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.

NORTHLAKE BEHAVIORAL HEALTH SYSTEM 23515 HIGHWAY 190 MANDEVILLE, LA 70448 July 1, 2020
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on record reviews and interviews, the CEO failed to effectively manage the hospital as evidenced by:
1. Failing to ensure a system for controlling infections and communicable diseases of patients and personnel were established during a national pandemic of COVID-19. This deficient practice was evidenced by failure to ensure patients with signs and symptoms of COVID-19 including those patients with pending test results were separated from other patients; failure to ensure social distancing was implemented for patients participating in group therapy, as recommended per CDC guidelines prevention of spread of COVID-19, and failure to ensure screening of visitors for COVID-19 prior to hospital entry and ongoing screening of staff for COVID-19 symptoms and any potential COVID-19 exposure was performed upon staff arrival for their shifts.

2. Failing to participate in appointment, reappointment, of the Medical Staff, both initially and ongoing in accordance with the Bylaws and regulations of the hospital and the statutory requirements of the State of Louisiana and failure to participation and delineation of privileges in hiring of medical staff. This deficient practice was evidenced by S2COO and S5Psych being solely responsible for initial and ongoing appointment/reappointment, of the Medical Staff, and delineation of privileges in hiring of medical staff, with no oversight from S1CEO.

3. Failure of the Chief Executive Officer to assume the responsibility and authority for the operation of the hospital's Quality Assurance program and failure to participate in Quality Assurance.

Findings:

Review of the hospital's current organizational chart revealed S1CEO was listed as the hospital's Interim CEO and CFO. Further review revealed S2COO was listed as the hospital's Chief Operations Officer and S5Psych was listed as the hospital's Medical Director.

Review of the hospital's Medical Staff Bylaws, version December 2019, revealed the following, in part: Whereas, Northlake Behavioral Health System ("NBHS") has a single medical staff with the overall responsibility for the quality of all clinical care provided to patients and for the ethical conduct and the practices and standards of its members. Therefore, the physicians and other professional staff organize into a single medical staff in conformity with these Bylaws.
Governing Body Involvement: The Board of Directors ("the Board') of Northlake Behavioral Health: Systems (NBHS) appoints the Chief Executive Officer (CEO) of Northlake Behavioral Health System (NBHS). The CEO shall have the administrative authority of this hospital and, as representative of the Board, shall be the appointing authority for this facility. As the CEO, he/she shall be responsible for the overall operation of the facility to include control, utilization, and the conservation of its physical and financial assets and the recruitment and direction of its staff. The CEO shall serve as liaison between the Medical Staff of the hospital and the Board. The CEO shall assure that the hospital meets all applicable State, Federal, and JCAHO standards.
The Board of Directors of Northlake Behavioral Health Systems delegates to the Chief Executive Officer the authority to appoint the Medical Staff, reappoint, and delineate privileges both initially and ongoing in accordance with the Bylaws and regulations of the hospital and the statutory requirements of the State of Louisiana.
Northlake Behavioral Health System shall develop and institute a hospital-wide Performance Improvement Program. The Chief Executive Officer shall assume the responsibility and authority for the operation of this program.

In an interview on 06/30/2020 at 11:40 a.m. with S1CEO, he confirmed he is both the CEO and CFO of the hospital. He indicated he is usually onsite at the hospital 2 to 3 days per week and he is currently working on the cost reports. S1CEO indicated his function at the hospital is primarily financial at this time and he focuses on the non-clinical/finance areas of management of the hospital. He indicated the clinical aspect of hospital management is handled by S2COO and S3DON. He indicated the Governing Body meetings primarily involved S2COO and S3DON. He indicated he does not participate in the Governing Body Meetings at the hospital. S1CEO indicated all medical decisions such as hiring of medical staff are left to S5Psych (Medical Director) and S2COO. S1CEO confirmed he is not involved in the hospital's Quality Assurance program because he is too busy with management of the financial aspects of the hospital. He indicated he has not been involved in any of the hospital's COVID-19 preparation for handling COVID-19 issues in the hospital or the COVID-19 management plan. He indicated he had reviewed the medical clinic contracts and provided advice, but he mainly looked at the contracts related to the compensation aspect.

