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Based on interviews and document review, it was determined the governing body failed to ensure governing body meeting minutes documented the appointment of two (2) of five (5) medical staff members selected for credentialing and privileging review (Medical Staff Member (MSM) #3 and MSM #5).

The findings include:

During the review of physician credentialing and privileging documentation on 12/15/16 with Employee #7, Employee #7 was unable to provide evidence of current appointment and/or reappointment for MSM #3 and MSM #5. Employee #7 was asked to provide the surveyor MSM #3's and MSM #5's appointment letters and the minutes of the governing body meeting when the aforementioned medical staff members were appointed.

On 12/15/16 at 3:22PM, the facility's CEO (chief executive officer) reported that MSM #3 and MSM #5 was appointed/reappointed by email ballots; the CEO reported the email ballots would not be available for the surveyors review until 12/16/16. On the morning of 12/16/16 the survey team was provided copies of email communication which indicated MSM #3 and MSM #5 was approved by a majority of the members of the Board of Managers; this email approval did not occur during a meeting.

The facility's unit manager (Employee #2) reported that MSM #3's appointment/reappointment was not addressed in the board meeting minutes. The survey team was provided a copy of MSM #3's appointment letter. The appointment letter was dated 9/26/16 and indicated that MSM #3 had been appointed for the time period of 10/01/16 - 9/30/18. The Board of Managers 8/9/16 meeting minutes included the following statement: "Due to there not being a quorum present for voting. The ballot of physicians as contained in the Board packet will be sent to the members by email for voting." The draft copy of the Board of Managers 12/6/16 meeting minutes included the following statement: "MEDICAL STAFF CREDENTIALING: (name omitted) presented the roster of physicians as contained in the Board packet for approval of privileges at Centra Specialty Hospital. (name omitted) states (he/she) has used due diligence in reviewing the credentialing packets to assure the applicants have the appropriate licensure and carry the proper insurance in addition to other qualifications that are set forth in the Credentialing Policy. The applicants have gone through the credentialing process required by Centra Health and been approved by the Head of the Department in their specialty. They have also been approved for appointment by the CSH Medical Executives Community. There are three physicians and one allied healthcare provider seeking initial appointment to CSH and three medical staff members being presented for reappointment. A copy of the physician credentialing roster is on file with the minutes. Motion: To approve the medical staff privileges as presented (motioning names omitted). Motion carried unanimously. " No evidence of discussion related to the email votes for the appointment/reappointment for MSM #3 to the medical staff was documented in these draft meeting minutes.

The survey team was provided a copy of MSM #5's appointment letter. The appointment letter was dated 1/26/15 and indicated that MSM #5 had been appointed for the time period of 1/01/15 - 1/31/17. The Board of Managers 1/25/15 meeting minutes included the following statement: "MEDICAL STAFF CREDENTIALING: (name omitted) discussed the roster of providers on that are due for reappointment at Centra Specialty [sic]. (He/She) stated that (he/she) has reviewed all of the files and there were no issues found. (name omitted) has used due diligence in reviewing the credentialing packets to assure the applicants have the appropriate licensure and carry the proper insurance in addition to other qualifications that are set forth in the Credentialing Policy. The applicants have gone through the credentialing process required by Centra Health and been approved by the Head of the Department in their specialty. They have also been approved for appointment by the CSH Medical Executives Community. All applicants are seeking reappointment at CSH ... Due to not having a quorum for voting, the ballot for medical staff credentialing will be sent by (name omitted) to the Board members for vote via email ballot." The Board of Managers 5/12/15 meeting minutes did not include information related the results of the email ballots for MSM #5.

The following information found in the facility's 'HOSPITAL OPERATING AGREEMENT' [sic] (which was provided to the survey team on the morning of 12/16/16 by the facility's CEO):
- "Board of Managers. The governing body vested with authority to manage the Hospital under this Agreement."
- "ARTICLE V. MANAGEMENT ... Duties And Responsibilities ... appointing physicians to and removing physicians from the medical staff ..."
- "Quorum and Voting. A majority of Managers in office immediately before a meeting begins shall constitute a quorum for the transaction of any business properly to come before the Board of Managers. The act of a majority of the Managers present in person or by proxy at a meeting which a quorum is present shall be the act of the Board of Managers. In no event can the Manager appointed by the Member constitute a majority."
- "Means of Communication. The Board of Managers, or a committee thereof may permit a Manager or a committee member to participate in a meeting by or conduct a meeting through the use of any means of communication by which all Managers or committee member participating may simultaneously hear each other during the meeting."

