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Based upon record review and interview, the hospital failed to ensure the development of governing body bylaws outlining the legal responsibility for the conduct of the hospital.

An interview was conducted with the Chief Clinical Officer (CCO) on 6/30/10 at 1:30 pm in the conference room. The CCO reported being unaware of the existence of governing body bylaws and would have to call the corporate office and have the bylaws faxed.

On 7/1/10 at 1:30 pm, the CCO presented a document that had been sent from the corporate office and stated "this was sent from corporate office as the governing body bylaws".

Review of the document presented as the governing body bylaws revealed a document titled "COMPANY AGREEMENT". The agreement outlined the formation of the company as a Limited Liability Company. Article I, Section 1.3 revealed the following: "Purpose. The purposes for which this Company is organized are: (a) For the transaction of any or all lawful business; (b) To enter into any lawful arrangements for sharing profits and/or lossed in any transaction or transactions, and to promote and organize other entities; (c) To invest, buy, sell, lease or deal in any property, whether personal, intangible, real or mixed or to render services; (d) To have and exercise all rights and powers that are now or may hereafter be granted to a limited liability company by law." The document contained the names of the sole member and 2 managers of the limited liability company. The document did not identify who was responsible for the conduct of the hospital operations.

Review of a document provided as the Governing Body meeting minutes titled "Minutes of Meeting" and dated 5/26/10 revealed attendees for this meeting included the sole member and the 2 managers identified in the limited liability company agreement.

An interview was conducted with the Clinical Director on 7/1/10 @ 2:00 pm. The Clinical Director reported that meeting on 5/26/10 had been the only meeting held since the change of ownership.
The CCO also reported the Administrator, who was identified as the Corporate Director for Texas Operations in the "Minutes of Meeting" was "to serve as interim Chief Executive Officer and represent the corporation in oversight and direction of the hospital". The CCO reported the Administrator was terminated on 6/24/10 and no one has been officially appointed to be in charge but seems to have fallen back on the CCO.

Based upon record review and interview, there were no medical staff bylaws approved by the governing body and there were 12 of 12 physicians reviewed who had not granted delineation of privileges and appointed to the medical staff by the governing body.

REFER TO TAG - A0046, A0048

Based upon record review and interview, the governing body failed to approve the medical staff bylaws, rules and regulations that defined appointment categories to the medical staff.

Review of a copy of the proposed medical staff bylaws revealed the following documentation: "Article 4 - APPOINTMENT CATEGORIES 4.1 Categories - Appointments to the Medical Staff shall be divided into Temporary, Provisional, and Active." The Article of the medical staff bylaws pertaining to appointment categories further defined the requirements the medical staff had to meet in each category.

Review of a document provided as the Governing Body meeting minutes titled "Minutes of Meeting" and dated 5/26/10 revealed no approval of Medical Staff Bylaws, Rules and Regulations. These were the only meeting minutes provided.

An interview was conducted with the Clinical Director on 7/1/10 @ 2:00 pm. The Clinical Director reported that meeting on 5/26/10 had been the only meeting held since the change of ownership.

Based upon record review and interview, the governing body failed to follow the proposed medical staff bylaws when appointing physicians to the medical staff. Review of 12 of 12 physicians credentialing files revealed no physicians currently appointed to the medical staff.

A copy of the Medical Staff Bylaws, Rules and Regulations was provided on 7/1/10 at 1:30 pm. The Clinical Director reported the corporate office in Florida had sent the document by e-mail. Review of the Medical Staff Bylaws, Rules and Regulations revealed a proposed document that had not been approved by the Governing Body.

Review of a document provided as the Governing Body meeting minutes titled "Minutes of Meeting" and dated 5/26/10 revealed no approval of Medical Staff Bylaws, Rules and Regulations. These were the only meeting minutes provided. Further review of the meeting minutes revealed a section titled "Medical Staff Members" that states the following: "Per recommendation of the corporate Medical Director and medical executive committee, the following staff have been recommended for re-appointment and initial appointment to the medical staff. 1. Physician #6 - Active-Reappointment; 2. Physician #2 - Active-Reappointment; 3. Physician #9 - Active-Reappointment; 4. Physician #33 - Active-Reappointment; 5. Physician #3 - Active-Reappointment; 6. Family Nurse Practitioner #34 - Initial Appointment.