In an interview on 06/30/2020 at 1:20 p.m. with S5Psych (Medical Director), he confirmed he is the Medical Director for the hospital and has been in that position since 01/2020. S5psych indicated he believed S2COO was the hospital's CEO. He reported S2COO is in control of all of the meetings and controls everything related to running the hospital. When asked if he knew S1CEO, he indicated he did not know him. S5Psych indicated the decision for who was appointed to the Medical Staff was determined by S2COO. He indicated S2COO selects the people to review for appointment to the Medical Staff and he interviews them. He indicated S2COO selected the people who became members of the Medical Staff. He indicated since he has been Medical Director he has not hired or fired anyone.

In an interview on 07/01/2020 at 12:08 p.m. with S2COO, she indicated the members of the Governing Body, including herself, were S1CEO, S3DON, and S5psych. She reported her experience background was 24 years in medical billing, collections, and practice management. She reported she ran physician groups and has a medical business management background. She confirmed she is not clinical and has not managed any previous hospitals prior to coming on at Northlake. She reported in August 2019 the hospital didn't make 3 payrolls because cost reporting was not done on time and Medicare was withholding payments. S2COO indicated she and S5Psych would appoint Medical Staff members, but S5Psych has the final say in who gets hired. S2COO indicated S1CEO is helping a lot during the hospital's financial crisis. S2COO indicated S1CEO's function is predominately financial. She indicated he comes a few times a week and works on cost reporting. S2COO indicated she focuses on the operational side of management and tries to run the hospital smoothly and efficiently. S2COO indicated she understood S1CEO should play a more active role. S2COO reported she knew they were supposed to have a COO and CEO. S2COO acknowledged she is doing a lot of things that the CEO should be doing. S2COO indicated they could not afford to hire someone from the outside to serve as the hospital's CEO. S2COO indicated she is functioning as CEO, COO and the Business Officer. S2COO indicated S1CEO's focus is financial and he doesn't have time to be involved with Quality Assurance or Clinical Operations. She said thought she could orchestrate the operations aspect of the hospital.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital's QAPI program failed to ensure performance improvement activities focused on problem-prone areas that could affect health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital to identify breaks in staff communication of pending cultures and patient infections to the infection control nurse for tracking and trending had been identified as a problem to be addressed in the hospital's QAPI plan.

Findings:

Review of Patient #1's medical record revealed the patient had an order dated 06/26/2020 for a COVID-19 test for symptoms of COVID-19 times one week. Further review revealed the patient had been sent for COVID-19 evaluation and a test on 06/27/2020.

In an interview on 06/30/2020 at 2:20 p.m. with S13IC, she indicated staff notifying her of patients' infection control issues sometimes occurs and at times the information is not relayed to her. She reported she usually finds out based on her own review of patients' charts and from S20Pharm when patients are started on antibiotics. She confirmed she had been unaware, prior to 06/29/2020, that Patient #1 had a COVID-19 test pending tested on [DATE]). S13IC indicated the nurse on the unit should have notified the House Supervisor as well as the infection control nurses.

Review of quality documentation, provided as current by S18QA/Risk, revealed no documented evidence that breaks in staff communication of pending cultures and patient infections to the infection control nurse for tracking and trending had been identified as a problem to be addressed in the hospital's QAPI plan.

On 07/01/2020 at 2:00 p.m. an interview was conducted with S13IC and S14IC. S13IC confirmed nursing staff had failed to inform her Patient #1 had a COVID-19 test pending. S13IC and S14IC confirmed there are breaks in communication of patients' infection status such as pending tests, being started on antibiotics for infections and they should have been notified and in the loop as the hospital's infection control nurses. S14IC indicated they needed to address communication issues related to patient infections and pending cultures/tests in QA and a PI needed to be initiated.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to nursing personnel in accordance with specialized qualifications and competencies as evidenced by failure to have 29 direct patient staff members out of 256 direct care members certified in Cardiopulmonary Resuscitation. Findings:

Review of the Hospital's policy, Staff Training and Development, revealed in part, all employees, volunteers, affiliations of Northlake Behavioral Health Systems (NBHS), and contracted staff will be required to complete training and in-services while employed or affiliated with NBHS...IX. Mandatory and Required Training: CPR -required within two years of initial training.

