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.

UNITYPOINT HEALTH - DES MOINES IOWA METHODIST MEDI 1200 PLEASANT STREET DES MOINES, IA 50309 Feb. 11, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on documents reviewed and staff interviews Iowa Methodist Medical Center (IMMC) administrative staff failed to:

1. Independently create and maintain Patient's Rights information exclusive to IMMC. Please see A-0116 and A-0117.

2. Independently create and maintain Patient Rights policies and procedures exclusive to IMMC. Please see A-0116 and A-0117.

3. Independently maintain a grievance process or utilize staff dedicated to IMMC for the grievance process. Please see A-0118.

4. Independently create and maintain Restraint and seclusion policies. Please see A-0167, A-0167, and A-0208.

The cumulative effects of these failures and deficient practices resulted in the hospital's inability to ensure all Patient's Rights. The facility census was 485 patients when the survey team made entrance on 1/22/2019.
VIOLATION: GOVERNING BODY Tag No: A0043
I. Based on document review and staff interview, Iowa Methodist Medical Center's administrative staff failed to:

1. Establish or maintain Iowa Methodist Medical Center as a separate and distinct from other entities that encompassed Health System B, which included Hospital A (a separately certified hospital). Please refer to A-0043.

2. Appoint a Chief Executive Officer who was responsible exclusively for the management of Iowa Methodist Medical Center. Please refer to A-0057.

3. Prepare and establish an overall institutional budget which was independent of Health System B, which included Hospital A (a separately certified hospital). A-0073.

4. Submit the hospital's budget plan to the state health planning agency as required by the regulation. Please refer to A-0074.

5. Develop and maintain contracts that were exclusive to Iowa Methodist Medical Center. Please refer to A-0083.

6. Maintain a list of contracts that were exclusive to Iowa Methodist Medical Center. Please refer to A-0085.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibilities of the hospital The facility census was patients when the survey team made entrance on 1/22/19.

II. Based on interviews, review of meeting minutes, hospital bylaws, facility organizational chart, and contracted services, the governing body of Iowa Methodist Medical Center (IMMC) failed to establish or maintain a facility that was separate and distinct from other providers encompassing the Health System B. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. During an interview on 1/14/19 at 3:00 PM, the Chairman of the Board of Directors revealed the governing body was responsible for the oversight of the Iowa Methodist Medical Center as well as Hospital A, a separately certified hospital. The Chairman confirmed there was only 1 governing body for oversight of Health System B, which included IMMC and Hospital A. The Chairman further confirmed the facilities in Health System B (IMMC and Hospital A) operated under the same set of written governing body bylaws. The Chairman also verified the Chief Operating Officer for IMMC was hired by Health System B governing body and was responsible for both IMMC and Hospital A.

2. Review of the Board of Director's Meeting minutes from February 16, 2017 through December 20, 2018 confirmed that business from both IMMC and Hospital A, as well as other Health System B entities, were consistently integrated into the meeting minutes and failed to address which actions applied to IMMC. Co-mingled topics routinely included reappointment of medical staff members, Quality Assessment Reports, and financial information from all sources within Health System B.

3. Review of hospital bylaws for Health System B, dated January 1, 2018, and included IMMC and Hospital A, revealed in part, "...[Health System B], after consultation with the Board of Directors, shall select and appoint a competent President [Chief Executive Officer] who shall be its direct executive representative in the management of the [Health System B's name]...."

4. Review of the current organizational chart revealed the lines of authority for both IMMC and Hospital A were drawn directly under the responsibility of the same individual, further confirming that the CEO was responsible for both IMMC and Hospital A.

5. Review of a sample of contracts from the list of contracts provided by IMMC staff, on 1/9/18 at 1:00 PM with the Contract Coordinator, revealed approximately 158 general contracts and 113 physician contracts. Review of 7 general contracts and 1 physician contract revealed Health System B contracted directly with the service provider, not IMMC or Hospital A, a separately certified hospital.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on interviews, review of the facility-provided organizational chart, governing body bylaws, and governing body meeting minutes, the governing body failed to appoint a Chief Executive Officer (CEO) who was responsible exclusively for the management of Iowa Methodist Medical Center (IMMC). The failure to appoint a CEO exclusively for the management of the hospital had the potential to affect all of the patients of IMMC. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. During an interview on 1/7/19 at 1:20 PM, the Executive Director of Clinical Decision Support and Quality for Health System B revealed Health System B had 1 Chief Executive Officer (CEO), who was responsible for both IMMC and Hospital A. Health System B included IMMC and Hospital A, a separately certified hospital.

During an interview on 1/14/19 at 3:00 PM, the Chairman of the Board of Directors verified Health System B's governing body hired the CEO, and the CEO was responsible for both IMMC and Hospital A.

2. Review of the current organizational chart revealed the lines of authority for both IMMC and Hospital A were drawn directly under the responsibility of the same individual, further confirming that the CEO was responsible for both IMMC and Hospital A.

3. Review of hospital bylaws for Health System B, dated January 1, 2018, and included IMMC and Hospital A, revealed in part, "...[Health System B], after consultation with the Board of Directors, shall select and appoint a competent President [Chief Executive Officer] who shall be its direct executive representative in the management of the [Health System B]...."

4. Review of Board of Director's Meeting minutes dated June 6, 2018 confirmed the governing body for the Health System B appointed a single CEO, who had responsibility for both IMMC and Hospital A.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on staff interview, review of policies and the 2017 and 2018 operating budget, Iowa Methodist Medical Center (IMMC) failed to prepare and establish an overall institutional budget that was independent of Hospital A, and exclusive to IMMC. The failure to prepare and establish and overall institutional budged that was independent of Hospital A, a separately certified hospital; and exclusive to IMMC had the potential to affect all patients of the hospital. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of the policy "Operating and Capital Expenditure Budgets" for Health System B which included IMMC and Hospital A, a separately certified hospital, dated 12/16, revealed in part, "The Senior Vice-President of Finance is responsible for coordinating the timing of the budget cycle to include necessary approvals and incorporation into the consolidated [Health System B's name] budget process...."

Review of the 2017 and 2018 operating budget revealed the operating budget contained sources of revenue from both IMMC and Hospital A (a separately certified hospital). The operating budget contained expenses for both IMMC and Hospital A.

2. During an interview on 1/9/19 at 12:30 PM, the Chief Financial Officer (CFO) verified the operating budget was not exclusive to IMMC, and included income and expenses from IMMC and Hospital A (a separately certified hospital).
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0074
Based on review of documentation and staff interview, Iowa Methodist Medical Center (IMMC) failed to submit the hospital's budget plan to the state health planning agency as required by the regulation. Failure to submit the hospital budget plan specific to the individual facility to the state health planning agency prevented the state health planning agency from reviewing the hospital's capital expenditures specific to that facility. The hospital administrative staff identified 1 of 1 hospital budget plan. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of documentation revealed the hospital lacked evidence the hospital staff submitted the budget to the state health planning agency.

2. During an interview on 1/14/19 at 11:50 AM, the Executive Director of Clinical Decision Support and Quality for Health System B, which included IMMC and Hospital A (a separately certified hospital), acknowledged the hospital staff failed to send the hospital's 2018 budget to the state health planning agency.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on a review of a selected sample of contracts and staff interviews, the governing body failed to develop and maintain contracts that were exclusive to Iowa Methodist Medical Center (IMMC). Failure of the governing body to
develop and maintain contracts that were exclusive to IMMC had potential to not allow the governing body to evaluate the effectives of the contracts services at IMMC and therefore affects all patients of the hospital. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of contracts from the list of contracts provided by IMMC staff, on 1/9/18 at 1:00 PM with the Contract Coordinator, revealed approximately 158 general contracts and 113 physician contracts. Review of 7 general contracts and 1 physician contract revealed Health System B contracted directly with the service provider, not ILH or Hospital A, a separately certified hospital.

2. During an interview on 1/9/19 at 10:25 AM, the Executive Director of Clinical Decision Support and Quality for Health System B revealed the contracts for services at IMMC did not exclusively cover IMMC. Instead, the contacted services agreements were between the contractors and the Health System B, which included IMMC and Hospital A (a separately certified hospital).

3. During an interview on 1/9/18 at 1:00 PM, the Contract Coordinator verified the list of contracts included contracts with IMMC and Hospital A.

4. During an interview on 1/14/19 at 3:00 PM, the Chairman of the Board of Directors stated Health System B developed the contracts with the contracted services and the governing body reviewed all the contracts, including contracts which may be specific to IMMC or Hospital A (a separately certified hospital).
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on a review of a selected sample of contracts and staff interviews, the governing body failed to maintain a list of contracts that were exclusive to Iowa Methodist Medical Center (IMMC). Failure maintain a list of contracts that were exclusive to IMMC could potentially result in the staff and governing body lacking adequate oversight of all the contracted services. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of contracts from the list of contracts provided by IMMC staff, on 1/9/18 at 1:00 PM with the Contract Coordinator, revealed approximately 158 general contracts and 113 physician contracts. Review of 7 general contracts and 1 physician contract revealed Health System B contracted directly with the service provider, not IMMC or Hospital A, a separately certified hospital.

