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Based on document review and interview, the hospital's quality program failed to ensure the policy governing contracted services was approved and followed.

Findings:

The hospital staff did not review it's own policy regarding contract services. The policy was developed in 2009, but did not evidence approval by the governing body, administrator or medical staff. The policy was not implemented and during the course of a complaint investigation, it was determined that the contracted therapy agency was not providing services in accordance with physician's orders or within the scope of professional services. Documentation did not evidence a review of the contracted services contract or provided therapists.

Patient # 7 did not receive a complete physical therapy evaluation and a plan of care was not developed by the Physical Therapist. Care was being provided by this PT and by a LPTA (therapy assistant) with no established goals or interventions.

Patient # 3 had physician's orders for therapy to assess and treat the patient's ability to complete activities of daily living. This was not completed.

Patient # 4 had physician's order for Occupational Therapy. This was not completed.

The contract was reviewed and it did not include a procedure in which the contracted services or individual therapists would be evaluated by the hospital. The contract stated: "...it is the desire of hospital to maintain a department of physical therapy, occupational therapy on its premises..."and the contracted therapy agency would "...employee therapists and other personnel as are necessary in the opinion of (Therapy agency name) to adequately and continuously staff the department and meet the needs of Hospital's patients and Medical staff...". This contract was signed by the then hospital Administrator and the president of the rehab company on May 1, 2009.

The hospital's policy regarding contract services was presented on 8/22/12 at 1:10 p.m. by Employee # 2. The policy (Contract Employees) included the effective date of 12/2009. The policy did not evidence approval by the Administrator or Medical Staff. The policy did not evidence a review by the hospital staff since 2009. The policy stated contractor, would ensure individuals who provide services through contractural arrangements would ensure appropriate documentation. This stated documentation was not present in the only PT's personnel record: Written job description, evidence of competency, performance evaluations and evidence of applicable insurance coverage. The policy stated the "appropriate Department director" was responsible for evaluating the service provided. The policy also stated: "An annual review of all contacted (sic) services will be conducted by the respective department directors and Administrator. Contracts for medica services will be reviewed by Medical Staff. This review will address quality and timeliness issues and will include decisions to continue or discontinue each service."
Employee # 1 (Hospital Administrator) and Employee # 2 were interviewed on 8/22/12 at 1:58 p.m. regarding the above concern. The Administrator stated she had not reviewed the contract services as she had only been employed five weeks. The CNE (Employee # 2) stated she was not aware of a review of contract services. The Administrator and CNE stated they were unaware the PT was completing her own evaluations and that her documentation did not evidence appropriate patient evaluations or the physician's orders for OT services were not being completed. The Administrator stated she had not reviewed the contract for therapy services and was unaware it did not address how the contracted therapy services would be evaluated.

No further information was provided during the survey to evidence the contracted services policy was intermittently reviewed or that therapy services were adequate for the needs of the patients. The hospital employees did not provide evidence that the contract services were monitored or evaluated according to the hospital policy or that the contract was sufficient to ensure patients received physician's ordered care.

Based on a complaint investigation, document review and interview, the agency staff failed to ensure each patient receiving therapy had a plan of treatment established by a physical therapist, for one of 9 patient's reviewed, Patient # 7.

Findings:

Patient #7's clinical record included a physician's order dated 6/5/12 for "...Physical Therapy (PT) and Occupational Therapy for strengthening and ADLs (activities of daily living)".

The PT evaluation for Patient #7 was found to be incomplete. It did not contain goals, an evaluation of strength, mobility, balance, or gait. There was no "care plan" for PT found in the clinical record. This patient was treated by the therapy assistant (LPTA), at times. The PT did not respond when questioned regarding the LPTA's treatment of a patient without goals, objectives and interventions created by a physical therapist.