An interview was conducted with the Clinical Director on 7/1/10 @ 2:00 pm. The Clinical Director reported that meeting on 5/26/10 had been the only meeting held since the change of ownership.

A. Review of credentialing file of Physician #6 revealed no credentialing application, no request for delineation of privileges and no approved delineation of privileges. A document signed by the Chief Clinical Officer dated 2/8/2010 granting temporary privileges not to exceed 120 days pending final review and approval by the Medical Executive Committee and Governing Body. The 120 days expired on 6/8/2010. According to the "Minutes of the Meeting" dated 5/26/10, Physician #6 was reappointed to the Medical Staff but had never been appointed to the Medical Staff.

B. Review of credentialing file of Physician #2 revealed a credentialing application dated 10/30/08, request for delineation of privileges without Medical Executive Committee or Governing Body approval dated 10/24/08, and a letter of appointment dated 12/30/08 for a 2 year appointment to active staff beginning 12/2/2008.

An interview was conducted with Physician #2 on 6/30/10 at 11:00 am. in the conference room. Physician #2 reported she discontinued her affiliation with the facility in January, 2009 and returned to the facility April, 2010. Physician #2 reported that she did not make application to active medical staff or request delineation of privileges upon her return in April, 2010.

According to the "Minutes of the Meeting" dated 5/26/10, Physician #2 was reappointed to the Medical Staff but had never been appointed to the Medical Staff upon returning to the facility in April, 2010 after not being affiliated with the facility for 16 months.

C. Review of credentialing file of Physician #9 revealed a credentialing application dated 11/19/08, no delineation of privileges approved by Medical Executive Committee and Governing Body. There was a letter of appointment dated 12/30/08 granting temporary privileges beginning 12/2/2008 not to exceed 150 days(5/2/2009). According to the "Minutes of the Meeting" dated 5/26/10, Physician #9 was reappointed to the Medical Staff but had not been appointed to the active Medical Staff.

D. Review of credentialing file of Physician #33 revealed a credentialing application without a date, no request for delineation of privileges, no approval of delineation of privileges, and no appointment letter granting appointment to the Medical Staff. According to the "Minutes of the Meeting" dated 5/26/10, Physician #6 was reappointed to the Medical Staff but had never been appointed to the Medical Staff.

E. Review of credentialing file of Physician #3 revealed a credentialing application dated 11/10/2008,
request for delineation of privileges with no Medical Executive Committee or Governing Body approval, and an appointment letter dated 12/30/08 granting temporary privileges beginning 12/2/08 not to exceed 150 days(5/2/09). According to the "Minutes of the Meeting" dated 5/26/10, Physician #3 was reappointed to the Medical Staff but had not been appointed to the active Medical Staff.

F. Review of credentialing file of Physician #4 revealed no credentialing application, no copy of license, no copy of Drug Enforcement Agency (DEA) Certificate, nocopy of Department of Public Safety (DPS) Certificate. There was a request for delineation of privileges dated 11/17/08 but no Medical Executive Committee or Governing Body approval.

G. Review of credentialing file of Physician #5 revealed no credentialing application, no copy of license, no copy of Drug Enforcement Agency (DEA) Certificate, nocopy of Department of Public Safety (DPS) Certificate. There was a request for delineation of privileges dated 11/17/08 but no Medical Executive Committee or Governing Body approval.

H. Review of credentialing file of Physician #7 revealed a credentialing application and request for delineation of privileges dated 3/24/10. There was no letter of appointment and no approval of Medical Executive Committee or Governing Body for the delineation of privileges.

I. Review of credentialing file of Physician #8 revealed a credentialing application and request for delineation of privileges dated 12/1/09. There was no letter of appointment and no approval of Medical Executive Committee or Governing Body for the delineation of privileges.

J. Review of credentialing file of Physician #10 revealed a credentialing application and request for delineation of privileges dated 12/9/09. There was no letter of appointment and no approval of Medical Executive Committee or Governing Body for the delineation of privileges.