2. During an interview on 1/9/18 at 1:00 PM, the Contract Coordinator verified the list of contracts included contracts included contracts with Health System B. The Contract Coordinator identified the contracts were not between IMMC and the contractor, but instead with Health System B, which included IMMC and Hospital A, a separately certified hospital.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
Based on document review of Patient Rights information provided to patients on admission/registration and staff interview, the facility failed to ensure that Iowa Methodist Medical Center (IMMC) had its own independent Patient Rights information. The facility used Health System B's Patient Rights brochure which included information for IMMC and separately certified Hospital A. Failure of Iowa Methodist Medical Center to have its own Patient Rights information could potentially result in IMMC's patients failing to realize they could fully exercise their patient rights as a patient at IMMC. The facility census was 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed the hospital staff provided Patient Rights information on admission and or registration to patients using a patient's rights brochure which was not specific to IMMC, but instead was the same for all hospitals in Health System B, which included IMMC and Hospital A, a separately certified hospital.

B. Review of the brochure "Patient Rights and Responsibilities [Health System B's name]," updated 02/2016, revealed the brochure was written as a single brochure for all patients of Health System B. Health System B's Patient Rights and Responsibilities brochure did not list Iowa Methodist Medical Center's name anywhere in the brochure.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on document review and staff interview Iowa Methodist Medical Center (IMMC) failed to independently meet the requirements to provide patient rights information to patients upon admission and/or registration for services. Failure of IMMC to independently provide patient rights information specific to IMMC could potentially result in patients failing to realize they had rights while receiving services at IMMC and had the ability to exercise their rights. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19

Findings include:

1. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed the hospital staff provided Patient Rights information on admission and or registration to patients using a patient's rights brochure which was not specific to IMMC, but instead was the same for all hospitals in Health System B, which included IMMC and Hospital A, a separately certified hospital.

B. Review of the brochure "Patient Rights and Responsibilities [Health System B's name]," updated 02/2016, revealed the brochure was written as a single brochure for all patients of Health System B. Health System B's Patient Rights and Responsibilities brochure did not list Iowa Methodist Medical Center's name anywhere in the brochure.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review of Patient Right information provided to patients regarding grievances on admission, review of policies and procedures related to grievances, and staff interviews, Iowa Methodist Medical Center (IMMC) failed to create an independent process for resolution of grievances. IMMC's failure to to independently inform patients of their grievance rights and to establish and maintain an independent process for resolution of grievances could potentially result in IMMC's patients failing to realize they could fully utilize the hospital's grievance process. The administrative staff identified a census of 485 patients when the survey team entered on 1/22/19.

Findings include:

1. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed that the Patient Rights information provided to patients on admission and/or registration for services at IMMC was not specific to IMMC but was system wide, which included IMMC and Hospital A, a separately certified hospital.

2. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed the hospital staff provided Patient Rights on admission and or registration, a patient's rights brochure which was not specific to IMMC, but instead was the same for all hospitals in Health System B, which included IMMC and Hospital A, a separately certified hospital.

The brochure informs patients in part, "You may use the [Hospital System B's name] complaint/grievance resolution process for submitting a written or verbal concern to your caregivers, our Guest Relations department, ... or hospital administration." The complaint/grievance process options to submit a complaint or grievance are identified as:

A. "The e-mail address for sending concerns directly to [Hospital System B's name] was webquestions@[Hospital System B]."

B. Patients are informed they will "receive a written response upon receipt of your grievance from [Health System B's name] ...."

3. Review of the policy "PATIENT AND FAMILY COMPLAINT/GRIEVANCES" for Health System B, which included IMMC and Hospital A, a separately certified hospital, dated 10/2016, was not exclusive to IMMC. The purpose of the policy identified "[Health System B's name] strives to be responsive to the needs of the patients ... to whom its services are provided." The policy revealed in part, "Use the [Health System B's name] complaint/grievance process for submitting a written or verbal complaint to your caregivers, Guest Relations, your healthcare practitioners, or Administration." The complaint/grievance process options to submit a complaint or grievance was identified as:

A. "The e-mail address for sending concerns directly to Health System B was webquestions@[Health System B's name]."

B. "Receive a written response upon receipt of your grievance from [Health System B's name] on average within seven (7) calendar days."

The policy and procedure further identified the "Processing of Grievances," revealed in part, " For each grievance received, an initial investigation is done by Guest Relations to determine the type of problem ... information will be shared with the Clinical Quality Department... [and an] aggregate summary of grievance will be reviewed annually with Management Review Group." "The [Health System B's name] Board of Directors delegates the implementation and effective operation of the 'Patient and Family Complaint/Grievance Policy' to the Grievance Committee of [Health System B's name]. The [Health System B's name] Grievance Committee consisted of the Vice President of Medical Affairs, Guest Relations Coordinators and Clinical Risk Manager; and ad hoc of the relevant department leadership."

4. During an interview on 1/9/2019 at 10:45 AM, the Assistant Vice President of Medical Affairs (VPMA) and Guest Relations Coordinator (GRC) B, revealed that MMCH grievances are reviewed and processed by Health System B. Health System B does not have an independent grievance process for IMMC.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on document review and staff interviews, the acute care hospital failed to independently create policies and procedures instructing staff on how to safely use and apply restraints in the hospital. Failure of Iowa Methodist Medical Center (IMMC) to independently create policies and procedures regarding restraining patients could potentially result in the staff members attempting to utilizing a restraint method or device potentially not available at IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings included:

1. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed that the Patient Rights information provided to patients on admission and/or registration for services at IMMC was not specific to IMMC but was system wide, which included IMMC and Hospital A, a separately certified hospital.

Licensed Independent Practitioners (LIP) received restraint training as part of their initial orientation, written restraint information was included in the orientation manual, and every 2 years, at recredentialing, the LIP attested that they understood and would abide by the restraint policies and procedures. Iowa Methodist Medical Center's LIP training records are maintained in the LIP's credentialing files (a personnel file for LIPs). Health System B considered the medical staff for IMMC and Hospital A (a separately certified hospital) to be a single medical staff.

2. During a second interview on 1/9/2019 at 2:45 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed policies and documents are developed for Health System B and did not differentiate between Iowa Methodist Medical Center and Hospital A, a separately certified hospital.

3. During an interview on 1/9/2019 at 11:15 AM, Assistant Vice President of Nursing revealed the policy "RESTRAINT AND SECLUSION" was not specific to IMMC and was developed for Health System B, which consisted of IMMC and Hospital A, a separately certified hospital.

4. Review of the policy "RESTRAINT AND SECLUSION USE" for Health System B, which included IMMC and Hospital A, a separately certified hospital, dated 03/2018, revealed the policy did not include IMMC's name, instead only listing Health System B's name.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
Based on document review and staff interview, Iowa Methodist Medical Center (IMMC) failed to have its own hospital policy, procedure and records to ensure the physicians and other licensed independent practitioners (LIP) met the requirements for training regarding the use of restraints. Failure to have their own policy, procedures and training records could potentially result in the hospital staff lacking the ability to verify the LIP training on restraints. The hospital's administrative staff identified a census of 485 patients upon entrance of the survey team on 1/22/19.

Findings include:

1. Review of the policy "RESTRAINT AND SECLUSION USE" for Health System B, which included IMMC and Hospital A, a separately certified hospital, dated 3/2018, revealed in part "[Health System B's] philosophy is to strive toward a restraint and seclusion free environment ... usage of restraints or seclusion require an order by a licensed independent practitioner."

"Licensed independent practitioner educational information is provided initially upon credentialing in the licensed independent practitioner's orientation package. This education is provided again during the recredentialing cycle (every 2 years). The restraint education includes hospital requirements for restraint orders for non-violent and non self-destructive behaviors, seclusion orders (mental health units only), and restraint orders for violent or self destructive behaviors, type of restraints in use at [Health System B's name], face-to-face patient assessment, notification of the attending physician, and definition of terms."

"Definitions ... For purposes of this policy, LIP includes M.D. (physician/resident physician), D.O. (physician/resident physician), .. and ARNP (advanced registered nurse practitioner)."

2. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed physicians and licensed independent practitioners (LIP) received restraint training as part of their initial orientation, written restraint information was included in the orientation manual, and every 2 years, at recredentialing, the LIP attested that they understood and would abide by the restraint policies and procedures. IMMC did not have a restraint and seclusion policy or education and training independent of Health System B's providers. IMMC and Hospital A are considered 1 Medical Staff.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
I. Based on document review and staff interviews, Iowa Methodist Medical Center's (IMMC) administrative staff failed to:

1. Maintain a separate and independent medical record department for IMMC. Please see A-0431.

2. Maintain a separate and independent medical record for each patient at IMMC. Please See A-048.

The cumulative effects of these failures and deficient practices resulted in the hospital's inability to carry out the responsibility of the Condition of Participation for Medical Record Services (42 CFR 482.24). The hospital's administrative staff identified a census of 485 inpatients when the survey team made entrance on 1/22/2019.