On 8/22/12 at approximately 9:00 a.m., the survey team interviewed Employee # 8 (PT) who stated, "...the unit secretary calls me when they receive an order for PT and I then go review the chart. I write on the eval what I am going to work on with each patient; transfers, gait, ambulation, and do the evaluation." When interviewed regarding the OT and ADL orders, Employee #8 stated, "We do not have an OT on staff. There should be no OT orders...I did not address any OT or ADL needs for the patients, just PT..." Regarding the LPTA's treatment of Patient # 7, without a complete evaluation, goals, objectives or interventions, the PT did not respond.

A review of the Quality Improvement meeting minutes did not evidence an oversight of the Physical Therapist's notes or provision of appropriate services.

Based on document review and interview, the hospital Administrator failed to ensure an adequate contract was established, maintained and monitored with the entity providing patient's with physician's ordered therapy.

Findings:

The hospital contracted an outside agency to provide rehabilitation services for it's patients. Physician's ordered Occupational Therapy and ADL training was not completed for Patient #'s 3, 4 and 7. The current Administrator was unaware the contract was insufficient to ensure quality patient care was provided. The contract employee policy was not reviewed or approved by the Administrator or Medical Staff. The contract with the rehab agency did not include a manner in which the agency's performance would be evaluated. The only Physical Therapist provided by this contract agency did not complete an evaluation for one patient, and did not develop a plan of care for this treatment. The hospital's Quality review documentation did not evidence an evaluation of the PT's evaluation, documentation or treatment.

On 8/22/12 at approximately 9:00 a.m., the survey team interviewed Employee # 8 (PT) who stated, "...the unit secretary calls me when they receive an order for PT and I then go review the chart. I write on the eval what I am going to work on with each patient; transfers, gait, ambulation, and do the evaluation." When interviewed regarding the OT and ADL orders, Employee #8 stated, "We do not have an OT on staff. There should be no OT orders...I did not address any OT or ADL needs for the patients, just PT..."

Patient #'s 3, 4 and 7's clinical records included physician's orders for OT (occupational therapy) or ADL (activities of daily living) training. These services were not provided.

(see 0293 for additional information.)

The Physical Therapist was interviewed on 8/22/12 at approximately 9:00 a.m., and she stated she was the only PT at the facility, in addition to one LPTA (therapy assistant). The PT stated in her absence, therapy evaluations would be delayed until her return. The PT stated she had completed her own performance evaluations and was unsure how the contracted agency's performance was monitored by the hospital. The PT stated her department director was located in Mississippi at the corporate headquarters. The therapist stated she would receive verbal notification from the unit secretary that PT services were ordered, and she would then review the clinical record for orders. The PT stated she was unaware that OT and ADL services had been ordered for Patient #'s 3, 4 and 7. Employee #8 stated, "We do not have an OT on staff. There should be no OT orders...I did not address any OT or ADL needs for the patients, just PT..."

A review of the Quality Improvement meeting minutes did not evidence an oversight of the Physical Therapist's notes or provision of appropriate services. No evidence was provided to indicate the physician's and patient/representatives were informed this service was not available.

The Chief Nurse Executive (Employee # 2) was interviewed on 8/22/12 at 12:40 p.m. regarding the above concern. The CNE stated therapy was provided by a contracted therapist, but did not include Occupational Therapy. The contract was reviewed and it did not include a procedure in which the contracted services or individual therapists would be evaluated by the hospital. The contract stated: "...it is the desire of hospital to maintain a department of physical therapy, occupational therapy on its premises..."and the contracted therapy agency would "...employee therapists and other personnel as are necessary in the opinion of (Therapy agency name) to adequately and continuously staff the department and meet the needs of Hospital's patients and Medical staff...". This contract was signed by the then hospital Administrator and the president of the rehab company on May 1, 2009.

