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Based on record reviews and interview, the facility failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by:
1) the facility to failed ensure the QAPI Program specified the method and frequency of data collection for indicators as evidenced by failure to have a documented QAPI Plan or documented evidence of current data on quality indicators (see findings in Tag A-0273);
2) the facility's governing body failed to ensure the QAPI program reflects the complexity of the hospital's organization and services, involves all hospital departments and services and maintains and demonstrates evidence of its QAPI program. This deficient practice was evidenced by the failure to provide a QAPI plan or any findings, data or functions of QAPI taking place (see findings in Tag A-0308); and
3) the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the facility's performance by having insufficient staff designated to conduct the QAPI functions of the facility. This deficient practice is evidenced by assigning this responsibility to S11QA who is not a full time employee and oversees 3 locations for this provider (see findings in Tag A-0315).

Based on observation, record review and interview, the facility failed to ensure compliance with patient rights as required by the state regulations for Behavioral Health Service providers. The deficient practice was evidenced by:
1) failure to post a copy of patient rights in a conspicuous location in the offsite Behavioral Health clinic; and
2) failure to ensure all patient rights were included in facility policy and communicated to patients.
Findings:

1) failure to post a copy of patient rights in a conspicuous location in the offsite Behavioral Health clinic

Observations during a facility walk through on 04/01/2025 at 2:43 PM failed to reveal the patients' rights posted in the facility.

In interview on 04/01/2024 at 2:45 PM, S1CEO verified the patients' rights were not posted in the facility.

2) failure to ensure all patient rights were included in facility policy and communicated to patients

A review of facility policy, "Bethesda Outpatient Program, Subject: Client Rights," Policy #: BOP - 030, with an effective date of 12/02/2022 and last reviewed on 12/28/2023, and the review of information presented to and signed by the patient on admissions, "Patients' Legal and Human Rights," failed to reveal the following patient rights set forth in the state regulations for Behavioral Health Service providers: The right to have a family member, chosen representative and/or his or her own physician notified of admission to the BHS provider at the request of the client; The right to receive treatment and medical services without discrimination based on race, age, religion, national origin, gender, sexual orientation, or disability; The right to receive care in a safe setting; The right to receive the services of a translator or interpreter, if applicable, to facilitate communication between the client and the staff; The right to participate or refuse to participate in experimental research when the client gives informed, written consent to such participation, or when a client's parent or legal guardian provides such consent, when applicable, in accordance with federal and state laws and regulations; The right to be informed, in writing, of the policies and procedures for filing a grievance and their review and resolution; The right to receive treatment in the least restrictive environment that meets the client's needs; The right to not be restrained or secluded in violation of federal and state laws, rules and regulations; The right to be informed in advance of all estimated charges and any limitations on the length of services at the time of admission or within 72 hours; The right to be informed of the nature and purpose of any services rendered, the title of personnel providing that service, the risks, benefits, and side effects of all proposed treatment and medications the probable health and mental health consequences of refusing treatment, and other available treatments which may be appropriate; and The right to have a copy of these rights, which includes the information to contact HSS during routine business hours.

In interview on 04/01/2024 at 4:30 PM, S2SWPD confirmed the above mentioned findings.

Based on record review and interview, the facility failed to ensure the patient's right to received care in a safe setting. This deficient practice was evidenced by:
1) failure to document a provider admission order to designate the outpatient program level of care on 3 (#1 - #3) of 3 (#1 - #3) medical records reviewed;
2) failure to ensure 4 (S4PhD, S6RN, S8MHT, S10FNP) of 6 (S2SWPD, S4PhD, S6RN, S7MHT, S8MHT, S10FNP) personnel files revealed documentation of training in de-escalation techniques;
3) failure to ensure 1 (S8MHT) of 2 (S7MHT, S8MHT) unlicensed personnel were screened through the Louisiana Department of Health (LDH) Adverse Actions Website prior to hire; and
4) failure to ensure a patient or non-patient contacting the facility via telephone in a crisis situation is appropriately and timely referred to appropriate care.
Findings:

1) failure to document a provider admission order to designate the outpatient program level of care on 3 (#1 - #3) of 3 (#1 - #3) medical records reviewed

A review of Patients #1 - #3 medical records failed to reveal a provider order for admission to the BHS provider's outpatient program and a designation of the level of care to be provided. The proper level of care could not be identified without a provider order. This could create an unsafe setting for a patient with the potential to not be properly monitored.

