training for housekeeping. S3 (Housekeeper) presently on leave starting 6/28/2019. S4 (Chief Financial Officer) lacked documentation of training for housekeeping. S5 (Housekeeper) currently on leave starting 5/25/2009. (The facility has a total of three housekeepers with documentation of training in housekeeping. Two of those are on leave. A Chief Financial Officer and a Cook with no documentation of training for housekeeping are functioning in the housekeeper roles.)

8. Interview on 8/21/2019, at approximately 2:00 pm, with S4 (Chief Financial Officer) confirmed if fully staffed the facility would have 3.5 housekeepers. Present today is one housekeeper and S4 functioning as second housekeeper. S2 (Cook) (functioning as a housekeeper) had called in today (not working). Two (S3 and S5) housekeepers are on leave.