The hospital's policy regarding contract services was presented on 8/22/12 at 1:10 p.m. by Employee # 2. The policy (Contract Employees) included the effective date of 12/2009. The policy did not evidence approval by the Administrator or Medical Staff. The policy did not evidence a review by the hospital staff since 2009. The policy stated contractor, would ensure individuals who provide services through contractural arrangements would ensure appropriate documentation. This stated documentation was not present in the only PT's personnel record: Written job description, evidence of competency, performance evaluations and evidence of applicable insurance coverage. The policy stated the "appropriate Department director" was responsible for evaluating the service provided. The policy also stated: "An annual review of all contacted (sic) services will be conducted by the respective department directors and Administrator. Contracts for medica services will be reviewed by Medical Staff. This review will address quality and timeliness issues and will include decisions to continue or discontinue each service."
Employee # 1 (Hospital Administrator) and Employee # 2 were interviewed on 8/22/12 at 1:58 p.m. regarding the above concern. The Administrator stated she had not reviewed the contract services as she had only been employed five weeks. The CNE (Employee # 2) stated she was not aware of a review of contract services. The Administrator and CNE stated they were unaware the PT was completing her own evaluations and that her documentation did not evidence appropriate patient evaluations or the physician's orders for OT services were not being completed. The Administrator stated she had not reviewed the contract for therapy services and was unaware it did not address how the contracted therapy services would be evaluated.

No further information was provided during the survey to evidence the contracted therapy services were adequate for the needs of the patients. The hospital employees did not provide evidence that the contract services were monitored or evaluated according to the hospital policy or that the contract was sufficient to ensure patients received physician's ordered care.

Based on record review, document review and interview, the hospital Administrator failed to ensure contracted services provided sufficient staff to provide physician's ordered services for three of 9 patients reviewed, Patient #'s 3, 4 and 7. Physician's orders for Occupational Therapy or activities of daily living training was not followed, as the contracted therapy services did not provide and Occupational Therapist and the Physical Therapist did not address these needs.

Findings:

The CAH/Swing Bed therapy services were reviewed in conjunction with allegations the facility did not have sufficient staffing to provide care as ordered.

Patient #'s 3, 4 and 7's clinical records included physician's orders for OT (occupational therapy) or ADL (activities of daily living) training. These services were not provided.

1. Patient # 3's clinical record included a physician's order dated 8/20/12: "Swing for PT-strengthening and ADLs (activities of daily living). The clinical record did not evidence this order was completed. No documentation evidenced that Patient # 3 received ADL training by a therapist, PT or OT. The PT's notes did not evidence a therapy reassessment after this date, and did not evidence an evaluation of the patient's ability/inability to complete ADLS. The documentation did not evidence the PT addressed ADL tasks. The record did not include an OT evaluation or documentation the patient/responsible party were informed OT was not provided at this skilled nursing provider. The clinical record did not evidence that the physician or patient/responsible party was informed that the hospital/swing bed did not offer OT services.

2. Patient # 4 was admitted directly to the swing bed (skilled nursing) care. A physician's order dated 8/15/12 ordered PT and OT services. The record did not evidence an OT evaluation or services. The PT evaluation was conducted 8/16/12 and did not address an evaluation of OT services. The clinical record did not evidence that the patient or physician was aware or informed that OT services were not available. The patient was interviewed on 8/21/12 and was not aware of the physician's order for OT services.

(see 3. below.)

The Physical Therapist was interviewed on 8/22/12 at approximately 9:00 a.m., and she stated she was the only PT at the facility, in addition to one LPTA (therapy assistant). The PT stated in her absence, therapy evaluations would be delayed until her return. The PT stated she had completed her own performance evaluations and was unsure how the contracted agency's performance was monitored by the hospital. The PT stated her department director was located in Mississippi at the corporate headquarters. The therapist stated she would receive verbal notification from the unit secretary that PT services were ordered, and she would then review the clinical record for orders. The PT stated she was unaware that OT and ADL services had been ordered for Patient #'s 3, 4 and 7. Employee #8 stated, "We do not have an OT on staff. There should be no OT orders...I did not address any OT or ADL needs for the patients, just PT..."

A review of the Quality Improvement meeting minutes did not evidence an oversight of the Physical Therapist's notes or provision of appropriate services.