K. Review of credentialing file of Physician #11 revealed a letter of appointment dated 5/25/08 granting Administrative Emergency Temporary Privileges for a period of 90 days(8/25/08). A request for delineation of privileges dated 5/25/08 was not approved by Medical Executive Committee or Governing Body. A credentialing application and request for delineation of privileges dated 11/18/08. No privileges were granted and no appointment to the Medical Staff was found.

L. Review of credentialing file of Physician #12 revealed a credentialing application and a request for delineation of privileges dated 8/12/09. There was no letter of appointment and no approval of Medical Executive Committee or Governing Body for the delineation of privileges.

An interview was conducted on 7/1/10 at 3:00 pm with the Chief Clinical Officer in the conference room. The Chief Clinical Officer confirmed all physicians listed above were practicing in the facility and /or telemedicine with the exception of Physician #6 and Physician #10.

Based upon record review and interview, the governing body failed to approve medical staff bylaws, rules and regulations.

A request was made of the Clinical Director at the entrance conference on 6/30/10 at 10:00 am, for a copy of the Medical Staff Bylaws, Rules and Regulations. The Clinical Director reported that to her knowledge there was no Medical Staff Bylaws, Rules and Regulations at the facility. The Clinical Director reported she would contact the corporate office to determine if the copy of the Bylaws, Rules and Regulations were at the corporate office.

A copy of the Medical Staff Bylaws, Rules and Regulations was provided on 7/1/10 at 1:30 pm. The Clinical Director reported the corporate office had sent the document by e-mail. Review of the Medical Staff Bylaws, Rules and Regulations revealed a proposed document that had not been approved by the Governing Body. The Document contained statements such as follows: "Whereas, the facility, is a free-standing , private for profit facility servicing the Cambridge, Ohio community,...", "Only physicians and advanced nurse practitioners licensed to practice in the state of Ohio, shall be eligible for membership on the Medical Staff. " "The physician must have a license to practice in the State of Ohio."

Review of a document provided as the Governing Body meeting minutes titled "Minutes of Meeting" and dated 5/26/10 revealed no approval of Medical Staff Bylaws, Rules and Regulations. These were the only meeting minutes provided. An interview was conducted with the Clinical Director on 7/1/10 @ 2:00 pm. The Clinical Director reported that meeting on 5/26/10 had been the only meeting held since the change of ownership.

An interview was conducted with the Medical Director on 7/1/10 at 1:30 pm in the conference room. The Medical Director reported that she had not reviewed the Bylaws, rules and regulations.

Based upon record review and interview, the facility's governing body failed to review and resolve 6 out of 6 grievances.

Review of policy #RTS-08 Patient Grievance/ Resolution Process revealed that "The employee receiving the grievance will discuss verbally or in writing the formal grievance with Administration and the appropriate Chief Clinical Officer within 24 hours of the grievance." "Investigation of the grievance will begin within 48 hours of Administration or Department Director receiving the grievance." "A final written response will be provided to the complainant within 1 week and will include hospital decision, name of the hospital contact person, steps on behalf of grievance, results of grievance process, and date of completion." "Documents all patient grievances and appropriate resolution on the Patient Concern Response Form. These forms are maintained in the Risk Management Department." The policy did not include review and resolution by the governing body.

Review of a document provided as the Governing Body meeting minutes titled "Minutes of Meeting" and dated 5/26/10 revealed no evidence of documentation that the governing body had reviewed or resolved the grievances. No documentation found of delegation to a grievance committee, or that the grievance process was reviewed and/or resolved through the hospital's QAPI 's process, and that the patient and /or family member was informed of any resolution to their grievance.

1. In reviewing the grievance document from patient #11, the documentation on the complaint / grievance form dated 03/24/2010, patient #11 complained about not receiving sugar free pudding at dinner, but sugar free pudding was provided to other patients. There was a signed written response from Patient Advocate dated 03/25/2010, but no signature by Chief Clinical Officer as indicated on the form. There was no evidence that the Chief Clinical Officer and /or Department Director had been notified. There was no documented evidence of follow-up with employee involved in the complaint. There was no documented evidence that the patient /or Family member had been notified of a resolution. There was no documented evidence that the governing body had reviewed or resolved the grievance.

