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Based on review of the facility's Governing Body meeting minutes, Operating Agreement, quality improvement data, policies and procedures, and staff interviews, it was determined that the Governing Body failed to take responsibility for services furnished under contracts. Findings included:

A review of the Governing Body committee meeting minutes for year 2018 through year to date 2019 failed to reveal that the Governing Body discussed or reviewed contracted services.

A review of the facility's Operating Agreement dated 3/28/17 and signed by the original members of 'The Company' failed to reveal that the facility's the Governing Body was accountable for ensuring that contracted services were provided in a safe manner that allowed the facility to be in compliance with the conditions of participation.

A review of the facility's policies and procedures revealed that policies that pertained to quality improvement/performance improvement had not been approved by the medical staff or Governing Body. Further review of the policies failed to reveal that contracted services were addressed in the quality improvement plan.

A review of the quality improvement/performance improvement data revealed that the facility failed to collect or report measures on contracted services.

An interview with Administrative Assistant/Medical Staff (Assistant GG) took place on 9/23/19 at 12:30 p.m. in the Board Room. Assistant GG explained that she had been in the role for greater than twenty (20) years. Assistant GG stated that she was responsible for the Medical Executive Committee (MEC) meeting minutes, Governing Body meeting minutes, and medical staff credentialing. Assistant GG explained that the facility is owned and operated by a group of investors (Affabilis, LLC) based in Texas. She explained that the document titled 'Operating Agreement' functioned as the Governing Body bylaws and that 'manager' as defined in the Operating Agreement referred to a managing investor of Affabilis, LLC. She explained that Affabilis, LLC had multiple investors, however the facility had one manager that was the primary contact for the facility. Assistant GG explained that this manager was usually onsite at least once a month and 'was a phone call away' for any questions or concerns. Assistant GG explained that she emailed the managers any items that needed approval or a vote as well as copies of meeting minutes including Medical Executive Committee (MEC). Email correspondence served as the Governing Body Meeting.

During an interview with the Performance Improvement Coordinator (Coordinator) CC on 9/24/19 at 1:00 p.m. in the conference room, she explained that the quality improvement/performance improvement program continued to be revised with the addition of a new Director of Nurses. She confirmed that contracted services, except or dialysis, did not currently participate in the facility's quality improvement/performance improvement program.

An interview with the Director of Nurses (DON BB) took place on 9/24/19 at 3:00 p.m. the conference room. DON BB explained that the performance improvement policy and procedures were in 'draft' form and had not been approved by the staff.

Based on review of the facility's Governing Body meeting minutes, Operating Agreement, quality improvement data, policies and procedures, and staff interviews, it was determined that the Governing Body failed to ensure that services performed under contract were done so in a safe, efficient manner.

Findings included:

A review of the Governing Body committee meeting minutes for year 2018 through year to date 2019 failed to reveal that the Governing Body discussed or reviewed contracted services.

A review of the facility's Operating Agreement dated 3/28/17 and signed by the original members of 'The Company' failed to reveal that the facility's the Governing Body was accountable for ensuring that contracted services were provided in a safe manner that allowed the facility to be in compliance with the conditions of participation.

A review of the facility's policies and procedures revealed that policies that pertained to quality improvement/performance improvement had not been approved by the medical staff or Governing Body. Further review of the policies failed to reveal that contracted services were addressed in the quality improvement plan.
A review of the quality improvement/performance improvement data failed to reveal that the facility collected or reported measures on contracted services.

An interview with Administrative Assistant/Medical Staff (Assistant GG) took place on 9/23/19 at 12:30 p.m. in the Board Room. Assistant GG explained that she had been in the role for greater than twenty (20) years. Assistant GG stated that she was responsible for the Medical Executive Committee (MEC) meeting minutes, Governing Body meeting minutes, and medical staff credentialing. Assistant GG explained that the facility is owned and operated by a group of investors (Affabilis, LLC) based in Texas. She explained that the document titled 'Operating Agreement' functioned as the Governing Body bylaws and that 'manager' as defined in the Operating Agreement referred to a managing investor of Affabilis, LLC. She explained that Affabilis, LLC had multiple investors, however the facility had one manager that was the primary contact for the facility. Assistant GG explained that this manager was usually onsite at least once a month and 'was a phone call away' for any questions or concerns. Assistant GG explained that she emailed the managers any items that needed approval or a vote as well as copies of meeting minutes including Medical Executive Committee (MEC). Email correspondence served as the Governing Body Meeting.

During an interview with the Performance Improvement Coordinator (Coordinator) CC on 9/24/19 at 1:00 p.m. in the conference room, she explained that the quality improvement/performance improvement program continued to be revised with the addition of a new Director of Nurses. She confirmed that contracted services, except or dialysis, did not currently participate in the facility's quality improvement/performance improvement program.

An interview with the Director of Nurses (DON) BB took place on 9/24/19 at 3:00 p.m. the conference room. DON BB explained that the performance improvement policy and procedures were in 'draft' form and had not been approved by the staff.

Based on review of the facility's Operating Agreement, policies and procedures, and staff interviews, it was determined that the Governing Body failed to maintain a list of contracted services.

Findings included:

Review of the facility's Operating Agreement dated 3/18/17 failed to reveal that delineation of contractor responsibilities were addressed.

A review of the policy and procedures provided by the facility failed to reveal that contracted services were addressed in policies and procedures.