II. Based on policy review, staff interviews and observation of the Health Information Management (HIM) department staff and space, Iowa Methodist Medical Center (IMMC) failed to maintain a separate and independent medical record service as evidenced by the sharing of employees, medical record electronic and storage systems, and the HIM department only offering patients the ability to request copies of their medical records at IMMC (which required the staff at Hospital A to print out copies of the medical record for a patient requesting their medical record at IMMC). Iowa Methodist Medical Center failed to demonstrate the ability to have an independent department for medical record services. Failure of the hospital to have an independent Medical Record service had the potential to affect the medical records information needs of all patients of the acute care hospital. The hospital's administrative staff identified a census of 485 patients upon the survey team's entrance on 1/22/2019.

Findings include:

1. Review of policy "Admission Policies - Administrative and Financial Aspects," dated 12/2017, revealed in part, "...[Health System B] will offer any person admitted to [Health System B] access to treatment or accommodations that are available and medically indicated...." The policy was not specific to IMMC and indicated it applied to both IMMC and Hospital A, a separately certified hospital.

2. An interview on 1/10/19 at 10:37 AM with the Director of HIM & CDI (Clinical Documentation and Improvement) and the Manager of HIM Operations revealed they are employed by Hospital System B and supervise the medical record systems for all hospitals in Health System B, which includes IMMC and Hospital A, a separately certified hospital. The Director of HIM & CDI disclosed the HIM department is centralized on IMMC's campus.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on document review and staff interview, Iowa Methodist Medical Center (IMMC) failed to have its own hospital policy and records to ensure physicians and other licensed independent practitioners (LIP) met the requirements for training regarding the use of restraints. Failure of the hospital to have their own policy and records to ensure physicians and other LIP's met the requirements for training regarding the use of restraints could potentially result in the hospital staff not verifying the training of the LIP on restraints and seclusion. The hospital administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. Review of the policy "RESTRAINT AND SECLUSION USE" for Health System B, which included IMMC and Hospital A, a separately certified hospital, dated 3/2018, revealed in part "[Health System B's] philosophy is to strive toward a restraint and seclusion free environment ... usage of restraints or seclusion require an order by a licensed independent practitioner."

"Licensed independent practitioner educational information is provided initially upon credentialing in the licensed independent practitioner's orientation package. This education is provided again during the recredentialing cycle (every 2 years.) The restraint education includes hospital requirements for restraint orders for non-violent and non self-destructive behaviors, seclusion orders (mental health units only), and restraint orders for violent or self destructive behaviors, type of restraints in use at [Health System B's name], face-to-face patient assessment, notification of the attending physician, and definition of terms."

"Definitions ... For purposes of this policy, LIP includes M.D. (physician/resident physician), D.O. (physician/resident physician), ... and ARNP (advanced registered nurse practitioner)."

2. During an interview on 1/9/2019 at 1:05 PM, the Executive Director, Clinical Decision Support & Quality for Health System B revealed physicians and licensed independent practitioners (LIP) received restraint training as part of their initial orientation, written restraint information was included in the orientation manual, and every 2 years, at recredentialing, the LIP attested that they understood and would abide by the restraint policies and procedures. IMMC did not have a restraint and seclusion policy, or education and training, independent of Health System B's providers. IMMC and Hospital A are considered 1 Medical Staff.
VIOLATION: QAPI Tag No: A0263
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent quality assurance (QA) department, including staffing, documents and meetings. Please refer to A-0263.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to independently and separately develop an effective quality assessment and performance improvement program. The hospital's administrative staff identified 485 patients upon entrance on 1/22/2019.


II. Based on staff interviews and document review, Iowa Methodist Medical Center's (IMMC) administrative staff failed to ensure the hospital had a separate and independent Quality Assurance (QA) department for 1 of 1 QA programs. Failure to create a separate and independent QA program resulted in the hospital failing to ensure their QA program focused on concerns and priorities for the hospital, and did not include information from another separately certified hospital. The administrative staff identified 485 patients upon entrance on 1/22/2019.

Findings include:

1. During an interview on 1/14/19 at 2:15 PM, the Executive Director, Clinical Decision Support and Quality, stated the department was responsible for QA for Health System B, which included IMMC and Hospital A, a separately certified hospital. She reported to the Executive Vice President/Chief Operating Officer for Health System B. Her main office is at IMMC but she spends a lot of her time at Hospital A as well. She indicated the QA department staff's main offices are at IMMC, but their work was organized by function and they also spend time at Hospital A. She confirmed that the staff are all employees of Health System B and their paycheck comes from Health System B. She confirmed that the Nursing Quality committee included members from IMMC and Hospital A. The Management Review Committee also included members from IMMC and Hospital A. The Management Review Committee Service Line information was integrated with Hospital A, but the quality data was reported separately for IMMC and Hospital A.

2. Review of the Quality Management System (QA Plan), dated 11/2018, revealed that the Scope of the Quality Management System for Health System B includes IMMC and Hospital A, a separately certified hospital, and includes all clinical and non-clinical areas. The "[Health System B's name] Plan for the Provision of Care" describes the clinical services and number of beds provided by IMMC and Hospital A, the affiliated ambulatory services listed on the hospital licenses of both facilities, and the contracted patient care services.

3. Review of the "Plan For the Provision of Patient Care", dated 12/17, revealed that IMMC and Hospital A were affiliates of [Health System B] which established mission and vision statements which guide planning, budgeting, and policy development.

4. Review of the job description for the "Executive Director, Clinical Decision Support and Quality [Health System B]." "The individual assumes responsibility for the support of the Quality Management System and serves as a resource to the Medical staff affiliated with [Health System B]." The job description indicates the candidate will work with both IMMC and Hospital A to provide Quality Assurance assistance and provide supervision to staff at both hospitals.

5. Review of a sample of the Nursing Quality Improvement meeting minutes dated 10/15/18, 11/19/18, and 12/17/18 revealed the meeting was held at IMMC. The meeting minutes revealed the staff combined data from IMMC and Hospital A together, and reported only the single number to the committee. The data did not include any information specific to IMMC, except for a single reference to the rate of bed sores at Hospital A (a separately certified hospital).

6. Review of a sample of Management Review Committee meeting minutes dated 9/26/18, 10/24/18, 11/28/18, revealed the meeting was held at IMMC. The meeting minutes reported information by Service Line (grouping of similar departments into categories to report information together, and contains information from both IMMC and Hospital A combined together in the report).
VIOLATION: MEDICAL STAFF Tag No: A0338
I. Based on document review and staff interviews, Iowa Methodist Medical Center's (IMMC) administrative staff failed to:

1. Ensure a separate and independent medical staff for the purpose of providing care to patients requiring acute inpatient services. Please refer to A-0338.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/2019.


II. Based on document review and staff interviews, Iowa Methodist Medical Center's (IMMC) administrative staff failed to ensure a separate and independent medical staff for the purpose of providing care to patients requiring acute inpatient services. The medical staff was fully integrated into other aspects of Health System B, which included IMMC and Hospital A, a separately certified hospital. Failure to ensure a separate and independent organizational medical staff could potentially result in the medical staff's inability to evaluate the care of patients at IMMC, instead of including the care for patients at Hospital A, a separately certified hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of documents as follows:

a. Medical Staff Bylaws, reviewed May 2018, identified the Bylaws covered both IMMC and Hospital A, a separately certified hospital;

b. Medical Staff Organization and Functions Manual, reviewed December 2018, identified the Manual covered both IMMC and Hospital A, a separately certified hospital;

c. Credentialing Policy Manual, reviewed December 2018, identified the Manual covered both IMMC and Hospital A, a separately certified hospital,

d. Policy on Allied Health Dependent Providers, dated June 2018, identified the Policy Manual covered both IMMC and Hospital A, a separately certified hospital.

The Medical Staff Bylaws, Medical Staff Organization and Functions Manual, Credentialing Policy Manual, and Policy on Allied Health Dependent Providers failed to be specific to Iowa Methodist Medical Center.

Review of Roster of Practicing Staff, provided by the Executive Director Clinical Decision Support and Quality, showed 426 practitioners that provided services to IMMC and Hospital A, and included 32 physicians listed with privileges only at Hospital A.

Review of Medical Executive Committee Meeting Minutes for August 7, 2018 through December 11, 2018 confirmed the lack of separation between the medical staff, as discussion of issues from both IMMC and Hospital A were intermingled throughout the meeting minutes including approval of Medical Staff Policies for both IMMC and Hospital A.

Review of Credentials Committee Meeting Minutes for August 1, 2018 through October 3, 2018 confirmed the lack of separation between the medical staff, as discussion of issues from both IMMC and Hospital A were intermingled throughout the meeting minutes.

Review of an example of Medical Staff policy, "EMTALA CALL", dated 1/22/2018, revealed the policy was signed by the Chief of Staff IMMC and Chief of Staff Hospital A (the Chief of Staff is the physician responsible for the administrative functions of the Medical Staff).

Review of physician credential files revealed 3 of 4 physicians had privileges for both IMMC and Hospital A (Practitioners G, H, I). The credential files did not differentiate which privileges the physicians could perform at each hospital. The credential files lacked documentation the list of privileges available to physicians took into account the unique and individual capabilities and capacity of each hospital.