Based on interviews and document review, it was determined the governing body failed to ensure contract services were addressed by the facility's quality assurance and performance improvement program (QAPI).

The findings include:

On 12/13/16 at 10:00 am, the surveyor reviewed the list of services provided by contract with Staff Member (SM) #1; SM #1 is the facility CEO (chief executive officer). SM #1 was asked to provide evidence of the involvement and/or review of contracted services in the hospital's quality program. Contracted services included but were not limited to radiological services, laboratory services, food and dietetic services, physical environment, nuclear medicine services, and rehabilitation services. SM #1 stated that he/she "goes over" contracted services with a "liaison" of the corporation providing the services and at that time addresses any problems that may have arisen. SM #1 could not provide the surveyor with evidence of a review of contracted services. SM #1 was asked to provide any data used to monitor the quality of contracted services, SM #1 stated the hospital was not collecting data for contracted services.

On 12/13/16 at 3:30 pm, SM #17 (identified as Chair of the Quality Council) was interviewed. SM #17 stated the hospital's quality plan was created yearly in December by the leadership team, with results reported to the board (governing body) quarterly. SM #17 stated the Quality Council was a nursing initiative and always tracks nine (9) quality items; however he/she confirmed that contracted services were not among the items tracked.

The hospital document entitled "Centra Specialty Hospital Organizational Improvement Plan" stated in part "The Board of Managers of CSH is ultimately responsible for Performance Improvement" and "The Administrative Team determines the measures and thresholds to be monitored and is responsible for oversite and coordination of the Performance Improvement Plan". The aforementioned document fails to provide evidence of a directive specific to the monitoring of contracted services provided to the hospital.

Surveyor review of minutes of administrative meetings and unit meetings for 2016 failed to provide evidence of contracted services being monitored for quality purposes. The aforementioned documents failed to provide evidence of discussions related to the performance of contracted services and/or of the discussion or inclusion of data provided on a corporate level.

Review of the "Quality & Patient Safety" scorecard for October 2016, failed to provided evidence of the review and/or monitoring of contracted services for quality purposes for this hospital. Review of "Service QAPI Summary Reporting Period: 3Qtr2016" provided data related to pharmacy, laboratory and radiology on a corporate level but failed to provide quality data specific to this hospital.

The above findings were discussed for a final time with SM #1 on 12/19/16, no further information or evidence was provided to the survey team.

Based on staff interviews and facility document reviews, it was determined the facility's staff failed to provide patients with a copy of their patient rights at the time of admission for Patients #1, 2, 3, 5, 6, 7, 9, 10, 11, 14, 16, 18, 19, 21, and 22, fifteen (15) of twenty-two (22) in-patients.

The findings were:

On 12/15/16 and 12/16/16 a review of the clinical records was conducted. During the review of Patients #1, 2, 3, 5, 6, 7, 9, 10, 11, 14, 16, 18, 19, 21, and 22's clinical records, it was discovered that the facility's staff were unable to provide evidence that these patients were provided with or signed a copy of their patient rights. The surveyors were assisted in navigating the electronic health record by facility staff.

On 12/15/16 an interview was conducted with Staff Member (SM) #4. SM #4 stated at the time of registration staff are to have the patients/families review and sign a copy of their patient rights. At that time the staff would give the patients/families a copy. He/she stated the signed copy is scanned into the electronic health record.

A review of the facility's policy titled, "Ethics and Patient Rights and Responsibilities (policy review date 12/07/16), took place on 12/16/16 at 10:40 a.m. The document included, in part, the following statements: "Centra patients receive a copy of their "patient rights" at the time of registration. Patients are asked to review and sign a copy of the patient rights. The signed copy is scanned into the patient's medical record and a copy is given to the patient."

An end of day meeting took place on 12/15/16 at 4:10 p.m. with the facility's management team. The management team was informed that during the course of medical records review with SM #4, the surveyors were unable to find evidence that patients/families had reviewed or signed a copy of their patient rights.

