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Based on review of documentation and interview it was determined that the facility failed to ensure that patient medical records were promptly completed after discharge.

Findings were:
Patient medical records were not promptly completed after discharge.
A review of facility documents entitled: "LTAC Suspension List" revealed the names of two physicians, staff #43 and #51 who were listed for four consecutive months (01/23/17, 02/09/17, 03/21/17 and 04/11/17) on the suspension list.

Review of facility document entitled: Covenant Specialty Hospital Med Rec Deficiency Aging by Physician revealed that staff #51 had 8 medical record items which were delinquent. The range of these delinquent items ranged from 32 to 101 days delinquent past patient discharge. The date of this report which was provided to the surveyor was 04/11/17 @ 0813.

Review of facility document entitled: Covenant Specialty Hospital Med Rec Deficiency Aging by Physician revealed that staff #43 had 69 medical record items which were delinquent. The range of these delinquent items ranged from 32 to 74 days delinquent past patient discharge. The date of this report which was provided to the surveyor was 04/11/17 @ 0813.

Review of facility document entitled: Covenant Specialty Hospital Med Rec Total Deficient Charts which was provided to the surveyor on the morning of 4/12/2017 revealed that staff #43 now only had 21 delinquent charts.

Review of the Covenant Specialty Hospital Medical Staff Rules and Regulations with revised date of March 15, 2011 stated on page 11: "4) Delinquent Medical Records- All physicians are responsible for completing their medical records within 30 days of a patient's discharge. Failure to complete incomplete records by the suspension date will result in the record becoming delinquent and the physician will be suspended of any and all privileges including admitting, emergency room, consults, etc. Suspension Day will be the every other Thursday of every month. Three (3) thirty-day suspensions in one calendar year will result in referral to the Executive Committee for review."

In an interview with staff #1 on the afternoon of 4/11/2017 at approximately 3:25pm the surveyor was informed that the hospital did not have a consistent process in reviewing delinquent medical records. In the same interview, staff member #1 also confirmed that the above requirement (item 4, delinquent medical records) in the medical staff rules and regulations had not been followed and that the hospital's chief medical officer had not been consistently informed about the delinquent medical records.

On the morning of 4/12/2017 the surveyor was presented with a Covenant Health System letter for review. The date of this letter was 1/19/2017 and was addressed to staff #43. This letter stated: "As you recall, we reminded you a few days ago that your patients' medical records were incomplete. This memo is to inform you that your medical staff privileges have been suspended for incomplete medical records (online charts). As defined in the Medical Staff Rules and Regulations of Covenant Medical Center and Lakeside campuses. This is a serious matter that needs your immediate attention." The letter also stated: "Please remember suspension for incomplete medical records means: You may not admit new patients; You may not schedule new patients for procedures or continue to be assigned as the anesthesiologist on new cases; You may continue to provide services to currently hospitalized patients; You may take regularly scheduled ER Call; and Please respond today by taking care of this matter so your patients' records will be fully documented." In an interview on the morning of 4/12/2017 with staff #2, it was confirmed that staff #43 had not been suspended and was still allowed to admit patients to Covenant Specialty Hospital.

Based on review of documents and staff interview, the facility failed to ensure that verbal or telephone orders were signed by a practitioner within 48 hours in accordance with facility policy.

Findings included:

Covenant Specialty Hospital Medical Staff Rules and Regulations (Revised March 15, 2011), stated, in part, "3. Verbal Orders ...c. Verbal orders must be authenticated in accordance with state and federal law. Within 48 hours, Verbal orders must be dated, signed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient ...and initiated by the prescribing practitioner as soon as possible."

Review of the medical records for Patients #7, 10, and 12 revealed verbal or telephone orders which had not been signed by a practitioner within 48 hours.
Patient #7 had the following verbal or telephone orders which had not been signed by a practitioner as of 4/11/17:
Order for Benadryl written on 6/14/16.
Order to DC Oxacillin written on 6/21/16.
Order for dialysis on 6/2/16.