2. During an interview on 1/14/19 at 12:40 PM, the Chief Medical Officer (CMO) indicated the medical staff for IMMC and Hospital A have different memberships, but function as a combined medical staff for decision making. The CMO revealed the Medical Executive Committee consists of member from both IMMC and Hospital A. The CMO acknowledged the Medical Executive Committee Meeting minutes do not reflect any specifics for IMMC or Hospital A.

During an interview on 1/17/19 at 10:10 AM, the Executive Director Clinical Decision Support and Quality acknowledged the physician's credential files are maintained at IMMC.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and staff interview, Iowa Methodist Medical Center's (IMMC) administrative staff failed to:

1. Ensure a separate and independent organized nursing service department. IMMC shared the Chief Nurse Executive (CNE) position as well as policies and procedures with Hospital A, a separately certified hospital. Please refer to A-0386.

2. Ensure IMMC had its own distinct independent nursing staff to provide nursing care for Iowa Methodist Medical Center (IMMC) patients. IMMC shared nursing employees with Hospital A, a separately certified hospital. Please refer to A-0393.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital. The facility census was 485 on entrance on 1/22/2019.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on review of the facility Organizational Charts, job descriptions, facility policies, and staff interview, Iowa Methodist Medical Center (IMMC) failed to have nursing service staff to provide care exclusively for IMMC patients. Failure to ensure a separate and independent organizational nursing service could potentially impact past and present patients of IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of the Nursing Services Organizational Chart dated May 1, 2018 demonstrated the lack of a separate Chief Nursing Executive (CNE) for Iowa Methodist Medical Center. The organization chart revealed Health System B commingled the administrative oversight for the nursing care at 2 separately certified hospitals (IMMC and Hospital A) into a single organization. The CNE was responsible for overseeing nursing care at both hospitals.

Review of the undated facility Organization Chart showed the Chief Nursing Executive reported to the President/Chief Executive Officer (CEO) for Health System B. Health System B included IMMC and Hospital A, a separately certified hospital.

2. Review of the job description for the CNE, effective date November 2001, revealed in part, "The Chief Nurse Executive (CNE) for [Health System B's name] functions as the senior leader for nursing services responsible for effective operations of patient care...."

3. Review of 5 random policies revealed the following labeled as Health System B's policies as follows:

a. "Nursing Services: Nursing Administration," dated 1/2/19, revealed in part, "Purpose: To define the administrative authority and essential elements required for nursing practice at [Health System B] ... The professional nursing staff of Iowa Methodist Medical Center (IMMC), [and Hospital A's name]... believes the following: Nursing is an essential and integral component of patient care at Iowa Methodist Medical Center, [and Hospital A's name]..."

b. "Plan For The Provision of Patient Care", dated 12/2017, revealed in part, "...Iowa Methodist Medical Center [Hospital A's name], ... are affiliates of the [Health System B's name] which establishes mission and vision statements which guide planning, budgeting, and policy development...."

c. "Global Nursing Documentation", dated 12/2017, revealed in part, "Purpose: To provide principles and guidelines for patient care documentation with an electronic health record (EHR) system..."

d. "Medical Emergency Team (MET) - Adult", dated 12/2017, revealed in part, "... to provide urgent and emergent critical care interventions for a patient becoming unstable or requiring advanced assessment and interventions per MET team Protocols at [Health System B's name]...."

e. "[Health System B's name] Policy/Procedure Development", dated 8/2017, revealed in part, "..."[Health System B's name]: The organization comprised of Iowa Methodist Medical Center, [and Hospital A's name]..."

4. During an interview on 1/10/19 at 7:30 AM, the Chief Nursing Executive verified she had overall responsibility and accountability for the nursing care for IMMC, and Hospital A. The CNE confirmed she was responsible for system work at Health System B. The CNE stated there was one nursing enterprise between the 2 separately certified hospitals. When asked if the nursing staff for IMMC was a distinct group, the CNE stated all nursing units hire their own staff to a particular unit but these staff can work at any other hospital in Health System B in their own specialty area, which includes Hospital A (a separately certified hospital). The CNE stated IRT (Internal Resource Team - float pool) staff were hired into a unit but may work at any other hospital in Health System B. The CNE revealed "we are one business entity - [Health System B's name]." The payroll for Health System B was a single system for both hospitals, and staff get paid on one pay check even if they would work at more than one hospital in Health System B. When asked what differentiates IMMC from Hospital A, the CNE stated currently IMMC is under a different provider number than Hospital A. That was the only difference.
VIOLATION: RN/LPN STAFFING Tag No: A0393
Based on document review and staff interviews, Iowa Methodist Medical Center (IMMC) failed to employ its own distinct independent staff to provide nursing care for Iowa Methodist Medical Center (IMMC) patients. IMMC shared nursing employees with Hospital A, a separately certified hospital. Failure to have distinct independent nursing staff could potentially result in putting patients at risk of not receiving adequate nursing care. The hospital administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/2019.

Findings include:

1. Review of job descriptions examples revealed the following:

a. "RN [Registered Nurse] Acute Intensive Care Unit," "Critical Care Unit - [Hospital A]," with effective date 4/2017, revealed in part, "...Qualifications: Minimum Requirements... Other: ...Work may occasionally require [staff to work at] ... other [Health System B] facilities...."

b. "Registered Nurse - Acute," "3 East," with effective date April 28, 2017, revealed in part, "...3 East is a 27 bed medical-surgical unit that provides acute care services to inpatients and observation patients...Qualifications: Minimum Requirements...Other: ...Work may occasionally require [staff to work at] ... other [Health System B] facilities...."

c. "Registered Nurse - Acute," Emergency Departments at IMMC, [Hospital A], with effective date April 14, 2017, revealed in part, "...Qualifications: Minimum Requirements...Other: ...Work may occasionally require [staff to work at] ... other [Health System B] facilities...."

2. Review of policy "Inpatient Units Staffing and Scheduling Practices," dated 10/20/2014, revealed in part, "...Provide continuity of care and safe patient care at [Health System B]...Reassignment (Floating) of Staff: If the number of scheduled staff is greater that either the budgeted staff (refer to staffing plan) or the patient needs, then unit management or the charge nurse will need to reassign (float) or cancel (low census...) staff. This is necessary to ensure that both the needs of the patients and the hospital are met...IRT [Internal Resource Team] staff can be reassigned twice during their shift. Floor staffs will only be assigned once other than their home unit during their shift...."

3. Review of nursing schedule for Critical Care/ED (Emergency Department) from 8/19/18 to 1/5/2019 revealed on 18 different Registered Nurses worked at both IMMC and Hospital A, a separately certified hospital, during the same shift on 52 occasions during the reviewed timeframe.

4. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital A on the same shift revealed 104 different Registered Nurses worked at 2 separately certified hospitals during the same shift on 246 separate occasions.

Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital A on the same shift revealed 45 different Patient Care Technicians worked at 2 separately certified hospitals during the same shift on 141 separate occasions.

5. During an interview on 1/10/19 at 7:30 AM, the Chief Nursing Executive (CNE) verified there was one nursing enterprise for IMMC and Hospital A. When asked if the nursing staff for IMMC was a distinct group, the CNE stated all nursing units hire their own staff to a particular unit, but these staff can work at any other hospital in [Health System B] in their own specialty area, meaning they could float to work at IMMC or another inpatient unit on Hospital A's provider based facility. The CNE stated the IRT [Internal Resource Team - float pool] staff were hired into a unit but may work at any other hospital in Health System B. The CNE stated we are one business entity - [Health System B], payroll was one system, and staff get paid on one pay check even if they would work at more than one hospital in Health System B. When asked what differentiates IMMC from Hospital A, the CNE stated currently IMMC is under a different provider number than Hospital A.

During an interview on 1/7/19 at 2:45 PM, the Executive Director Medical/Surgical Nursing revealed that she has responsibility for the nurse managers of inpatient units for medical/surgical inpatient units at IMMC, and Hospital A. The Executive Director for Medical/Surgical Nursing confirmed she was responsible for overseeing a group of Registered Nurses and Patient Care Technicians staff units at IMMC, and Hospital A. There is one centralized scheduling software system, and all nursing schedules for IMMC and Hospital A were entered into that system. There is only one human resources department for IMMC and Hospital A, and the checks/payroll come from Health System B.

During an interview on 1/7/19 at 3:40 PM, Nurse Manager D, stated if the census drops on the medical/surgical unit and the unit does not require all of the nursing staff assigned to the unit, the extra staff from the unit will float to work on another inpatient unit at IMMC, or the staff can float to work at Hospital A.

During an interview on 1/7/19 at 4:15 PM, Registered Nurse E, stated they had floated to other floors at IMMC and had also floated to Hospital A in the past. Registered Nurse E verified the nursing policies/procedures are the same between IMMC and Hospital A. Registered Nurse E stated they do not receive a separate pay check when they work at Hospital A.

Review of documentation from 10/1/18 through 1/5/19 of employees that worked at IMMC and also worked at Hospital A on the same date, revealed that RN E worked in 2 separately certified hospitals on the same date, 11/1/18.