Based on interviews and document review, it was determined the facility staff failed to have documentation to ensure the facility's grievance process was followed for a complaint reported verbally by a patient's spouse (Patient #7) and it was determined the facility staff failed to correctly identify the complaint as a grievance.

The findings include:

The facility staff failed to follow the facility's written policy and procedures which provided guidance for responding to a grievance.

The survey team was provided a copy of the facility's 'Patient Grievance Policy' on 12/13/16 at 4:15PM. This policy was documented with a 'start date' of 6/30/09, an 'approval date' of 9/7/16, and a review date of 9/7/19. (The facility's CEO (chief executive officer) reported the review date was documented to indicate when this policy needs to be reviewed.) The 'Patient Grievance Policy' included the following definition: "A GRIEVANCE is a written or verbal complaint that is made by a patient, or the patient's representative, regarding the patient's care which is not resolved by Staff Present during the patient encounter at the time of the complaint. It includes allegations of abuse, neglect or harm, including actions that may have been allegedly inflicted by other patients or residents."

Facility documentation in its 'Riskmaster' computerized event/incident program included evidence of an event being reported on 9/10/16 at 8:20AM which met the facility's aforementioned definition of a grievance. Patient #7 was named in the grievance. Patient #7's spouse verbally reported the complaint to Staff Member #3. Documentation indicated that Patient #7's physician was quickly notified of details of the complaint and the patient was transported via ambulance to an emergency department of a different facility. (The facility being surveyed did not have an emergency department.) Documentation also indicated the 'nursing supervisor' and the 'administrator on call' were notified of the event.

The facility's aforementioned 'Patient Grievance Policy' included the following 'PROCEDURE ... Investigation ... The involved site administrators, managers(s) and/or supervisors have primary responsibility for investigating and responding to grievances for their area. a. Service Excellence, Risk Management, and Compliance will be involved in the investigation and response as deemed appropriate and/or applicable for the nature of the grievance. b. Information included in a grievance investigation should include, as applicable: i. Date and Time of the alleged incident ii. Circumstances around the alleged incident iii. Location of the alleged incident iv. Names of any witness, patients and employees v. Written accounts of the alleged incident from any witnesses, patients and employees that are (1) legible, (2) signed and (3) dated vi. Recommendations for corrective and preventative action".

On 12/14/16 at 10:38AM, a facility's Risk Manager (Staff Member (SM) #14) accessed the facility's electronic grievance log to show the survey team the log. SM #14 reported that this event would not be captured on the grievance log because during the investigation the event was determined to not be a grievance.

During an interview on 12/15/16 at 10:09AM, the facility's CFO (chief financial officer), with the facility's Director of HR present, acknowledged the alleged event which resulted in the complaint reported on 9/10/16 at 8:20AM met the facility's definition of a 'grievance'. The CFO was the 'administrator on call' when the grievance was reported by the patient's spouse.

During an interview on 12/15/16 at 2:17PM, the facility's CEO (chief executive officer) acknowledged the aforementioned alleged event which resulted in the complaint reported on 9/10/16 at 8:20AM met the facility's definition of a 'grievance'.

Documentation in the facility's 'Riskmaster' computerized event/incident program did not include investigation of the alleged event. The 'Risk Master' documentation addressed meeting the patient's potential immediate needs and informing the necessary individuals. A copy of the 'paper file' maintained for this allegation was provided to the survey team. The 'paper file' contained documentation of conversations and two (2) conference calls, related to the alleged event, these occurred on the same day the allegation was made by the patient's spouse. The documentation of this allegation did not include written statements by the individuals possibly involved in the event. The documentation of this allegation did not include a written conclusion. The documentation of this allegation did not include information related to the decision to allow the individual identified as potentially being involved in the allegation to return to work. The survey team was provided with copies of email communication involving multiple individuals and multiple topics related to this allegation; these emails had not been filed with the 'paper file' or the 'Riskmaster' documentation of this allegation.

During an interview on 12/15/16 at 1:48PM, the facility's CEO reported that adverse events and grievances have not been taken to quality meetings.