Review of the Performance Improvement Dashboard for May 2020 revealed 31 patient care staff members were not certified in Cardiopulmonary Resuscitation (CPR).

An interview was conducted on 07/01/2020 at 11:50 a.m. with S18QA/Risk Manager. She reported the facility has had a problem with noncompliance rates of patient care staff members not being certified in CPR. She further reported the hospital currently has an in house staff member to conduct CPR training to improve the compliance rate of the patient care staff being CPR certified.

A phone interview was conducted with S2COO on 07/02/2020 at 2:00 p.m. She reported the correct numbers after review of the personnel records were 29 direct care workers out of 256 direct care workers were not certified in CPR.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on observations, record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel were established during a national pandemic of COVID-19. This deficient practice was evidenced by the hospitals:
1. failure to implement policies and procedures related to separating patients with signs and symptoms of COVID-19 including those patients with pending test results for 1(Patient #1) of 1 patients observed with a pending COVID-19 screen from a total patient sample of 6 ( #1-#6). This deficient practice had the potential to affect all 19 patients currently housed on the Esplanade III Unit;
2. failure to implement social distancing of inpatients, as recommended per CDC guidelines, as evidenced by failure to ensure social distancing of 13 patients (#4, #6, #R1- #R11) observed in group therapy;
3. failure to direct surveyors to the dedicated main entry for visitor screening for COVID-19 upon arrival on site and failing to perform surveyor screening (4 surveyors on day one and 3 surveyors on days 2 and 3) upon arrival for 3 of 3 days on site; and
4. failure to perform screening of staff for COVID-19 symptoms and any potential COVID-19 exposure upon arrival for their shifts as evidenced by performing an initial symptom screen questionnaire once and no longer screening for symptoms/potential exposure every shift.

Findings:

Centers for Disease Control currently recommends facilities are actively screening visitors. The CDC further states to screen everyone (patients, health care providers, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SAR-CoV-2 infection and ensure they are practicing source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature > or = 100.0F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection.

Centers for Disease Control encourages physical distancing. Examples of how physical distancing can be implemented for patients include, but not limited to: Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart. In some circumstances, such as higher levels of community transmission or numbers of patients with COVID-19 being cared for at the facility, and when healthcare-associated transmission is occurring, facilities might cancel in-person group activities in favor of an exclusively virtual format.

Centers for Disease Control further recommends infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection. As a measure to limit health care providers' exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated health care providers, to care for patients with suspected or confirmed SARS-CoV-2 infection. Dedicated means that health care providers are assigned to care only for these patients during their shift. Limit transport and movement of the patient outside of the room to medically essential purposes. Whenever possible, perform procedures/tests in the patient's room.

1.Failure to implement policies and procedures related to separating patients with signs and symptoms of COVID-19 including those patients with pending test results.

Review of the hospital policy titled, "Coronavirus Screening and Reporting", revealed in part, patients with suspected signs and symptoms of COVID-19, initiate droplet precautions and isolation. This includes: place face mask on patient making sure to cover nose and mouth completely; place patient in a single private room with door closed; and only essential personnel should enter the room to minimize the number of health care providers who enter the room.

On 06/29/2020 at 11:10 a.m. an observation was made of Patient #1 on Unit Esplanade III. The patient was observed walking in the hallway at the entry of the unit, greeting the surveyor and all who came onto the unit. He was observed to have on a mask.

Review of Patient #1's medical record revealed an admission date of [DATE], with an admission diagnosis of Depression with Suicidal Ideations with Asthma and Hypertension as comorbidities.

Further review of Patient #1's medical record revealed the following orders:
06/26/2020 at 5:00 p.m.: COVID-19 test secondary to shortness of breath, cough, chills times 1 week with Asthma and Hypertension as comorbidities ordered by S4MD. A yellow sticky note was noted on the order indicating - Labs not ordered.

06/26/2020 7:15 p.m. Guaifenesin DM elixir 10 cc's by mouth every 6 hours as needed for cough. The order was a clarified verbal order by S4MD.

06/27/2020 9:05 a.m. To emergency room via Northlake Transportation for evaluation and rule out COVID (and test). The order was written by the on call physician.