During an interview on 1/8/19 at 4:35 PM, Registered Nurse F (IRT - Internal Resource Team [float pool]), stated they have been trained to work at IMMC and Hospital A. RN F verified the nursing policies/procedures are the same between IMMC and Hospital A. RN F stated they do not receive a separate pay check when they work at Hospital A. RN F stated if they work an extra shift, they get paid overtime and it didn't matter which facility they worked at - IMMC or Hospital A.

Review of documentation from 10/1/18 through 1/5/19 of employees that worked at IMMC and also worked at Hospital A on the same date, revealed that RN F worked in 2 separately certified hospitals on the same date, 11/21/18 and 12/12/18.

During an interview on 1/14/19 at 4:25 PM, Intensive Care Unit Nurse Manager reported they hired staff into IMMC or Hospital A's ICU. During the interview process, the Intensive Care Unit Nurse Manager clearly discussed with prospective employees the expectation that the candidate could potentially work at both IMMC and Hospital A during the same shift, as the hospital evaluated the number of nurses needed at each unit every 4 hours, and could potentially mean a nurse would need to work at a different hospital during the shift. During the summer time, IMMC's ICU had fewer patients, and this meant ICU staff may have to float to Hospital A, a separately certified hospital.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on interviews and observation of the Health Information Management (HIM) Department, Iowa Methodist Medical Center (IMMC) failed to maintain a separate and independent medical record for each inpatient and outpatient receiving services from IMMC, nor were the medical records for IMMC retained independently of other provider types in the HIM Department. Failure to have a separate and independent medical record for each patient retained independently from other provider types had the potential to affect the medical record information needs of all patients of the acute care hospital. The facility had a census of 485 on entrance on 1/22/19.

Findings included:

1. During an interview on 1/10/19 at 10:37 AM, the Director of HIM & Clinical Documentation Improvement (CDI) confirmed that a patient is assigned a Medical Record Number (MRN) upon admission for the first time to either of the hospitals in Health System B (IMMC or Hospital A, a separately certified hospital). The patient will will keep the same MRN, regardless if the patient presented to IMMC or Hospital A. The medical record was only separated by a unique account number generated for each admission, and not by which hospital the patient received care.

The Director of HIM & CDI stated the the HIM Department is "centralized" on IMMC's campus and is staffed 24/7 by staff employed by Health System B.
VIOLATION: Condition of Participation: Pharmaceutical Se Tag No: A0489
I. Based on document review and staff interviews, Iowa Methodist Medical Center (IMMC) administrative staff failed to:

1. Ensure there was a separate and independent pharmacy service exclusive to IMMC. Please refer to A-0489.

2. Ensure a separate and independent organized pharmacy department. IMMC shared the Pharmacy Manager as well as pharmacy staff with Hospital A, a separately certified hospital. Please refer to A-0493.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital under the Condition of Participation for Pharmaceutical Services (42 CFR 482.25). The hospital's administrative staff identified a census of 485 patients upon the survey team's entrance on 1/22/2019.


II. Based on staff interviews and document reviews, Iowa Methodist Medical Center (IMMC) failed to have a separate and independent pharmacy service. The failure of the hospital to have it's own pharmacy services specific to their patients could potentially result in the hospital failing to ensure the patients of IMMC had access to pharmaceutical services dedicated to the hospital and could potentially result in the pharmacy staff failing to detect trends unique to Iowa Methodist Medical Center. The hospital's administrative staff identified 485 inpatients upon entrance of the survey team on 1/22/2019.

Findings include:

1. Review of the [Health System B] organizational chart revealed that the Pharmacy Department reports to an Executive Vice President/Chief Operating Officer for Health System B, which included IMMC and Hospital A, a separately certified hospital.

2. During an interview on 1/14/19 at 3:40 PM, the Executive Director of Clinical Decision Support and Quality revealed that IMMC pharmacy quality data is reported to the Pharmacy and Therapeutics (P&T) committee and to the Management Review Committee (committee that consisted of Health System B senior leaders and other appointed members).

3. Review of a sample of the P&T meeting minutes from August, September and October 2018 revealed the name of the meeting was [Health System B] Pharmacy and Therapeutics Committee. The meeting minutes did not include information which allowed the reader to identify data unique to IMMC. Instead, the information reported to the committee contained information combined together for IMMC and Hospital A, a separately certified hospital.
VIOLATION: LABORATORY SERVICES Tag No: A0576
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent laboratory department, including staffing, supplies, and contracts. Please refer to A-0576.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interview, the hospital's administrative staff failed to ensure the Iowa Methodist Medical Center (IMMC) laboratory department separately and independently met it's obligations for staffing, supplies, and contracted services for 1 of 1 laboratory department. Failure to separately and independently met the obligations for staffing, supplies, and contracted services could potentially result in the laboratory staff offering services which the laboratory department could not provide. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/9/19 at 10:00 AM, the Executive Director of Laboratory Services for IMMC revealed she was responsible for laboratory services for Health System B, which included IMMC and Hospital A, a separately certified hospital. She reported to the Executive Vice President/Chief Operating Officer for Health System B. She indicated her main office was at IMMC. She had 8 managers report to her directly. Several of the managers who report to her had managerial responsibilities at Hospital A, a separately certified hospital. A few of the IMMC laboratory staff worked at IMMC and Hospital A, a separately certified hospital. IMMC and Hospital A shared laboratory supplies between 2 separately certified hospitals. The blood bank agreement was with Health System B, which included IMMC and Hospital A, a separately certified hospital.

2. Review of the organizational chart confirmed that the Executive Director of Laboratory reported to the Executive Vice President/Chief Operating Officer for Health System B.

3. Review of the agreement for blood bank services revealed the contract was with Health System B (which included IMMC and Hospital A, a separately certified hospital). IMMC lacked a separate contract for the provision of blood bank services.

4. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, indicating staff members who worked at both IMMC and Hospital A on the same shift revealed 2 laboratory staff members worked at the 2 separately certified hospitals on 10 separate occasions. The 2 staff members worked at both separately certified hospitals during the same shift on the following dates: 10/3/18; 10/4/18; 10/10/18; 10/18/18; 10/24/18; 12/5/18; 12/19/19; 12/20/18; and 12/27/18. Additionally, a single staff member worked at both of the 2 separately certified hospitals during the same shift on 10/3/18.
VIOLATION: PHARMACY PERSONNEL Tag No: A0493
Based on document review and staff interviews, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent organized pharmacy department. IMMC shared the Pharmacy Manager as well as pharmacy staff with Hospital A. The failure of the hospital to maintain it's own independent pharmacy staff could potentially result in the hospital lacking the ability to fully meet the pharmaceutical needs of it's patients. The hospital's administrative staff identified a census of 485 patients upon entrance of the survey team on 1/22/2019.

Findings include:

1. During an interview on 1/9/19 at 9:05 AM, the Pharmacy Manager revealed that he was responsible for the IMMC pharmacy and Hospital A, a separately certified hospital. He reports to the Executive Director of Pharmacy for Health System B, which included IMMC and Hospital A.

He identified that IMMC and Hospital A had the same medication formulary (a list of medications stocked at the pharmacy and available for physicians to order for patients at the hospital.

The Pharmacy and Therapeutics (P&T) committee functioned for both IMMC and Hospital A. The P&T committee received information from both IMMC and Hospital A, combined the data together, and only reported the combined data. The P&T committee did not identify data individually from IMMC and Hospital A.

2. Review of documentation listing employees which worked at IMMC and Hospital A, from 10/1/18 to 1/5/19, revealed that 1 pharmacist worked in 2 separately certified hospitals during the same shift on 11/21/18.
VIOLATION: RADIOLOGIC SERVICES Tag No: A0528
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to:

1. Ensure a separate and independent radiology department, including staffing and protocols. Please refer to A-0528 and A-0547.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital. The hospital's administrative staff identified a census of 485 patients upon entrance of the survey team on 1/22/2019.


II. Based on document review and staff interview, the administrative staff failed to ensure that Iowa Methodist Medical Center (IMMC) maintained a separate and independent radiology department, including maintaining unique staffing and protocols. Failure to maintain a separate and independent radiology department could potentially result in the radiology staff utilizing protocols for procedures which IMMC either lacked the staffing or equipment to perform. The hospital's administrative staff identified a census of 485 patients upon the survey team's entrance on 1/22/2019.

Findings include:

1. During an interview on 1/9/19 at 9:30 AM, the Executive Director of Radiology for IMMC revealed she was responsible for radiology services for Health System B which included IMMC and Hospital A, a separately certified hospital. She reported to the Executive Vice President/Chief Operating Officer for Health System B. She indicated her main office was at IMMC. She also stated all IMMC radiology staff could work at Hospital A. She indicated that the IMMC radiology protocols were the same as the radiology protocols for Hospital A.

2. Review of the organizational chart confirmed that the Executive Director of Radiology reported to the Executive Vice President/Chief Operating Officer for Health System B, which includes Hospital A, a separately certified hospital.

3. Review of the radiology department organizational chart, and an interview with the Executive Director of Radiology for IMMC on 1/9/19 at 9:30 AM, confirmed that radiology managers and supervisors also have departmental responsibilities at Hospital A, a separately certified hospital.