Based on interviews and document review, it was determined the facility staff failed to provide a written notice of the facility staff's determination regarding a grievance reported verbally by a patient's spouse (Patient #7).

The findings include:

Facility documentation in its 'Riskmaster' computerized event/incident program included evidence of an event being reported on 9/10/16 at 8:20AM which met the facility's definition of a grievance. Patient #7 was named in the grievance. Patient #7's spouse verbally reported the complaint to Staff Member #3.

The survey team was provided a copy of the facility's 'Patient Grievance Policy' on 12/13/16 at 4:15PM. This policy was documented with a 'start date' of 6/30/09, an 'approval date' of 9/7/16, and a date to be reviewed of 9/7/19.

The 'Patient Grievance Policy' included the following 'Grievance Response Times and Requirements' for the 'Acute Care Hospitals': "1. Immediately (within 1 working day) - Notify applicable leadership and Service Excellence Specialist. 2. Within 7 Calendar Days If the investigation is complete and/or the grievance resolved: Manager/Director/Vice President - provide a written letter (email only if the original grievance was received by email) with the Notice of Decision including: i. Hospital Contact Person ii. Steps taken on behalf of the patient to investigate the grievance iii. Results of the process iv. Date of completion ... If the investigation is not complete and/or grievance not resolved: Manager/Director/Vice President - provide a written letter (email only if the original grievance was received by email) notifying the patient/patient representative that: i. The grievance is still being addressed ... The responding area will follow-up within another 7 calendar days".

Evidence of a written letter to the complainant addressing the facility's investigation of the grievance was not found. During an interview with the facility's Director of Risk Management on 12/14/16 at 9:58AM, the Director of Risk Management stated the investigation was shared with the complainant verbally but no written information related to the investigation was sent to the complainant.

Based on observations, staff interviews, and facility document reviews, it was determined the facility's staff failed to obtain informed consents to allow patients to make informed decisions effecting their privacy and personal dignity for Patient #5, Patient #6, Patient #18, and Patient #19, four (4) of four (4) in-patients sampled who were visually monitored via cameras located in the patients ' rooms.

The findings were:

On 12/15/16 at 2:15 p.m. the surveyor was at the nurse's station when he/she noticed facility staff monitoring in-patients on a computer screen. Staff verified that each of the patient rooms were equipped with cameras. The staff reported the cameras were only active in the room where patients were a high risk of fall or injuring themselves.

On 12/15/16 at 1:30 p.m. the clinical record of Patient #5 was reviewed. The record stated the patient was admitted on 12/12/16 with the diagnoses of acute respiratory failure and pneumonia. Staff Member (SM) #4 was unable to provide the surveyor with any consent form or documentation that the patient/family and or representative were aware of the cameras. The clinical record contained evidence the hospital staff failed to ensure that Patient #5 was afforded the right to reasonable informed participation in decisions regarding his/her privacy and personal dignity, by failing to provide the aforementioned clear and concise information to the patient and/or representative, prior to visually monitoring the patient.

On 12/15/16 at 2:00 p.m. the clinical record of Patient #6 was reviewed. The record stated the patient was on 10/13/16 with the diagnosis of acute/chronic hypoxia and respiratory failure. Staff Member (SM) #4 was unable to provide the surveyor with a consent form or documentation that the patient/family and/or representative were aware of the cameras. The clinical record contained evidence the hospital staff failed to ensure that Patient #6 was afforded the right to reasonable informed participation in decisions regarding his/her privacy and personal dignity, by failing to provide the aforementioned clear and concise information to the patient and/or representative, prior to visually monitoring the patient.

On 12/15/16 at 2:45 p.m. the clinical record of Patient #18 was reviewed. The record stated the patient was admitted on 12/01/16 with the diagnosis of acute respiratory failure and end stage renal disease. SM #4 was unable to provide the surveyor with any consent form or documentation that the patient/family and/or representative were aware of the cameras. The clinical record contained evidence the hospital staff failed to ensure that Patient #18 was afforded the right to reasonable informed participation in decisions regarding his/her privacy and personal dignity, by failing to provide the aforementioned clear and concise information to the patient and/or representative, prior to visually monitoring the patient.