During an interview with Administrative Assistant/Medical Staff (Assistant GG) on 9/23/19 at 2:00 p.m. in the Board Room, she acknowledged that Operating Agreement served as the Governing Body Bylaws. She stated that contracted services were not addressed in the agreement.

Based on review of the facility's committee meeting minutes, Operating Agreement, quality improvement data, policies and procedures, and staff interviews, it was determined that the Governing Body failed to ensure that services performed under contract participated in the quality improvement/performance improvement program.

Findings included:

A review of the Governing Body committee meeting minutes for year 2018 through year to date 2019 failed to reveal that the Governing Body discussed or reviewed contracted services.

A review of the facility's Operating Agreement dated 3/18/17 failed to reveal that quality improvement activities were addressed. Continued review of the agreement failed to reveal that contracted services were addressed.
A review of the quality improvement/performance improvement data failed to reveal that the facility collected or reported measures on contracted services.

The facility failed to provide any policies and procedures pertaining to contracted services.

A review of the facility's policies and procedures revealed that policies that pertained to quality improvement/performance improvement had not been approved by the medical staff or Governing Body. Further review of the policies failed to reveal that contracted services were addressed in the quality improvement plan.

During an interview with the Performance Improvement Coordinator (Coordinator) CC on 9/24/19 at 1:00 p.m. in the conference room, she explained that the quality improvement/performance improvement program continued to be revised with the addition of a new Director of Nurses. Coordinator CC confirmed that contracted services, except or dialysis, did not currently participate in the facility's quality improvement/performance improvement program.

An interview with the Director of Nurses (DON) BB took place on 9/24/19 at 3:00 p.m.in the conference room. DON BB explained that the performance improvement policy and procedures were in 'draft' form and had not been approved by the staff.

During an interview with the Administrative Assistant/Medical Staff (Assistant GG) on 9/23/19 at 2:00 p.m. in the Board Room, he/she acknowledged that Operating Agreement served as the Governing Body Bylaws. She stated that contracted services were not addressed in the agreement.

Based on record review and interview, the facility failed to designate infection control officers to develop and implement policies governing control of infections and communicable diseases.
Findings include:

A review of LPN PI Coordinator CC and RN Director of Nursing (DON) BB's personnel files failed to revealed documentation of designation from the facility that they served as the Infection Control Officers for the facility. In addition, a review of LPN PI Coordinator CC and RN Director of Nursing (DON) BB's personnel files failed to revealed any documentation of Infection Control program responsibilities.

During the entrance conference on 9/23/19 at 11:30 a.m., LPN CC stated she was the person responsible for the facility's Infection Control program.

During an interview on 9/24/19 at 2:30 p.m., RN BB and LPN CC stated they shared responsibilities of facilitating the Infection Control program, but stated they did not have specific infection control training to facilitate the program.

Based on review of policy, organizational chart, Medical Executive Committee meeting minutes, and interviews it was determined that the facility failed to provide a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience or capabilities to supervise and administer the services properly.

Review of Policy RC-1.1, Introduction to the Respiratory Care Department, effective March 2019 and approved by Chief Executive Officer, Chief Operating Officer, and Director of Nurses, revealed the organization included, a medical doctor fully qualified in respiratory care problems and in administering oxygen and other gases, approved by the Medical Staff and Administration of Columbus Specialty Hospital who will provide professional supervision of this department. Medical direction is available on a continuous basis.

Review of the facility ' s organization chart revealed the Limited Liability Company oversight of the facility includes the Program Director for Respiratory Services within the facility.

Review of meeting minutes of the Medical Executive Committee (MEC) for the past 12 months, revealed the facility has been actively seeking a pulmonologist to join the medical staff and provide oversight for the Respiratory Therapy Department since 8/15/18.
Review of MEC meeting minutes on 8/15/18 revealed a pulmonologist had been approached and they were awaiting a decision. On 11/28/18, the MEC meeting minutes revealed the previous pulmonologist was no longer interested. At that time, the minutes reveal management was talking with the neighboring acute care hospital regarding a contract arrangement for a pulmonologist. Review of MEC meeting minutes from 2/27/19 revealed that the pulmonologist with whom they had previously talked had shown renewed interest. The management of the facility had started working with him on a contract for three of his midlevel practitioners to come with him. Review of meeting minutes from 5/15/19 revealed the contract with a Pulmonologist was pending the agreement with the Pulmonologist ' s current organization. Review of meeting minutes from 8/14/19 revealed there is no Director of Respiratory Care at the facility and they are continuing to seek someone to fill that position.

During an interview with Chief Operating Officer ZZ on 9/23/19 at 2:30 p.m. in the Leadership Conference room of the facility, she confirmed that the facility does not have physician or doctor oversight for the Respiratory Care Department.

During an interview with Respiratory Therapist (RT) YY on 9/24/19 at 9:30 a.m. in the Director of Nurse ' s office, she said she has been a RT for over 20 years. She said she has been with this facility since 2017. RT YY said the patient ' s doctors give the orders for respiratory. She said the doctors talk to each other and they talk to the RTs about specific patients. She said all three of the main doctors at the facility have been doing ventilator weaning and respiratory care orders for a long time. RT YY said she is not aware of any performance improvement projects ongoing within the respiratory department. The respiratory therapists at the facility report to the Director of Nurses. She confirmed there is no specific doctor over the respiratory services.