Further review of Patient #1's medical record revealed an infection report dated 06/27/2020, completed by S17LPN, indicating Patient #1 had an Upper Respiratory Infection with a history of cough, chills, and shortness of breath times one week. Additional review of the documentation revealed the patient was to be sent to the hospital that day (6/27/2020) for a COVID-19 test. There was a handwritten notation indicating the report had been faxed to Infection Control on 06/27/2020 at 10:58 a.m.

Review of the interdisciplinary progress notes revealed the following nursing note, dated 06/27/2020 at 12:10 p.m., Patient remains isolated in room. Patient to wear mask when out of room to bathroom. Patient instructed of need to isolate in room and need to wear mask when out of room.

Patient #1's COVID-19 test result was not available until the evening of 06/30/2020 - 3 days after the test was performed (result was negative).

In an interview on 06/29/2020 at 11:15 a.m. with S8MHT, she indicated the patient with the mask on was Patient #1. She reported she thought Patient #1 had a fever and was wearing the mask as a precaution.

In an interview on 06/29/2020 at 11:25 a.m. with S9RN, she indicated the Patient #1 had a COVID-19 test pending, she thought he had a fever, but wasn't really sure why he had been tested .

In an interview on 06/29/2020 at 11:26 a.m. with S3DON, present during the observation, she indicated Patient #1 should have been reminded by staff to remain in his room while the COVID-19 test was pending and verified he should not have been out in the commons areas.

In an interview on 06/29/2020 at 2:30 p.m. with S9RN, she stated when a patient has pending tests, they are put on isolation, in their room, with a mask. She further stated if a patient goes to the hospital for a COVID-19 test, they are put in isolation when they come back.

In an interview on 06/29/2020 at 2:41 p.m. with S17LPN she reported she had called the supervisor to let her know Patient #1 needed a COVID-19 test and it wasn't done that night (night of 06/26/2020) because there wasn't a test available. S17LPN explained when tests were available onsite the nursing supervisors were performing the tests. She indicated the process that should be taken if a patient had a COVID-19 test pending or had COVID-19 symptoms was for the patient to be isolated to their room until the test came back. She indicated the patient should be wearing a mask when they left the room and the staff should escort them to the bathroom and back to their room. She said the bathroom was cleaned after the patient used the bathroom.

In an interview on 06/30/2020 at 1:20 p.m. with S5Psych, he stated after a COVID-19 test is done on a patient, the patient is isolated. He further stated he follows CDC guidelines.

In an interview on 06/30/2020 at 2:20 p.m. with S13IC, she reported in April 2020 they had a unit dedicated to COVID-19 patients. She explained one side of the unit was dedicated to patients with suspected COVID-19 with pending test results. S13IC further explained patients who tested COVID-19 positive were sent to the side of the unit dedicated to COVID-19 positive patients. S13IC indicated Patient #1 had "slipped through the cracks" and reported she was not sure how that had happened because staff working in admissions should have verified there was a negative COVID-19 test. She indicated that initially Patient #1 should have been tested in-house, by House Supervisors, if tests were available. She reported she had just found out on 06/29/2020 that Patient #1 had been sent out to be tested on [DATE]. She indicated she was to be kept informed of patients' COVID-19 status, as infection control nurse, and no one had informed her about Patient #1. S13IC indicated staff notifying her of patients' infection control issues sometimes occurs and at times the information is not relayed to her. She reported she usually finds out based on her own review of patients' charts and from S20Pharm when patients are started on antibiotics. S13IC indicated the nurse on the unit should have notified the House Supervisor as well as the infection control nurses. She confirmed Patient #1 should have been placed on the presumptive positive unit (Esplanade II) while his test was pending and was not sure why he had not been placed on that unit. She confirmed his COVID-19 test results were still pending at the time of the interview.

In an interview on 07/01/2020 at 9:50 a.m. with S11MHT, she revealed the patients are currently wearing masks and they started wearing masks yesterday (06/30/2020).

In an interview on 07/01/2020 at 9:55 a.m. with S12RN, she revealed all patients are currently wearing masks due to the possibility of a COVID positive patient (Patient #1).

In an interview on 07/01/2020 at 11:00 a.m. with S16NP, he stated the COVID-19 testing process was if a patient was having symptoms of COVID-19, the patient is isolated to a different unit and that patient is isolated until the test results come back.