In an interview on 04/01/2025 at 11:35 AM, S3LPN confirmed the above mentioned findings.

In an interview on 04/01/2025 at 1:35 PM, S2SWPD confirmed an admission order to a program was not written for the above mentioned patients.

2) failure to ensure 4 (S4PhD, S6RN, S8MHT, S10FNP) of 6 (S2SWPD, S4PhD, S6RN, S7MHT, S8MHT, S10FNP) personnel files revealed documentation of training in de-escalation techniques

A review of S4PhD, S6RN, S8MHT, and S10FNP personnel files failed to reveal documentation of de-escalation training. This could potentially create an unsafe setting for a patient(s) who exhibit escalating behaviors.

In an interview on 04/01/2025 at 2:41 PM, S2SWPD confirmed the above mentioned findings and further confirmed the above mentioned personnel would be scheduled to complete this training soon.

3) failure to ensure 1 (S8MHT) of 2 (S7MHT, S8MHT) unlicensed personnel were screened through the Louisiana Department of Health (LDH) Adverse Actions Website prior to hire

Review of LAC: Title 48, Chapter 92, Direct Service Worker Registry, revealed in part, the following:
9202. C. Licensed and/or certified health care providers shall access the registry to determine if there is a finding that a prospective hire, or currently employed or contracted DSW, has been determined to have committed exploitation, extortion, abuse or neglect of an individual being supported, or misappropriated the individual's property or funds. If there is such a finding on the registry, the prospective employee shall not be hired as a DSW nor shall a current employee have continued employment as a DSW with the licensed and/or certified health care provider.
§9231. Health Care Provider Responsibilities, A. Prior to hiring any DSW or trainee, the licensed and/or certified health care provider shall: 3. access the registry in accordance with the provisions of §9202.C-C.1.

Review of the Louisiana State Adverse Actions List Search website revealed in part: Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual's property or funds. If there is such a finding on the registry, the prospective employee shall not be hired.

A review of S8MHT personnel file revealed a date of hire as 02/24/2025 and failed to reveal documentation of the LDH Adverse Actions Website verification prior to hire. This could create an unsafe setting for patient(s) being observed and monitored by an unlicensed staff member that has been placed on this list for an offense.

In an interview on 04/01/2025 at 3:00 PM, S9OC confirmed the above mentioned findings

4) failure to ensure a patient or non-patient contacting the facility via telephone in a crisis situation is appropriately and timely referred to appropriate care

A review of facility policy, "Bethesda Outpatient Program, Subject: Inquiry/Screening," Policy #: BOP - 008, with an effective date of 12/02/2021 and last reviewed on 12/22/2022, revealed in part: "Inquiry/Screening: Policy: It is the policy of Bethesda Outpatient Program to provide services for intake assessments and referrals by trained professionals. Staff will be available weekdays between the hours of 8:00am and 4:00pm weekdays. After hours calls will be returned on the following business day. Purpose: To provide a systematic method for monitoring and processing admission inquiries to the outpatient programs while providing accurate and timely assessments."

Observations upon arrival to the off-site location of the facility on 03/31/2025 at 7:55 AM revealed the entry door locked, the interior of the facility appearing dark and a sign on the door revealed, "Bethesda Behavioral Health Programs 756 Colonial Drive Suite B 225-778-5214." Attempt to contact the facility at the before mentioned number revealed a voice mail.

In an interview on 04/01/2025 at 11:57 AM, S1CEO confirmed the telephone were going to voice mail and should be forwarded to staff member's cell phone. S1CEO confirmed if the message went to an unanswered voice mail, it could potentially have a negative effect on a patient in crisis.