The Chief Nurse Executive (Employee # 2) was interviewed on 8/22/12 at 12:40 p.m. regarding the above concern. The CNE stated therapy was provided by a contracted therapist, but did not include Occupational Therapy. The contract was reviewed and it did not include a procedure in which the contracted services or individual therapists would be evaluated by the hospital. The contract stated: "...it is the desire of hospital to maintain a department of physical therapy, occupational therapy on its premises..."and the contracted therapy agency would "...employee therapists and other personnel as are necessary in the opinion of (Therapy agency name) to adequately and continuously staff the department and meet the needs of Hospital's patients and Medical staff...". This contract was signed by the then hospital Administrator and the president of the rehab company on May 1, 2009.

The hospital's policy regarding contract services was presented on 8/22/12 at 1:10 p.m. by Employee # 2. The policy (Contract Employees) included the effective date of 12/2009. The policy did not evidence approval by the Administrator or Medical Staff. The policy did not evidence a review by the hospital staff since 2009. The policy stated contractor, would ensure individuals who provide services through contractural arrangements would ensure appropriate documentation. This stated documentation was not present in the only PT's personnel record: Written job description, evidence of competency, performance evaluations and evidence of applicable insurance coverage. The policy stated the "appropriate Department director" was responsible for evaluating the service provided. The policy also stated: "An annual review of all contacted (sic) services will be conducted by the respective department directors and Administrator. Contracts for medica services will be reviewed by Medical Staff. This review will address quality and timeliness issues and will include decisions to continue or discontinue each service."
Employee # 1 (Hospital Administrator) and Employee # 2 were interviewed on 8/22/12 at 1:58 p.m. regarding the above concern. The Administrator stated she had not reviewed the contract services as she had only been employed five weeks. The CNE (Employee # 2) stated she was not aware of a review of contract services. The Administrator and CNE stated they were unaware the PT was completing her own evaluations and that her documentation did not evidence appropriate patient evaluations or the physician's orders for OT services were not being completed. The Administrator stated she had not reviewed the contract for therapy services and was unaware it did not address how the contracted therapy services would be evaluated.

No further information was provided during the survey to evidence the contracted therapy services were adequate for the needs of the patients. The hospital employees did not provide evidence that the contract services were monitored or evaluated according to the hospital policy or that the contract was sufficient to ensure patients received physician's ordered care.


21229

3. Review of the clinical record for Patient #7 revealed a physician's order dated 6/5/12 for "...Physical Therapy (PT) and Occupational Therapy for strengthening and ADLs (activities of daily living)". Further review of the clinical record revealed Patient #7 received the physical therapy as ordered, however, there was no evidence of any treatment by Occupational therapy (OT) or ADL training. There was no physician's order to discontinue the occupational therapy or ADL training found in the clinical record.
In addition, the PT evaluation for Patient #7 was found to be incomplete. It did not contain goals, an evaluation of strength, mobility, balance, or gait. There was no "care plan" for PT found in the clinical record. This patient was treated by the therapy assistant (LPTA), at times. The PT did not respond when questioned regarding the LPTA's treatment of a patient without goals, objectives and interventions created by a physical therapist.

On 8/22/12 at approximately 9:00 a.m., the survey team interviewed Employee # 8 (PT) who stated, "...the unit secretary calls me when they receive an order for PT and I then go review the chart. I write on the eval what I am going to work on with each patient; transfers, gait, ambulation, and do the evaluation." When interviewed regarding the OT and ADL orders, Employee #8 stated, "We do not have an OT on staff. There should be no OT orders...I did not address any OT or ADL needs for the patients, just PT..."

A review of the Quality Improvement meeting minutes did not evidence an oversight of the Physical Therapist's notes or provision of appropriate services.

On 8/22/12 at 12:40 p.m., Employee # 2 (Chief Nurse Executive) stated, "No, there should be no OT orders written because we do not have OT...:" Employee # 2 did not provide evidence these physician's ordered services were completed for Patient #'s 3, 4 or 7.