4. Review of the Job/Position description for a Radiology Supervisor: "Work may occasionally require travel to other [Health System B] facilities. May drive a [Health System B's name] vehicle, rental or [your] own vehicle."

5. Review of documentation for the timeframe of 10/1/2018 through 1/5/2019 revealed that 11 radiology employees including 5 Ultrasound/Sonographers, 4 Radiology Technicians, and 2 Transporters, worked at IMMC and Hospital A (a separately certified hospital) during the same shift on 52 separate occasions.
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and food and dietetic service, including staffing, menus and contract. Please refer to A-0263.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interview, Iowa Methodist Medical Staff (IMMC) administrative staff failed to ensure the food and dietetic services separately and independently met their obligations through staffing, menus, and contracts for 1 of 1 food and dietetic service. Failure to separately and independently meet the requirements for staffing, menus, and contracts could potentially result in the food and dietetic staff attempting to offer services to patients which are not available at IMMC. The administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/9/19 at 9:20 AM, the Food Services Director revealed that she was a contracted employee and was responsible for the kitchens, cafeterias and room service for Health System B, which included IMMC and Hospital A, a separately certified hospital. She reported to the Executive Director of Integrated Services for Health System B, which included IMMC and Hospital A. All of the food and dietetic staff could potentially work at IMMC or Hospital A, a separately certified hospital. The food and dietetic service used the same patient menus at IMMC and Hospital A, a separately certified hospital.

2. During an interview on 1/10/19 at 8:05 AM, the Executive Director of Medical/Surgical Nursing and the Executive Director Clinical Decision Support and Quality both verified that Health System B (which included IMMC and Hospital A, a separately certified hospital) employed the "front line" dietary staff (the staff members who cook the food, place the food on plates, and serve the food to patients).

3. During an interview on 1/14/19 at 4:35 PM, the Clinical Nutrition Operations Manager stated that he oversaw outpatient dietitians, consultant dietitians, the Nutrition Counseling Center, and the room service call center for Health System B, which included IMMC and Hospital A, a separately certified hospital. He reported to the Executive Director, Integrated Services for Health System B. The consultant dieticians worked for Health System B, but provide services to community organizations and rural hospitals affiliated with Health System B. Sometimes the consultant dieticians would provide dietary care to patients at IMMC and Hospital A, a separately certified hospital. The consultant dietician could document on patient medical records at both IMMC and Hospital A, since the consultant dieticians had special log-in credentials and access to the medical record for patients at IMMC and Hospital A.

4. During an interview on 1/14/19 at 4:35 PM, the Clinical Nutrition Manager revealed she oversaw the inpatient dietitians for Health System B, which included IMMC and Hospital A, a separately certified hospital. She reported to the Executive Director, Integrated Services Health System B. They have a "relief staff" of dietitians and dietary technicians who worked at both IMMC and Hospital A. She stated these staff occasionally started their work day at IMMC and finished it at Hospital A (or vice versa). They could document in the patient's medical record at any location. IMMC and Hospital A used the same dietary policies, and did not individualize the dietary policies to meet the needs of the individual hospitals.

5. Review of the agreement for food services revealed the contractor provided services to Health System B, which included IMMC and Hospital A, a separately certified hospital. The contract did not specify the contractor provided services to IMMC, but only listed Health System B's name.

6. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, indicating staff members who worked at both IMMC and Hospital A on the same shift revealed 1 Dietetic Clerk worked at 2 separately certified hospitals on 7 separate dates. The Dietetic Clerk worked at both separately certified hospitals during the same shift on the following dates: 11/3/18; 11/4/18; 11/23/18; 11/27/18; 12/3/18; and 12/4/18. Additionally, 1 Food Service Host/Hostess worked at 2 separately certified hospitals on 12 separate dates. The Food Service Host/Hostess worked at both separately certified hospitals during the same shift on the following dates: 11/7/18; 11/22/18; 12/12/18; 12/13/18; 12/14/18; 12/19/18; 12/20/18; 12/21/18; 12/26/18; 12/28/18; 1/3/19; and 1/4/19.
VIOLATION: UTILIZATION REVIEW Tag No: A0652
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent utilization review plan, including staffing. Please refer to A-0652.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out the responsibility of the hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interviews, the hospital's administrative staff failed to ensure Iowa Methodist Medical Center (IMMC) separately and independently met the criteria for 1 of 1 utilization review plan, including separate staffing between IMMC and Hospital A, a separately certified hospital. Failure to separately and independently create a utilization review plan could potentially result in the hospital failing to offer utilization review services that fully meet the unique needs of IMMC's patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/15/19 at 7:50 AM, the Manager of Utilization Management confirmed she was responsible for UR for Health System B which included IMMC and Hospital A, a separately certified hospital. She reported to the Executive Vice President/Chief Operating Officer for Health System B. She had an office at both IMMC and Hospital A. She had 13 staff members which included 8 staff members located at IMMC, and 1 staff member who worked at Hospital A. There were 2 Internal Resource Team (float pool) staff who covered for planned and unplanned absences at both IMMC and Hospital A. During the weekends, 12 of the 13 utilization review staff worked from home, and provided utilization review services to patients at both IMMC and Hospital A. The utilization review staff would regularly provider utilization review services to patients at both IMMC and Hospital A during their shift. Additionally, during the course of a shift (both weekend and weekday), any utilization review staff member could assist another utilization review staff member, at either IMMC or Hospital A, by accessing the patient's medical record for IMMC and Hospital A through the utilization review software.

2. Review of the document, "Utilization Review Plan" for Health System B included language indicating the plan applied to Health System B, which consisted of IMMC and Hospital A, a separately certified hospital. The plan lacked language specific to IMMC, which would address the unique needs of patients at IMMC instead of patients at Hospital A, a separately certified hospital.

3. During an interview on 1/23/19 at 3:05 PM, the Executive Director, Clinical Decision Support and Quality confirmed that the document, "Utilization Review Plan" for Health System B applied to both IMMC and Hospital A, a separately certified hospital, and lacked language specific to IMMC.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on document review and staff interviews, Iowa Methodist Medical Center (IMMC) administrative staff failed to:

1. Ensure IMMC independently provided for the equipment, maintenance and repair needs of the hospital to ensure the safety of the patients. Please refer to A-701.

2. Ensure IMMC had its own distinct independent physical plant staff department, including staffing, exclusive to IMMC to maintain the physical plant and patient care equipment. Please refer to A-701.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively ensure the hospital independently and separately maintained the physical plant for the safety and well-being of patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
I. Based on observations, document review and staff interview, Iowa Methodist Medical Center (IMMC) administrative staff failed to independently provide for the equipment, maintenance and repair needs of the hospital. Failure to independently provide for the equipment, maintenance and repair needs of the hospital could potentially impact the safety of past and present patients of IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. Observations made during tours of the facility between 1/7/19 and 1/17/19 revealed the patient care equipment had inspection stickers which indicated Health System B's staff inspected the equipment for safety and approved the equipment for use on IMMC's patients.

2. Documentation review revealed the hospital lacked a contract or policy/procedure regarding the maintenance of patient care equipment to ensure the safety for use on IMMC's patients.

3. During an interview on 1/14/19 at 4:20 PM, the Executive Director Clinical Decision Support and Quality verified IMMC lacked a contract for the maintenance and repair needs of patient care equipment. The Executive Director Clinical Decision Support and Quality stated Health System B's (which included IMMC and Hospital A, a separately certified hospital) Biomedical department provided this service to IMMC. Health System B's Biomedical department was located at IMMC.


II. Based on organizational chart and document review, Iowa Methodist Medical Center (IMMC) failed to ensure IMMC had its own distinct independent physical plant department, including staffing, exclusive to IMMC to maintain the physical plant. IMMC shared a physical plant engineer with Hospital A, a separately certified hospital. Failure to ensure a separate and independent physical plant service could potentially impact the safety of past and present patients of IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. Review of the hospital's Organizational Chart revealed the physical plant department staff reported to a single individual responsible for the physical plant operations at IMMC and Hospital A, a separately certified hospital.

2. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, indicating staff members who worked at both IMMC and Hospital A (a separately certified hospital) on the same shift revealed 1 Operations Engineer worked at both IMMC and Hospital A during the same shift on 1/5/19.
VIOLATION: INFECTION CONTROL Tag No: A0747
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent infection control plan, including staffing. Please refer to A-0747.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively identify and control the spread of infections at the hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interview, the hospital's administrative staff failed to ensure that Iowa Methodist Medical Center (IMMC) independently and separately created and maintained 1 of 1 infection control plan, including maintaining separate staffing, from Hospital A, a separately certified hospital. Failure to create an independent and separate infection control plan could potentially result in the hospital staff failing to identify unique infection control risks facing the patients at IMMC, which are different than the risks faced by patients at Hospital A, a separately certified hospital. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/9/19 at 11:30 AM, the Infection Prevention Manager verified she was responsible for the infection control department for Health System B (which included IMMC and Hospital A, a separately certified hospital). She reported to the Executive Director, Clinical Decision Support and Quality for Health System B. The department had 4 nurse epidemiologists (nurses that work to reduce infections) that were employees of Health System B and all 4 nurse epidemiologists worked at both IMMC and Hospital A. A single Infection Control Committee for IMMC and Hospital A (a separately certified hospital) met month and included representatives from IMMC and Hospital A. IMMC and Hospital A lacked separate infection control policies, which addressed the unique patient needs found at each hospital.