In the morning of 12/16/15 the clinical record of Patient #19 was reviewed. The record stated the patient was admitted on 07/23/16. SM #4 was unable to provide the surveyor with a consent form or documentation that the patient/family and or representative were aware of the cameras. The clinical record contained evidence the hospital staff failed to ensure that Patient #19 was afforded the right to reasonable informed participation in decisions regarding his/her privacy and personal dignity, by failing to provide the aforementioned clear and concise information to the patient and/or representative, prior to visually monitoring the patient.
During the review of Patient #5, #6, and #18's clinical records, the Registered Nurse (RN) Clinical Educator was present and assisting the surveyor in navigating the electronic health record. The RN/Clinical Educator verified that each of the above patients had an active camera in the room and was or had been visually monitored at some point during their admission. The RN/Clinical Educator stated he/she was unaware of any consent form given to the patients/families informing them they were being visually monitored during their stay. The RN/Clinical Educator stated the nurses verbally informed the patients and or families that the patients are being visually monitored at the nurse's station. The clinical record failed to provide documentation by the primary care nurse that he/she had informed Patient #5, #6, and #18 they were being visually monitored at the nurses station.

On 12/15/16 at 2:45 p.m. an interview was conducted with SM #18. SM #18 stated that patients were told staff were "putting the camera on is that ok." He/she acknowledged they were unaware of any consent forms provided to the patients and or family regarding visual monitoring.

A review of the facility's policy titled "Informed Consent - CSH" (policy review date 12/16/15) and "Ethics and Patient Rights and Responsibilities" (policy review date 12/07/16) took place on 12/15/16 at 2:40 p.m. Both documents included, in part, the following statements:

"Photography, Video Recording or Observation - The hospital honors the patient's right to give or withhold informed consent to produce or use recordings, photographs or other images of the patient for purposes other than his or her care. Photographs or video recordings may be taken during a procedure for educational or continuing clinical care purpose. Recordings and photographs taken during procedures for which patient consent was not obtained will be deleted/destroyed and not used for any purpose. Recordings and photographs taken during procedures will not contain any identifiable patient information and will not be made part of the patient's medical record. Patients may request cessation of the production of recordings or photographs at any time during a procedure or may revoke the consent at any time after the procedure."

"Any photographing/recording of patients or observation by individuals other than those directly involved in the patient's care requires the written consent of the patient."

"Our fundamental purpose is to provide excellent care. In pursuit of that goal:
· We treat our patients with dignity;
· We respect our patients' rights to privacy and confidentiality;"

"Our organization respects the rights of patients and recognizes that each patients' cultural and personal values, beliefs, and preferences and provide considerate, respectful care focused on the patient's individual needs."

The Right to Participate in Care Decisions

"We respect the patient's right to participate in decisions about their care, treatment and services including the right to refuse care, treatment and services, in accordance with law and regulation. When a patient is unable to make decisions about his or her care treatment, and services, we involve a surrogate decision-maker in making decisions."

The Right to Informed Consent

"We respect every competent patient's right to make his or her own health care decisions after being informed of all relevant information. In order to support the patient's participation in decisions regarding his or her care, we provide inform consent. Informed consent includes the discussion of:

· The nature of the decision or procedure;
· Reasonable alternatives to the proposed intervention;"

An end of day meeting took place on 12/15/16 at 4:10 p.m. with the facility's management team. The management team was informed that during the course of medial record review with SM #4 the surveyors were unable to find consents for visually monitor patients.

Based on staff interviews, facility document reviews, and observations, it was determined that the facility staff failed to reassess and monitor non-violent behavioral restrained patients, according to facility policy for two (2) of four (4) patients sampled for restraint use (Patient #6 and Patient #20).

The findings were:

On 12/15/16 at 2:00 p.m. the clinical record of Patient #6 was reviewed. The record stated the patient was a 78 year old admitted on 10/13/16 with the diagnosis of acute/chronic hypoxia and respiratory failure. The clinical record indicated that Patient #6 had an order for non-violent behavioral wrist restraints. On 12/13/16 at 9:30 p.m. clinical documentation revealed that non-violent behavioral wrist restraints had been initiated on Patient #6, and the nurse had documented as such, on the reassessment and monitoring flow sheet. A review of the reassessment and monitoring flow sheet revealed from 12/13/16 at 9:30 p.m. until 12/14/16 at 7:12 a.m. no nursing reassessment and monitoring had been completed. No restraint reassessment and monitoring documentation could be found during that 10 hour time period. The RN/Clinical Educator was assisting the surveyor in navigating the electronic health record. On 12/15/16 at 2:15 p.m. the RN/Clinical Educator stated, "There is no documentation in the chart." No other documentation was given to the surveyor.