Based on record review and interview, the facility failed to ensure the patient's right to be free from all forms of abuse or harassment. This deficient practice was evidenced by the failure to ensure potential allegations and/or suspicion of abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations.
Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or LDH. This statute would include any issue under review for the determination whether the facility failed to take prudent action to prevent, and/or respond to an alleged occurrence such as a potential self-injurious behavior or an elopement.

A review facility incident reports revealed Patient #1 left the facility on 03/26/2025. A review of a written statement by S12LMSW dated 03/26/2025 at 11:00 AM revealed in part: "on the above date and approximate time while doing group, [Patient #1] walked out of the room as if he was going to the bathroom. Group started again at 11:00 AM he did not return so I asked staff where was he and if they saw him." A review of a written statement by S7MHT dated 03/26/2025, no time documented, revealed in part: the patient was thought to be in the restroom, but after a search, it was determined he was not in the restroom or the building.

In an interview on 04/01/2025 at 2:33 PM, S3LPN confirmed the facility has not submitted a self-report to HSS regarding the Patient #1 leaving the facility.

In an interview on 04/01/2025 from 9:00 AM, S2SWPD confirmed Patient #1 left the facility on 03/26/2025 during the time frame of group session #2 from 10:00 AM to 10:45 AM. Patient #1 asked for restroom break and at some point during this break, Patient #1 exited the facility unattended and the staff were unaware he had left the building. She further confirmed the facility had not reported the incident to HSS.

Based on record review and interview, the facility failed to ensure the QAPI Program specified the method and frequency of data collection for indicators as evidenced by failure to have a documented QAPI Plan or documented evidence of current data on quality indicators.
Findings:

A request was initiated with the initial document request upon entry on 03/31/2025 at 9:00 AM with S3LPN. This included: QAPI committee meetings and indicators/outliers from 10/01/2024 to 03/01/2025; QAPI Plan and program with governing body approval.

The following policies were received from S1CEO on 03/31/2025 at 1:00 PM: "Bethesda, Subject: Performance Improvement," policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025 and "Bethesda, Subject: Performance Measurement & Management," policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025. The information received did not reveal a QAPI data, meeting minutes or QI plan.

In an interview on 03/31/2025 at 1:00 PM, S1CEO confirmed these policies and indicated the facility was "working on the QI Plan and on the data."

A request was initiated on 03/31/2025 at 3:30 PM with S2SWPD for the QI Plan and QAPI data.

In an interview on 03/31/2025 at 3:30 PM S2SWPD confirmed she would have this information in the morning.

A review of meeting minutes identified by S1CEO as Departmental Meeting on 01/15/2025, no time available and Governing Body meeting minutes from 02/25/2025 at 4:30 PM failed to reveal documentation related to QAPI discussion.

In an interview on 04/01/2025 at 11:57 AM. S1CEO confirmed the above information and the facility was "working on the QI Plan and gathering the data."

The following policy was received from S1CEO on 04/01/2025 at 3:25 PM: "Bethesda, Subject: Performance Improvement Policy," policy number not available, an effective date of 06/01/2021, last reviewed on 10/15/2024. The information received did not reveal QAPI data, meeting minutes or QI plan.

In an interview on 04/01/2025 at 3:25 PM. S1CEO confirmed all information for QAPI had been presented to the surveyors. He indicated we could contact S11QA for further questions and he initiated a phone call with S11QA for the surveyors to discuss.

In a telephone interview on 04/01/2025 at 3:25 PM, S11QA confirmed the before mentioned policies and further confirmed the facility had no QAPI Plan and no other information to present.

Based on record review and interview, the facility's governing body failed to ensure the QAPI program reflects the complexity of the facility's organization and services, involves all facility's departments and services and maintains and demonstrates evidence of its QAPI program. This deficient practice was evidenced by the failure to provide a QAPI plan or any findings, data or functions of QAPI taking place.
Findings:

A request was initiated with the initial document request upon entry on 03/31/2025 at 9:00 AM with S3LPN. This included: QAPI committee meetings and indicators/outliers from 10/01/2024 to 03/01/2025; QAPI Plan and program with governing body approval.