2. Review of the position description for "Medical Director, Epidemiology and Infection Control," last revised 6/2010, under Primary Function and Relationship to Total Organization: "Serves as the Chief Infection Control Officer for all components of [Health System B]" (which includes IMMC and Hospital A, a separately certified hospital). The position description was not specific to IMMC.

3. A review of the document "Infection Prevention and Control Section of Clinical Quality Department," last revised 2/24/16, revealed in part, "Scope of Service: To provide education and interpretation of infection prevention standards, policies and procedures to all [Health System B's name] and medical staff departments." The document was not specific to IMMC and provided general guidance to Health System B hospitals, which included IMMC and Hospital A.

4. Review of the "Surveillance Plan for [Health System B's name] 2018," revealed the plan covered IMMC and Hospital A, a separately certified hospital. The surveillance plan did not identify the unique infection prevention challenges associated with IMMC or Hospital A, a separately certified Hospital. Instead, the plan combined IMMC and Hospital A's infection prevention surveillance into a single plan.

5. Review of the "Infection Prevention and Control 2018 Risk Assessment" revealed the plan covered IMMC and Hospital A, a separately certified hospital. The risk assessment did not identify the unique infection prevention risks associated with IMMC or Hospital A, a separately certified Hospital with vastly different patient types and conditions. Instead, the plan combined IMMC and Hospital A's infection prevention risk assessment into a single plan.

6. Review of Infection Control meeting minutes dated April 2018, July 2018, and October 2018 revealed the infection prevention staff commingled infection prevention data from IMMC and Hospital A, a separately certified hospital. The infection prevention staff failed to separate data from IMMC, which would allow the staff to independently analyze and assess infection prevention risks at IMMC.

7. During an interview with the Executive Director, Clinical Decision Support and Quality on 1/14/19 at 2:15 PM, confirmed Health System B, which included IMMC and Hospital A (a separately certified hospital), had a unified Infection Prevention Surveillance Plan and a unified Infection Prevention Risk Assessment. Health System B staff did not create separate Infection Prevention Surveillance Plans and Infection Prevention Risk Assessments for IMMC and Hospital A, even though IMMC and Hospital A served significantly different patient populations.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
I. Based on document review and staff interviews, Iowa Methodist Medical Center (IMMC) administrative staff failed to:

1. Ensure there was a separate and independent discharge planning service, including staffing, exclusive to IMMC. Please refer to A-0799.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively carry out their discharge planning to meet the unique needs of IMMC patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interview, Iowa Methodist Medical Center (IMMC) failed to have a separate and independent discharge planning service, including staffing. The failure of the hospital to have it's own independent discharge planning services specific to their patients could potentially result in the discharge planning staff failing to identify or meet the unique needs of IMMC's patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. Review of the Health System B organizational chart revealed the Discharge Planning staff reported to a Chief Medical Officer/Vice President Medical Affairs for Health System B, which included IMMC, and Hospital A, a separately certified hospital.

2. Review of policy "Continuity of Care - Discharge Planning [Health System B's name] 086," dated 7/2017, revealed in part, "Discharge planning is a systematic, coordinated, and interdisciplinary program to be certain that each patient receives the appropriate level of care throughout the continuum of care." The policy lacked information specific to IMMC, and instead applied to Health System B, which included both IMMC and Hospital A, a separately certified hospital.

3. During an interview on 1/14/19 at 10:40 AM, the Manager for Patient Care Facilitators and Manager of Social Services revealed the following:

a. Patient Care Facilitators were all nurses and work with Social Workers.

b. Managers provided oversight to staff at both of Health System B's hospitals (IMMC and Hospital A).

c. When a patient was admitted , a Patient Care Facilitator reviewed each admission for determination of level of need.

d. The Social Worker would get involved if there were social issues or if there were any placement needs.

e. Staff members were hired by Health System B. The staff members would work at a specific hospital (IMMC or Hospital A), but would see patients at either IMMC or Hospital A. The staff members did not separate their time spent at IMMC or Hospital A (a separately certified hospital) for payroll purposes.

f. Staff could document in any patient medical record, at any location, even if the patient was not at the same hospital as the discharge planning staff member.

g. Verified the department had policies/procedures which applied to IMMC and Hospital A, and did not differentiate between the unique needs for the patients of the 2 hospitals.
VIOLATION: NUCLEAR MEDICINE SERVICES Tag No: A1025
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent nuclear medicine department, including staff and policies. Please refer to A-1025.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively meet the unique nuclear medicine needs of IMMC's patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interview, the hospital's administrative staff failed to ensure the 1 of 1 Iowa Methodist Medical Center (IMMC) nuclear medicine department staff separately and independently met the nuclear medicine needs of IMMC's patients. Failure to independently and separately meet the nuclear medicine needs of IMMC's patients could potentially result in the nuclear medicine staff not meeting the unique nuclear medicine needs of IMMC's patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/10/18 at 12:10 PM, the Supervisor of Nuclear Medicine revealed she was responsible for nuclear medicine services for Health System B, which included IMMC and Hospital A (a separately certified hospital). She reported to the Executive Director of Radiology for Health System B. There were 10 nuclear medicine staff who all worked at both IMMC and Hospital A. All staff were employees of Health System B, their check came from Health System B, and they received overtime pay if they worked more than 40 hours/week at any Health System B location. She stated the nuclear medicine policies at IMMC were the same as nuclear medicine policies for Hospital A.

2. Review of Health System B's organizational chart revealed that the Radiology department reports to an Executive Vice President/Chief Operating Officer for Health System B, which included IMMC and Hospital A, a separately certified hospital.

3. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital A on the same shift revealed 5 different Nuclear Medicine Technologists worked at 2 separately certified hospitals during the same shift on 9 separate dates. The Nuclear Medicine Technologists worked at both separately certified hospitals during the same shift on the following dates: 10/16/18; 10/30/18; 11/4/18; 11/9/18; 11/10/18; 11/16/18; 11/19/18; 11/22/18; and 12/15/18.
VIOLATION: ORGANIZATION OF NUCLEAR MEDICINE Tag No: A1027
Based on document review and staff interview, the hospital's administrative staff failed to ensure the 1 of 1 Iowa Methodist Medical Center (IMMC) nuclear medicine department staff separately and independently met the nuclear medicine needs of IMMC's patients. Failure to independently and separately meet the nuclear medicine needs of ILH's patients could potentially result in the nuclear medicine staff not meeting the unique nuclear medicine needs of IMMC's patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/10/18 at 12:10 PM, the Supervisor of Nuclear Medicine revealed she was responsible for nuclear medicine services for Health System B, which included IMMC and Hospital A (a separately certified hospital). She reported to the Executive Director of Radiology for Health System B. There were 10 nuclear medicine staff who all worked at both IMMC and Hospital A. All staff were employees of Health System B, their check came from Health System B, and they received overtime pay if they worked more than 40 hours/week at any Health System B location. She stated the nuclear medicine policies at IMMC were the same as nuclear medicine policies for Hospital A.

2. Review of Health System B's organizational chart revealed that the Radiology department reports to an Executive Vice President/Chief Operating Officer for Health System B, which included IMMC and Hospital A, a separately certified hospital.

3. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital A on the same shift revealed 5 different Nuclear Medicine Technologists worked a 2 separately certified hospitals during the same shift on 9 separate dates. The Nuclear Medicine Technologists worked at both separately certified hospitals during the same shift on the following dates: 10/16/18; 10/30/18; 11/4/18; 11/9/18; 11/10/18; 11/16/18; 11/19/18; 11/22/18; and 12/15/18.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on document review and staff interviews, Iowa Methodist Medical Center's (IMMC) administrative staff failed to:

1. Develop and maintain policies and procedures that were distinct and independent to the IMMCH Emergency Department (ED). Please refer to A-1104.

2. Ensure there was separate and independent emergency department nursing staff exclusive to IMMC. Please refer to A-1110.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to separately and independently meet the emergency needs of patients at IMMC. The IMMC administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on staff interview and document review, the Iowa Methodist Medical Center (IMMC) administrative staff failed to develop and maintain policies and procedures that were distinct and independent to IMMC Emergency Department (ED) to respond to the medical emergencies within the IMMC ED. The failure of IMMC ED to develop and maintain policies and procedures distinct to IMMC ED could potentially result in the staff failing to meet the unique patient needs for patients that presented to IMMC and requested emergency care. The IMMC administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/15/2019 at 4:22 PM, the Executive Director of Clinical Decision Support and Quality for Health System B reported that ED nursing staff followed policies that were for Health System B, which included IMMC and Hospital A, a separately certified hospital. The IMMC ED staff failed to develop policies and procedures which independently and separately met the unique patient needs for patients at IMMC.