On 12/19/16 at 2:15 p.m. the clinical record of Patient #20 was reviewed. The record stated the patient was admitted on 04/15/16 with the diagnosis of respiratory failure secondary to a left ischemic stroke. The clinical record indicated that Patient #20 had an order for non-violent behavioral wrist restraints, dated 04/15/16 at 6:25p.m. On 04/15/16 at 6:25 p.m. clinical documentation reveals non-behavioral wrist restraints had been initiated on Patient #20, and the nurse had documented as such, on the reassessment and monitoring flow sheet. A review of the reassessment and monitoring flow sheet revealed from 04/16/16 at 6:18 p.m. until 10:00 p.m. and on 04/17/16 at 2:00 a.m. until 6:00 a.m. No nursing reassessment and monitoring had been completed. No restraint reassessment and monitoring documentation could be found for either of the two (2) four (4) hour gaps. The RN/Clinical Educator was unable to provide any evidence that the reassessment and monitoring had been completed during those time periods.

A review of the facility's policy titled, "Patient Restraints - CSH" (policy review date 02/12/14), took place on 12/16/16 at 10:40 a.m. The document included, in part, the following statements:

Reassessment/Monitoring Guidelines

"Monitoring and Documentation by a:
· RN/LPN (Nursing);
· Non-Violent Behavior-Frequency of Activity at Least:
· Vital signs: Q 4 hour & PRN
· Proper position of restraint/signs of injury Q 2 hour & PRN
· Circulation check Q 2 hour & PRN
· Least restrictive measure tried: Q 2 hour & PRN
· Mental status and emotional well-being Q 2 hour & PRN
· Rights, dignity, and safety Q 2 hour & PRN
· Level of distress or agitation Q 2 hour & PRN
· Evaluation for removal Q 2 hour & PRN
· Nutrition/hydration Q 2 hour & PRN
· Loosen and perform ROM Q 2 hour & PRN
· Hygiene Q 2 hour & PRN
· Elimination/I&O Q 2 hour & PRN
· Turn/reposition/ambulate Q 2 hour & PRN
· Skin integrity under restraint Q 2 hour & PRN."

RN (Registered Nurse), LPN (Licensed Practical Nurse), Q (every), PRN (as needed), ROM (range of motion), I&O (input/output).

An end of day meeting took place on 12/19/16 at 4:45 p.m. with the facility's management team. The management team was informed that during the course of medical records review with SM #4, the surveyors were unable to find evidence of continuous reassessment and monitoring on non-violent behavioral restraint patients.

Based on interviews and hospital document review it was determined that hospital staff failed to a) analyze the causes of medical errors and patient adverse events and b) implement any needed preventative actions related to adverse events for 5 of 5 events selected for review.

The findings include:

On 12/15/16 at 4:00 pm, Staff Member (SM) #1 was interviewed about the hospital's process for tracking adverse events and medication errors. SM #1 stated the events or errors are entered into the "RiskMaster" event reporting system by the individual who identifies the event. The "Riskmaster" system serves several different hospitals. The report is then sent to the manager of the unit where the event occurred. The unit manager is to review and/or investigate the event and enter into the "Riskmaster" system the results of their review and any actions and/or follow up required.

Five (5) events were randomly chosen by the surveyor for review. Review of documentation for the selected events failed to reveal any investigative detail, cause of event, preventative actions taken and/or if follow up was required. These areas on the document were blank, the documents failed to provide evidence of review by the unit manager or other administrative personnel.

On 12/19/16 at 10:50 am, SM #1 was asked about the missing documentation, he/she confirmed the documentation had not been completed. He/she informed the survey team that it had been discovered the event reports had been going to the email of the previous unit manager (who no longer was employed by the hospital). He/she further stated that the system had been changed last week to send email notifications to the current unit manager SM #2. SM #2 stated he/she remembered at least one of the events and had counseled the individuals involved but had not documented the counseling. SM #1 confirmed the documentation of the investigation/analysis of the event should have been on the paperwork provided to the surveyor. It was further confirmed that although adverse patient events were tracked, it was not the practice of the hospital to include monitoring and review of adverse events as a part of the quality program.