2. In reviewing the grievance document from patient # 3, the documentation on the complaint / grievance form dated 05/21/2010, patient #3 was a wittiness to another patient being abused by staff #17, who slapped and was rough with patient #14 when moving her out bed. There was a written response dated 05/25/2010, but there was no signature by any Behavioral Hospital staff. There was a place for the Patient Advocate to sign on the written response form, but the signature was missing. There were no results of the grievance process documented. There was no evidence of follow-up with employees involved in complaint. There was no evidence that the patient /or Family member had been notified of a resolution. There was no evidence that the governing body had reviewed or resolved the grievance.

3. In reviewing grievance document from patient # 2, the documentation on the complaint / grievance form dated 05/27/2010, patient #2 complained that staff #20 would not give patient #2 her medication. The medication nurse (#20) ignored and did not acknowledge patient #2. When patient #2 did receive medication it was given in a "harsh manner". Patient #2 also witnessed staff #17 being rough with a patient in a wheelchair. There was a written response dated 05/28/2010 by the Patient Advocate, but there was no signature by the Chief Clinical Officer as indicated on the form. There was no evidence of follow-up with employees involved in complaint. There was no evidence that the patient /or Family member had been notified of a resolution. There was no evidence that the governing body had reviewed or resolved the grievance.

4. In reviewing grievance document from patient #12, documentation on the complaint / grievance form dated 06/10/2010, patient #12 complained about medication schedule, missing two meals, cold room, no toothpaste available, and not enough pillows. The written response dated 06/10/2010, was written on the original Complaint /Grievance Form, the "Written Response Form" was not used. The actions written on the original Complaint /Grievance Form were patient times changed to home schedule, toothpaste provided, pillows provided, and room heater was explained to patient. There was no evidence of follow-up with employees or departments involved in the complaint. There was no evidence that the Chief Clinical Officer and/or Department Director was notified. There was no evidence that the patient /or Family member had been notified of a resolution. There was no evidence that the governing body had reviewed or resolved the grievance.

5. In reviewing grievance document from patient #9, documentation on the complaint / grievance form dated 06/11/2010, complained that 3 packs of cigarettes and 5 T-shirts were missing. " I want all items replaced." There was no signature on Complaint/Grievance Form, and no acknowledgment that any employee had seen the written complaint, except there was a sticky note attached dated 06/11/10, " I went and purchased 3 packs of cig. for him. Paid by BH." There was no evidence that Administration or the appropriate Department Director had been notified. There was no evidence of an investigation of the incident. There was no evidence that the patient /or Family member had been notified of a resolution. There was no evidence that the governing body had reviewed or resolved the grievance.

6. In reviewing grievance document from patient #13, documentation on the complaint / grievance form dated 06/21/2010, patient #13 complained about phones calls being blocked and not receiving snacks or desserts, and feels that her patient's rights have been taken away. There was no signature on Complaint/Grievance Form, and there was no acknowledgment that any employee had seen the written complaint. There was no evidence of an investigation of the incident. There was no evidence that Administration or appropriate Department Director had been notified. There was no evidence that the patient /or Family member had been notified of a resolution. There was no evidence that the governing body had reviewed or resolved the grievance.

The interview with the Clinical Director on 7/1/10 @ 2:00 pm, confirmed that their was no documentation that the grievances had been reviewed or resolved by the governing body.

Based upon record review and interview, the facility failed to clearly explain the grievance procedure.

In reviewing the Policy #RTS-08 Patient Grievance/Resolution Process it was revealed in the policy "Upon admission, the patient will be provided with the contact information for the Texas Department of State Health Services. They can be reached at: Texas Department of State Health Services,1100 W. Austin, TX 78756-3199,1-888-973-002."

Patient Handbook revealed who to contact, but no evidence of address or phone number of the Texas Department of State Health Services. No written procedure on how to submit a grievance concerning the facility.

Interview with the Chief Clinical Officer (CCO) confirmed that there was no documentation on how a patient/or family member could file a complaint against this facility with the Texas Department of Health.

Based upon record review and interview, the facility failed to have a resolution to the grievance process. Reviewed 6 out of 6 Complaint/Grievance Forms.