In an interview on 07/01/2020 at 2:00 p.m. with S14IC, she indicated patients who were symptomatic should be placed on the "COVID Unit". She further indicated she was not sure why the patient who was tested over the weekend did not go to the COVID Unit since they tested him due to symptoms of COVID-19.

2. Failure to implement social distancing as recommended per CDC guidelines for patients in the hospital who were observed in group therapy.

In an interview on 06/29/2020 at 10:15 a.m. with S2COO, she stated the facility uses CDC regulations regarding COVID-19. She further stated the patients keep their distance at 6 feet apart.

An observation was made of group therapy being conducted on 06/29/2020 at 11:05 a.m. 13 patients (#4, #6, #R1- #R11) were observed during therapy. 8 patients were seated at picnic tables, seated 4 per table, all within 2 feet of each, 5 patients were observed standing near the tables, and none of the patients were social distancing. S6Therapist (conducting the group) and S7MHT were present and were not observed to be reminding patients to social distance.

On 06/29/2020 at 11:05 a.m. S3DON, present during the observation, confirmed the patients referenced above were not socially distanced during group therapy.

In an interview on 06/30/2020 at 11:20 a.m. with S15ClinDirTher, she indicated when the weather is nice, the patients were taken outside for group and they do not practice social distancing because the patients usually sit in groups at the picnic tables.

3. Failure to direct surveyors to the dedicated main entry for visitor screening upon arrival on site.

Review of the hospital policy titled, "Coronavirus Screening and Reporting", revealed in part, D. Preventive actions to help prevent spread. 10. All visitors must complete screening questionnaire when being checked in.

An observation on 06/29/2020 at 9:30 a.m. revealed a sign on the administration building advising visitors to wear masks. Further observation revealed no additional signage or guidance regarding screening visitors for symptoms. The survey team (4 surveyors) entered the hospital's administrative building and they were not instructed to go the designated main entry for screening by S10Recep. The team was also not screened for symptoms and no temperature assessment was performed by staff upon entry into hospital.

An observation on 06/30/2020 at 9:30 a.m. revealed the survey team (3 surveyors) entered the hospital's administrative building and they were not instructed to go the designated main entry for screening by S10Recep. The team was also not screened for symptoms and no temperature assessment was performed by staff upon entry into hospital.

An observation on 07/01/2020 at 8:55 a.m. revealed the survey team (2 surveyors) entered the hospital's administrative building and they were not instructed to go the designated main entry for screening. The team was also not screened for symptoms and no temperature assessment was performed by staff upon entry into hospital. A third surveyor arrived onsite at 9:30 a.m. and that surveyor was also not screened for symptoms and no temperature assessment was performed by staff upon entry into hospital.

In an interview on 07/01/2020 at 9:30 a.m. with S10Recep, she verified there was no signage on the door directing visitors to go to the admissions building (another building) to get screened for symptoms and to have their temperatures taken.

In an interview on 07/01/2020 at 2:00 p.m. with S14IC, she confirmed surveyors should have been directed to enter the administration building (designated entrance during COVID-19 pandemic) to have their temperature assessed and to be screened for symptoms of COVID-19/any possible exposure to COVID-19.

4. Failure to perform staff screening for COVID-19 symptoms and any potential COVID-19 exposure upon arrival for their shifts.

Review of the hospital's staff screening logs revealed no documented evidence that staff was screened for COVID-19 symptoms and any potential COVID-19 exposure upon arrival for their shifts.

In an interview on 06/29/2020 at 10:55 a.m. with S11MHT, she indicated she only had her temperature screened prior to each shift for COVID-19 screening.

In an interview on 06/29/2020 at 11:00 a.m. with S21RN, she indicated she only had her temperature screened prior to each shift for COVID-19 screening.

In an interview on 06/29/2020 at 11:15 a.m. with S8MHT, she indicated she only had her temperature screened prior to each shift for COVID-19 screening.

In an interview at 2:00 p.m. on 07/01/2020 with S14IC, she indicated they only screened employees once for symptoms of COVID-19 and the employees signed an attestation at that time that they were symptom free and would inform them if they developed symptoms. She confirmed they only perform temperature screening prior to each shift as an ongoing means of screening staff for COVID-19.