Patient #10 had the following verbal or telephone orders which had not been signed by a practitioner as of 4/11/17:
Order for Trialysis cath on 4/6/17.
Order to "stop UF tx" on 4/8/17.
Order to start doxycyline on 4/11/17
Order for dialysis on 4/5/17.

The above findings were confirmed in an interview with Staff #52 the afternoon of 4/11/17.

Patient #12 had the following verbal or telephone orders which had not been signed by a practitioner as of 4/11/17:
Order for comfort care on 7/27/16.
Order for IV bolus on 7/17/16.
Order for Vasopressor Infusion Protocol on 7/27/16.

The above findings were confirmed in an interview with Staff #49 the afternoon of 4/11/17 on the patient unit, second floor.

Based on observation and review of documentation the facility failed to handle food in a safe manner. Food temperatures were not taken prior to serving patient meals to assure foods were kept out of the temperature danger zones, which could cause food borne illnesses.

Findings were:
During observation of food serving on 4/11/17 at 11:25 am the surveyor observed food trays being delivered to the facility. The trays for 2nd and 3rd floors were transferred in a metal cart. Trays were delivered to the second floor first. The menus were compared by staff.
Staff #55 was observed delivering trays, staff would verify the patients then set up the trays for the patients. During the observation one tray was returned to the cart because the patient was receiving hygiene care. The surveyor asked staff # 55 who was supposed to delivered the trays? Staff #55 said usually 3 techs delivered the trays but they were busy doing blood sugar checks.

Review of facility documentation Dietary Services agreement D. stated keep all perishable food or drink at or below 45 degrees Fahrenheit. Review of facility documentation patient Food Services Policies and procedures. Volume IV. Table and tray service. JCAHO STANDARDS page 2 of 2. TX.4.4 Food and nutrition products are distributed and administered in a safe, accurate timely, and acceptable manner.

Hazard Analysis Critical Control Point (HACCP) approved system. Public Health Control/Texas Department of State Health Services. Food Safety and Inspection Service, United States Department of Agriculture, Washington D.C. Revised January 1998. HACCP final rule states, temperatures of frozen storage min -10*F and Max 0 F. Refrigerated storage -34*F mini, and max 41*F.
Food shall be handled and stored to protect against cross contamination and to limit the growth of present microorganism. High risk foods (hot & cold) must be kept out of the temperature danger zone." B. Freezer Storage: Keep frozen foods at 0 degrees F or lower. D. Hot food Holding. 2. If food falls below 140F, reheat foods to 165F for 15 seconds within 2 hours.
Review of patient surveys 14 of 46,11/2016-01/2017 revealed patients were not completely satisfied with the temperatures of their meals.

In an interview with staff #53 dietitian and staff #54 food service director at the facility on 4/12/17 at 8:35am, staff #54 said the temperatures are taken prior the trays are loaded. Staff #54 said he did not know if the temperatures were taken prior to serving the patients.

Based on document review and interview with facility staff, the facility failed to ensure the Utilization Review Committee included at least two physicians.

Findings were:

A review of the facility's "Covenant Specialty Hospital Medical Records/Utilization Review Committee" meeting minutes dated February 10, 2017, revealed the committee did not include two physicians. The only physician on the committee was staff #50.

In an interview with the Regulatory Director, staff #52 in the facility conference room on the morning of 4/12/17, staff #52 confirmed the Utilization Review Committee did not include two physicians.

Based on observation and interviews with facility staff, the facility failed to ensure supplies were maintained to provide an acceptable level of safety and quality as expired medical supplies were found available for use in patient care areas. This potentially could have resulted in unsafe or ineffective medical supplies being used in patient care.