Refer to Tag # 119

Based upon record review and interview, the medical staff failed to review the credentials of applicants for medical staff membership for 12 of 12 physicians and make recommendations to the governing body.

REFER TO TAG - A0046

Based upon record review and interview, the medical staff bylaws were not approved by the medical staff and/or the governing body.

REFER TO TAG - A0048

Based upon record review and interview, the facility failed to ensure that contracted pharmaceutical services were providing medication-related care that included ordering, dispensing, and distributing medications to the facility. The Medical Staff failed to ensure policies and procedures were current for the pharmacy services provided. The facility also failed to ensure the consulting pharmacist was responsible for the pharmacy services.

An interview was conducted with the Chief Clinical Officer (CCO) on 6/30/10 at 1:30 pm in the conference room. The CCO reported that there currently was no pharmacy services agreement for obtaining medications due to the change of ownership that occurred in February, 2010. The CCO reported that the previous owner was delinquent in payment of services provided and the contracted pharmacy had discontinued providing medication services to the facility. A new agreement had been in negotiation and on the date of this interview had not been finalized. The contracted pharmacy services was currently providing medications inconsistently leaving the facility without frequently prescribed medications. The CCO reported they would be forced to utilize a local pharmacy when the physicians prescribed medications not in stock.

Review of Pharmacy policies and procedures revealed policies for the operation of an in-house pharmacy which the facility did not presently have in operation. Further review of the policies revealed there were no policies for the functions of the pharmacy services currently being provided through a contracted service that provides the medications and no policies for the responsibilities of a consultant pharmacist.

An interview was conducted with the Chief Clinical Officer on 7/1/10 at 2:00 pm. The Chief Clinical Officer confirmed there were no policies or procedures for the current operation of the pharmacy service.

Review of the "Agreement for the Provision of Pharmaceutical Consultant Services" revealed "The services to be provided will include: review of medication records, orders, and Quality Assurance as required by the Texas State Board of Pharmacy, compliance with Medicare Regulation, inservices, and the establishment and maintenance of a formulary for the hospital."

A telephone interview was conducted with the Consultant Pharmacist on 7/16/10 at 2:00 pm. The Consultant Pharmacist reported making weekly visits to the facility and checking to see that nurses had checked in stock medications received by the pharmaceutical service and ensure the proper storage in the Med-Dispense system. The Consultant reported she does not document the visit anywhere and does not co-sign the re-stock reports that the nurses sign when medications are received from the pharmaceutical service. The Consultant also reported she does not review medication orders and medication records, does not conduct quality assurance activities, and does not provide inservices as agreed. The Consultant reported she believed she was only there because they had to have a pharmacist. The Consultant also reported she had provided the facility with a 30 day notice that she would no longer provide consultant services effective 6/30/10.

Based upon record review and interview, the facility failed to ensure the consulting pharmacist was responsible for all the activities of the pharmacy services.

An interview was conducted with the Chief Clinical Officer (CCO) on 6/30/10 at 1:30 pm in the conference room. The CCO reported the facility had an agreement with a local pharmacist to provide consultant services to the facility and an agreement with pharmacy service to provide medications to the facility.

Review of the "Agreement for the Provision of Pharmaceutical Consultant Services" revealed "The services to be provided will include: review of medication records, orders, and Quality Assurance as required by the Texas State Board of Pharmacy, compliance with Medicare Regulation, inservices, and the establishment and maintenance of a formulary for the hospital."

A telephone interview was conducted with the Consultant Pharmacist on 7/16/10 at 2:00 pm. The Consultant Pharmacist reported making weekly visits to the facility and checking to see that nurses had checked in stock medications received by the pharmaceutical service and ensure the proper storage in the Med-Dispense system. The Consultant reported she does not document the visit anywhere and does not co-sign the re-stock reports that the nurses sign when medications are received from the pharmaceutical service. The Consultant also reported she does not review medication orders and medication records, does not conduct quality assurance activities, and does not provide inservices as agreed. The Consultant reported she believed she was only there because they had to have a pharmacist. The Consultant also reported she had provided the facility with a 30 day notice that she would no longer provide consultant services effective 6/30/10.