The following policies were received from S1CEO on 03/31/2025 at 1:00 PM: "Bethesda, Subject: Performance Improvement," policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025 and "Bethesda, Subject: Performance Measurement & Management," policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025. The information received did not reveal a QAPI data, meeting minutes or QI plan.

In an interview on 03/31/2025 at 1:00 PM, S1CEO confirmed these policies and indicated the facility was "working on the QI Plan and on the data."

A request was initiated on 03/31/2025 at 3:30 PM with S2SWPD for the QI Plan and QAPI data.

In an interview on 03/31/2025 at 3:30 PM S2SWPD confirmed she would have this information in the morning.

A review of meeting minutes identified by S1CEO as Departmental Meeting on 01/15/2025, no time available and Governing Body meeting minutes from 02/25/2025 at 4:30 PM failed to reveal documentation related to QAPI discussion.

In an interview on 04/01/2025 at 11:57 AM. S1CEO confirmed the above information and the facility was "working on the QI Plan and gathering the data."

The following policy was received from S1CEO on 04/01/2025 at 3:25 PM: "Bethesda, Subject: Performance Improvement Policy," policy number not available, an effective date of 06/01/2021, last reviewed on 10/15/2024. The information received did not reveal QAPI data, meeting minutes or QI plan.

In an interview on 04/01/2025 at 3:25 PM. S1CEO confirmed all information for QAPI had been presented to the surveyors. He indicated we could contact S11QA for further questions and he initiated a phone call with S11QA for the surveyors to discuss.

In a telephone interview on 04/01/2025 at 3:25 PM, S11QA confirmed the before mentioned policies and further confirmed the facility had no QAPI Plan and no other information to present.

Based on record review and interview, the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the facility's performance by having insufficient staff designated to conduct the QAPI functions of the facility. This deficient practice is evidenced by assigning this responsibility to S11QA who is not a full time employee and oversees 3 locations for this provider.
Findings:

A request was initiated with the initial document request upon entry on 03/31/2025 at 9:00 AM with S3LPN. This included: QAPI committee meetings and indicators/outliers from 10/01/2024 to 03/01/2025; QAPI Plan and program with governing body approval.

The following policies were received from S1CEO on 03/31/2025 at 1:00 PM: "Bethesda, Subject: Performance Improvement," policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025 and "Bethesda, Subject: Performance Measurement & Management," policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025. The information received did not reveal a QAPI data, meeting minutes or QI plan.

In an interview on 03/31/2025 at 1:00 PM, S1CEO confirmed these policies and indicated the facility was "working on the QI Plan and on the data."

A request was initiated on 03/31/2025 at 3:30 PM with S2SWPD for the QI Plan and QAPI data.

In an interview on 03/31/2025 at 3:30 PM S2SWPD confirmed she would have this information in the morning.

A review of meeting minutes identified by S1CEO as Departmental Meeting on 01/15/2025, no time available and Governing Body meeting minutes from 02/25/2025 at 4:30 PM failed to reveal documentation related to QAPI discussion.

In an interview on 04/01/2025 at 11:57 AM. S1CEO confirmed the above information and the facility was "working on the QI Plan and gathering the data."

The following policy was received from S1CEO on 04/01/2025 at 3:25 PM: "Bethesda, Subject: Performance Improvement Policy," policy number not available, an effective date of 06/01/2021, last reviewed on 10/15/2024. The information received did not reveal QAPI data, meeting minutes or QI plan.

In an interview on 04/01/2025 at 3:25 PM. S1CEO confirmed all information for QAPI had been presented to the surveyors. He indicated we could contact S11QA for further questions and he initiated a phone call with S11QA for the surveyors to discuss.

In a telephone interview on 04/01/2025 at 3:25 PM, S11QA confirmed the before mentioned policies and further confirmed the facility had no QAPI Plan and no other information to present.

In an interview on 04/01/2025 at 4:50 PM, S1CEO confirmed S11QA was the personnel assigned to quality assurance for all 3 facilities.