The findings were:

During a tour of the facility on the afternoon of 4/10/17 accompanied by the Infection Preventionist registered nurse, staff #27, the following expired medical supplies were observed in patient care areas available for use in patient care:
Emergency Treatment Room:
" 1 Adult SpO2 Sensor, expired 11/16
" 1 tubing connector, expired 3/14
" 14 packages of Kendall 4x4 gauze sponges, expired 6/14
" 2 packages of Veni gard IV catheter dressings, expired 9/13
Emergency Treatment Room crash cart contained the following expired supplies:
" 4 packages of Protect IV catheters, expired 2014
" 9 packages of Kendall 2X2 gauze pads, expired 2/17
" 4 packages of bioclusive transparent dressings, expired 11/09
" 5 packages of bioclusive transparent dressings, expired 8/13
" 10 packages of Kendall 4x4 gauze sponges, expired 3/17
" 3 Protect Plus safety IV catheters, expired 11/14
" 3 Protect Plus safety IV catheters, expired 3/12
" 4 packages of surgical gloves, expired 2012
" 1 Adult Colorimetric carbon dioxide detector, expired 1/17
" 2 Pro Vent arterial blood gas sampling kits, expired 11/16
Second floor medical/surgical crash cart contained the following expired supplies:
" 2 packages of bioclusive transparent dressings, expired 2/08
" 3 Protect safety IV catheters, expired 2/12
" 3 Protect safety IV catheters, expired 8/16
" 1 package of electrocardiogram conductive electrodes, expired 12/16
" 2 Adult Colorimetric carbon dioxide detector, expired 1/17
" 1 Adult Colorimetric carbon dioxide detector, expired 10/16
" 1 Pro Vent arterial blood gas sampling kit, expired 11/16

In an interview with the Infection Preventionist registered nurse, staff #27 during the tour on the afternoon of 4/10/17, staff #27 agreed that the above supplies were expired. In an interview with the Regulatory Director, staff #52 in the facility conference room on the morning of 4/11/17, staff #52 stated there was not a policy for expired medical supplies.

During a tour of the third floor nursing unit on the afternoon of 4/10/17 accompanied by staff #3 multiple expired supplies were observed in the emergency cart.
Findings were:
" 2 Bougle Adult introducer nasal cannula expired 5/2016
" 2 Pro Vents expired 8/2016, 12/2016
" Trach 7.0 mm tubes expired 2/2016, 12/2016
" Adult colorimetric CO2 expired 2/2016, 10/2016
" Satin Slip Stylet 14F expired 4/2015 was observed in the emergency cart.

In an interview with the Regulatory Director, staff #52, during the tour on the afternoon of 4/10/17, staff #52 confirmed the above supplies were expired.

During a tour of the facility on the afternoon of 4/10/17, the following expired supplies were found in the central supply storeroom, 7.6 mm ID inner cannula, 2 expired 7/16. In an interview with the operations manager, staff #51 during the tour on the afternoon of 4/10/17, staff #51 agreed that the supplies were expired.

Based on review of facility documents the infection prevention officer failed to ensure a safe work environment. Two agency contract nurses did not have documentation of annual health testing and immunizations.

Findings were:
Review of the personnel files for contract nurses #34 and #36 did not have annual TB testing and Flu vaccines.
Review of Employee Health services policy EHS #103 PURPOSE: To provide a program that reduces the transmission of infectious diseases and to assure that CHS personnel are immune to vaccine preventable diseases. This program outlines the new hire process, the annual testing and required immunizations. The program outlines the steps necessary to insure a safe work environment.

Review of Seventh Amendment to managing a vendor staffing agreement iv) Health Examination and Immunization: Medical Clearance. All HCW's providing services pursuant to this agreement shall have appropriate documentation of the immunizations, health examinations and test required by the client, including but not limited to health examination required upon hire. Tuberculosis screening (required annually), Influenza immunization (required annually or declination statement and varicella history.

In an interview with staff # 49 at the facility on the afternoon of 4/11/17 staff # 49 agreed with the findings.