Review of hospital document entitled "Riskmaster Event Reporting System" revealed the following statement regarding event reports: "These reports are used in ongoing monitoring, evaluation and improvement activities related to patient care and safety."

The above findings were discussed with SM #1 the morning of 12/20/16, no further information was provided to the survey team.

Based on interviews and hospital document review it was determined the hospital's governing body failed to ensure the quality program involved all hospital departments and services offered. The hospital failed to maintain evidence of the inclusion/involvement of contracted services in the quality program.

The findings are:

On 12/13/16 at 10:00 am, the surveyor reviewed the list of services provided by contract with Staff Member (SM) #1. SM #1 was asked to provide evidence of the involvement and/or review of contracted services in the hospital's quality program. Contracted services included but were not limited to radiological services, laboratory services, food and dietetic services, physical environment, nuclear medicine services, and rehabilitation services. SM #1 stated that he/she "goes over" contracted services with a "liaison" of the corporation providing the services and at that time addresses any problems that may have arisen. SM #1 could not provide the surveyor with evidence of a review of contracted services. SM #1 was asked to provide any data used to monitor the quality of contracted services, SM #1 stated the hospital was not collecting data for contracted services.

On 12/13/16 at 3:30 pm, SM #17 (identified as Chair of the Quality Council) was interviewed. SM #17 stated the hospital's quality plan was created yearly in December by the leadership team, with results reported to the board (governing body) quarterly. SM #17 stated the Quality Council was a nursing initiative and always tracks nine (9) quality items, however he/she confirmed that contracted services were not among the items tracked.

Review of hospital document entitled "Centra Specialty Hospital Organizational Improvement Plan" states in part "The Board of Managers of CSH is ultimately responsible for Performance Improvement" and "The Administrative Team determines the measures and thresholds to be monitored and is responsible for oversite and coordination of the Performance Improvement Plan". The aforementioned document fails to provide evidence of a directive specific to the monitoring of contracted services provided to the hospital.

Surveyor review of minutes of administrative meetings and unit meetings for 2016, failed to provide evidence of contracted services being monitored for quality purposes. The aforementioned documents failed to provide evidence of discussions related to the performance of contracted services and/or of the discussion or inclusion of data provided on a corporate level.

Review of the "Quality & Patient Safety" scorecard for October 2016, failed to provided evidence of the review and/or monitoring of contracted services for quality purposes for this hospital. Review of "Service QAPI Summary Reporting Period: 3Qtr2016" provided data related to pharmacy, laboratory and radiology on a corporate level but failed to provide quality data specific to this hospital.

The above findings were discussed for a final time with SM #1 on 12/19/16, no further information or evidence was provided to the survey team.

Based on interviews and document review, it was determined the facility staff failed to ensure discharge and/or transfer orders were written and/or signed by a provider for 2 of 22 sampled discharged and/or transferred patients (Patient #4 and Patient #7).

The findings included:

Patient #4's and Patient #7's clinical documentation failed to include a discharge and/or transfer order signed by a physician/provider.

On 12/19/16 at 4:00PM, the surveyor was provided with a copy of a transfer request entered by a unit secretary (not a nurse) into Patient #7's clinical record. This transfer request was documented as being entered based on a written provider order. No signed provider order was found in the patient's clinical record. This transfer request had an area that could have been co-signed by a medical provider; this area was blank. On 12/19/16 at 4:23PM, the facility's CEO (chief executive officer) reported he/she was unable to find a discharge order documented by a provider.

Review of Patient #4's clinical documentation on the morning of 12/20/16 revealed a transfer request entered by a unit secretary (not a nurse) that was documented as being based on a written provider discharge order. This transfer request had an area that could have been co-signed by a medical provider; this area was blank. No provider written discharge or transfer order was found in the patient ' s clinical record. On 12/20/16 at 10:00AM, the facility's CEO acknowledged he/she was unable to find a discharge order written or signed by a provider.