Based on the above record reviews and interviews, the complaint allegation is SUBSTANTIATED with deficient practice cited regarding following physician's orders and therapy services.

Based on clinical record review, complaint investigation, and staff interview, the facility staff failed to ensure a comprehensive care plan was developed for four of 9 (nine) Patients of the survey sample, Patient #'s 1, 2, 7, 8 and 9.

The findings included:

Patient #1, admitted 7/21/12 and transferred to "swing bed" status 7/26/12, with diagnoses that included but were not limited to: right hip fracture, heart failure, congestive heart failure, and presumed pulmonary embolism with tachypnea (rapid breathing) did not have a care plan developed which addressed oxygen therapy, anticoagulant therapy, physical therapy, nutrition therapy, and discharge planning.

Patient #2, admitted 7/31/12 and transferred to "swing bed" on 8/6/12, with diagnoses that included, but were not limited to: fibula fracture, urinary retention, diabetes, seizure disorder, and immobility. Patient #2 did not have a care plan developed which addressed, seizure precautions, Foley catheter for urinary retention, and discharge planning.

Patient #7, admitted 6/5/12 to "swing bed" status, with diagnoses that included, but were not limited to" clostridium difficile colitis, femur fracture, poor oral intake and debility, did not have a care plan developed which addressed isolation and clostridium difficile infection, dietary supplements and dietary needs, brace to right leg, physical therapy, and intravenous therapy .

Patient # 8's initial assessment and care plan dated 7/3/12 included the potential for skin break down. The patient experienced an actual alteration in skin integrity on 7/5/12 and required treatment to the areas, as evidenced by nurse's notes. The care plan was not updated to reflect this change in care. The patient's plan of care was not developed or revised to include the patient's nutritional status (nothing by mouth ordered 7/3/12), or intravenous fluids being administered.

Patient #9 admitted 6/22/12 and transferred to "swing bed 6/26/12 (discharged 7/1/12), with diagnoses that included, but were not limited to: pneumonia, chronic obstructive pulmonary disease (COPD), diabetes and hypertension did not have a care plan developed which included the use of oxygen therapy, discharge planning or advanced directives.

On 8/22/12 at 2:00 p.m., the survey team reviewed the findings with Employee # 1 and #2 regarding the care plan development. Employee #2 stated, "we need to do a better job, and we will certainly correct this..."

Based on complaint investigation, clinical record review and staff interview, the facility staff failed to review and revise the comprehensive care plan and ensure all members of the interdisciplinary team participated in the care planning for 5 of 9 (nine) patients of the survey sample, Patient #'s 1, 2, 7, 8, and 9.

The findings included:

Patient #1, admitted 7/21/12 and transferred to "swing bed" status 7/26/12, with diagnoses that included but were not limited to: right hip fracture, heart failure, congestive heart failure, and presumed pulmonary embolism with tachypnea (rapid breathing) did not have a care plan which was revised to include a new skin tear with treatment. There was also no evidence of an interdisciplinary team review/participation in the care planning.

Patient #2, admitted 7/31/12 and transferred to "swing bed" on 8/6/12, with diagnoses that included, but were not limited to: fibula fracture, urinary retention, diabetes, seizure disorder, and immobility. Patient #2 did not have a care plan reviewed and revised to include urology referral and initiation of trial voiding with the attempted discontinuation of the Foley catheter. There was also no evidence of an interdisciplinary team review/participation in the care planning.

Patient #7, admitted 6/5/12 to "swing bed" status, with diagnoses that included, but were not limited to" clostridium difficile colitis, femur fracture, poor oral intake and debility, did not have a care plan revised which addressed persistent nausea and vomiting and insertion of a nasogastric tube with NPO status and urinary tract infection. There was also no evidence of an interdisciplinary team review/participation in the care planning.