During an interview on 1/7/2019 at 4:20 PM, Emergency Department (ED) Supervisor A revealed Health System B, which included IMMC and Hospital A (a separately certified hospital), used policies, procedures, and guidelines which were the same for both hospitals in Health System B. IMMC ED's staff did not create separate and unique policies to allow the hospital to independently meet the unique needs for the patients at IMMC.

2. Review of an example of policies not being individualized and specific to IMMC included the EMTALA policy as follows:

a. Review of the policy "Transfer and Emergency Examination-EMTALA," dated 12/2017, revealed, in part, "PURPOSE: To establish a procedure for the examination, stabilization, and transfer of individuals coming to a [Health System B's name] emergency department ... Any department of the particular [Health System B's name] hospital regardless of whether it is located on or off the main hospital campus that is held out to public ... The following areas are considered to meet this definition: traditional emergency department areas at [Hospital A's name], ... [and] Iowa Methodist Medical Center the maternity centers at [Hospital A's name] and Iowa Methodist Medical Center."

b. Review of the policy "EMTALA Call," dated 4/2017, revealed in part, "To establish a procedure for the development, coordination and archiving of the EMTALA physician call schedules ... The Medical Staff Office will forward the call schedules to the [Health System B's name] Answering Service ... The [Health System B's name] Answering Service will communicate and document the change ... EMTALA Compliance ... [Health System B's name] Medical Staff Bylaws specify ... [Health System B] Medical Staff Credentialing Policy ..."
VIOLATION: EMERGENCY SERVICES PERSONNEL Tag No: A1110
Based on document review and staff interview, Iowa Methodist Medical Center (IMMC) administrative staff failed to employ its own distinct independent staff to provide nursing care for IMMC patients seeking emergency care. IMMC shared emergency department (ED) nursing employees with Hospital A, a separately certified hospital. Failure to have distinct, independent emergency department nursing staff could potentially result in putting patients at risk of not receiving adequate emergency care. The IMMC administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. Review of the "ED Job Description for Registered Nurse - Acute," revealed in part, "Department Name: Emergency Departments at Iowa Methodist Medical Center, [Hospital A's name]...Work may occasionally require travel to other [Health System B's name] facilities [such as IMMC or Hospital A]. May drive a [Health System B's name] vehicle, rental or own vehicle...."

The ED Job Description for Registered Nurse failed to contain specific and individual language regarding the unique responsibilities nursing staff have at IMMC.

2. During an interview on 1/7/2019 at 4:20 PM, the IMMC ED Supervisor A confirmed IMMC shared ED staff with Hospital A, a separately certified hospital; as all of the employees in the ED were employed by Health System B. The IMMC ED staff were cross-trained to be able to go to Hospital A, another separately certified hospital within Health System B. Kronos (a time keeping system) calculated the separately certified hospitals as one organization and the employees get paid overtime if they worked over the assigned 40 hour work week. When staff worked at IMMC and Hospital A in the same pay period, staff would receive one payroll check from Health System B.
VIOLATION: REHABILITATION SERVICES Tag No: A1123
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent rehabilitation department, including staffing, policies and procedures and protocols. Please refer to A-1123.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively and independently staff the departments for the health and safety of patients. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent rehabilitation department, including staffing, policies and procedures and protocols. Failure to ensure a separate and independent organizational nursing service could potentially result in the hospital staff failing to meet the unique needs of patients at IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/9/19 at 9:50 AM, the Manager of Inpatient Therapy Services revealed she was responsible for Inpatient Physical, Occupational, and Speech Therapy for Health System B, which included IMMC and Hospital A (a separately certified hospital). She reported to an Assistant Vice President for Health System B. She stated there was also a Manager of Outpatient Therapy Services, who was responsible for outpatient Physical, Occupational, and Speech Therapy for Health System B. That there were 18 clinical staff who were all employees of Health System B. Any employee could work at any inpatient or outpatient location at IMMC or Hospital A. She revealed her main office was at IMMC, and staffing assignments were managed by a scheduler who was also located at IMMC.

2. During an additional interview on 1/14/19 at 7:45 AM, the Manager of Inpatient Therapy Services clarified the staff schedule is done 6 weeks in advance and each day the scheduler would re-distribute staff based on unplanned patient needs. Any staff member could work at IMMC or Hospital A based on their skill set, interest, and patient needs. Additionally the inpatient therapy services had an "Internal Resource Pool," staff who were specifically hired and trained to work at any inpatient or outpatient location at IMMC or Hospital A. Staff could begin their day at one location within Health System B, and end it at another location. Staff were able to document on any Health System B patient, at any location within Health System B, via the electronic medical record.

3. Review of Health System B's organizational chart revealed the Rehab Therapy department staff reports to the Vice President Marketing/Business Development for Health System B, which included IMMC and Hospital A (a separately certified hospital).

4. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital A on the same shift revealed 24 employees including 1 Audiologist, 1 Certified Occupational Therapist Assistant, 5 Occupational Therapists, 6 Physical Therapists, 1 Physical Therapy Assistant, 1 Rehab Therapy Technician, 8 Speech Pathologists, and 2 Patient Financial Advocates who worked at 2 separately certified hospitals during the same shift.
VIOLATION: RESPIRATORY CARE SERVICES Tag No: A1151
I. Based on staff interviews and document review, Iowa Methodist Medical Center (IMMC) failed to ensure a separate and independent respiratory care department, including staffing, supplies, and protocols. Please refer to A-1151.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to effectively separately and independently meet the respiratory needs of the patients at IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.


II. Based on document review and staff interviews, the hospital's administrative staff failed to ensure 1 of 1 Iowa Methodist Medical Center (IMMC) respiratory care staff independently and separately met the respiratory care needs for the patients at IMMC, including separate staffing, supplies, and protocols. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/9/19 at 11:00 AM, the Respiratory Care Manager revealed that she was responsible for respiratory care services at Health System B, which included IMMC and Hospital A (a separately certified hospital). She reported to the Executive Director of Radiology for Health System B. Her main office was located at IMMC. She had 8 individuals directly report to her, 3 of which were supervisors that worked at both IMMC and Hospital A. The supervisors had their primary office at IMMC. All respiratory therapy staff were trained to work at both IMMC and Hospital A. All respiratory care workers were Health System B employees. When people were hired, they knew they worked for Health System B, and they would work at both IMMC and Hospital A. It was a common practice for staff to work at IMMC and Hospital A. The staff used the same types of equipment at IMMC and Hospital A and shared supplies between the 2 separately certified hospitals. The respiratory care staff followed the same protocols at IMMC and Hospital A.

2. Review of Health System B's organizational chart revealed the respiratory therapy department staff reported to the Vice President Marketing/Business Development for Health System B, which included IMMC and Hospital A (a separately certified hospital).

3. During an interview on 1/17/19 at 11:55 AM, Respiratory Therapist C revealed that "last Wednesday" (February 9, 2019), she worked at Hospital A for the first 8 hours of her shift, and then went to IMMC for the last 4 hours of her shift. On Friday and Saturday of last week, she worked at Hospital A, Sunday she worked at IMMC, and Monday she worked at Hospital A. The respiratory therapy supervisor or charge therapist made assignments and that sometimes you knew which separately certified hospital a therapist was going to work prior to a particular shift, and sometimes they didn't. Staff stay clocked in as they travel between locations, the assignment sheet documented where staff were working, and then someone on the "back end" would take that information and would allocate hours to the appropriate hospital.

4. Review of the Health System B Job/Position Description for Respiratory Therapist - Iowa Methodist Medical Center's, revealed in part, "Work may occasionally require travel to other [Health System B's name] facilities [such as IMMC or Hospital A]."

5. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital in the same shift revealed 34 different Respiratory Therapists who worked at 2 separately certified hospitals during the same shift.
VIOLATION: ORGANIZATION OF RESPIRATORY CARE SERVICES Tag No: A1152
Based on staff interview and document reviews, Iowa Methodist Medical Center (IMMC) failed to have 1 of 1 separate and independently qualified staff for the provision of respiratory care services. Failure to provide a separate and independent respiratory care staff could potentially result in IMMC failing to offer respiratory care services which met the unique needs of patients at IMMC. The hospital's administrative staff identified a census of 485 patients when the survey team made entrance on 1/22/19.

Findings include:

1. During an interview on 1/9/19 at 11:00 AM, the Respiratory Care Manager revealed that she was responsible for respiratory care services at Health System B, which included IMMC and Hospital A (a separately certified hospital). She reported to the Executive Director of Radiology for Health System B. Her main office was located at IMMC.

She had 8 individuals directly report to her, 3 of which were supervisors that worked at both IMMC and Hospital A. The supervisors had their primary office at IMMC. All respiratory therapy staff were trained to work at both IMMC and Hospital A. All respiratory care workers were Health System B employees. When people were hired, they knew they worked for Health System B, and they would work at both IMMC and Hospital A. It was a common practice for staff to work at IMMC and Hospital A.

2. Review of documentation for employee work schedules, from 10/1/18 to 1/5/19, including staff members who worked at both IMMC and Hospital in the same shift revealed 34 different Respiratory Therapists who worked at 2 separately certified hospitals during the same shift.