Patient # 8's initial assessment and care plan dated 7/3/12 included the potential for skin break down. The patient experienced an actual alteration in skin integrity on 7/5/12 and required treatment to the areas, as evidenced by nurse's notes. The care plan was not updated to reflect this change in care. The patient's plan of care was not developed or revised to include the patient's nutritional status (nothing by mouth ordered 7/3/12), or intravenous fluids being administered. The plan of care did not evidence an interdisciplinary team review of the patient's care.

Patient #9 admitted 6/22/12 and transferred to "swing bed 6/26/12 (discharged 7/1/12), with diagnoses that included, but were not limited to: pneumonia, chronic obstructive pulmonary disease (COPD), diabetes and hypertension did not have a care plan reviewed and revised to include the tapering of oxygen in preparation for discharge. There was no evidence that the interdisciplinary team had participated in the review of the care plan.

On 8/22/12 at 2:00 p.m., the survey team reviewed the findings with Employee # 1 and #2 regarding the care plan development. Employee #2 stated, "we need to do a better job, and we will certainly correct this..."

Based on clinical record review, complaint investigation, and staff interview, the facility staff failed to ensure physician's orders were carried out for 3 (three) of 9 (nine) patients of the survey sample. Patient #'s 3, 4, and 7.

The findings included:

1. Patient # 3's clinical record included a physician's order dated 8/20/12: "Swing for PT-strengthening and ADLs (activities of daily living). The clinical record did not evidence this order was completed. The clinical record did not include documentation to evidenced that Patient # 3 received ADL training by a therapist, PT or OT. The PT's notes did not evidence an evaluation of the patient's ability/inability to complete ADLS. The documentation did not evidence the PT addressed ADL tasks. The record did not include an OT evaluation or documentation the patient/responsible party were informed OT was not provided at this skilled nursing provider. The clinical record did not evidence that the physician or patient/responsible party was informed that the hospital/swing bed did not offer OT services.

2. Patient # 4 was admitted directly to the swing bed (skilled nursing) care. A physician's order dated 8/15/12 ordered PT and OT services. The record did not evidence an OT evaluation or services. The PT evaluation was conducted 8/16/12 and did not address an evaluation of OT services. The clinical record did not evidence that the patient or physician was aware or informed that OT services were not available. The patient was interviewed on 8/21/12 and was not aware of the physician's order for OT services.

3. Patient #7, admitted 6/5/12 to "swing bed" status (discharged 7/23/12), with diagnoses that included, but were not limited to" clostridium difficile colitis, femur fracture, poor oral intake and debility had physician's orders dated 6/5/12 for "Physical and Occupational Therapy for strengthening and ADL's (activities of daily living)". There was no evidence contained in the clinical record that Occupational therapy (OT) or ADL training was provided per physician's orders. The clinical record did not include documentation that the physician or patient/responsible party was informed that the agency did not employee or provide OT services. The PT evaluation was incomplete and did not evidence an assessment of the patient's strength, mobility, balance, or gait. The evaluation did not include goals. There was no "care plan" for PT found in the clinical record. This patient was treated by the therapy assistant (LPTA), at times.

On 8/22/12 at approximately 9:00 a.m., the survey team interviewed Employee # 8 (PT) who stated, "...the unit secretary calls me when they receive an order for PT and I then go review the chart. I write on the eval what I am going to work on with each patient; transfers, gait, ambulation, and do the evaluation." When interviewed regarding the OT and ADL orders, Employee #8 stated, "We do not have an OT on staff. There should be no OT orders...I did not address any OT or ADL needs for the patients, just PT..." When questioned about the LPTA's treatment of the patient without directive from the evaluation with no goals, interventions or plan of care-the PT did not respond.

On 8/22/12 at 12:40 p.m., Employee # 2 stated, "No, there should be no OT orders written because we do not have OT...:"

On 8/22/12 at 1:58 p.m. the Administrator and Chief Nurse Executive (Employees #'s 1 and 2) were interviewed and informed of the above concerns. No further information was presented to evidence compliance with this regulation. The clinical record did not include documentation that the physician or patient/responsible party was informed that the agency did not employee or provide OT services.