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Based on record review and interviews with hospital staff the governing body does not ensure that all services provided by the hospital are provided in a safe manner.

Findings:

1. The governing body does not ensure that all services performed under contract are provided in a safe and effective manner. See Tags A 0023, 0083, 0084, 0085 and 0398.

2. The governing body does not ensure that each patient's rights are protected and promoted. See Tags A 0122, 0144, 0145, 0154, 0160 and 0196.

3. The governing body does not ensure that radiological services are provided in a safe manner by qualified personnel. See Tags A 0539, 1545, 0546, 0553, 0554 and 0555.

4. The governing body did not ensure the infection control practitioner developed, implemented, and maintained an ongoing infection control program designed to identify, prevent, control and investigate infections and communicable diseases of patients and personnel and provide a sanitary and safe environment for patient care. See Tag A 0749.

Based on review of a list of hospital staff, personnel files and interviews with hospital staff, the hospital failed to maintain verification of current licensure and training for personnel working in the hospital.

Findings:

1. Staff Y, a registered nurse contracted to insert peripheral central catheters (PICC lines), did not have a license on file. There was no verification of licensure, proof of training, education, and qualifications to perform the procedure. Staff Y was documented in Pt #9's medical record as providing PICC line placement.

2. The facility listed radiology services as provided under contract. There was no information provided to the surveyors that the hospital verified licensure, proof of training, education, and qualifications to perform the procedures. There was no documentation the facility oriented and trained the contract personnel.

3. Staff B, a dietitian documented in Pt#8's medical record as providing a nutritional assessment. Staff B told surveyors the facility did not have any information on the dietitian as this dietitian was provided by the food service company which the hospital no longer contracts with.

4. Staff B told surveyors the facility used agency nursing to provide patient care. There was no information provided to surveyors to document the hospital verified licensure, proof of training, education, and qualifications to perform patient care. There was no documentation the facility oriented and trained the contract agency personnel. On 8/17/2011 surveyors were handed faxed information that pertained to Staff K and Staff L. The facility had no previous record pertaining to Staff K and Staff L's orientation to the facility, competencies, qualifications, evaluations, verifications of licensure, or completed health and immunization history.

5. These findings were reviewed with administration at the exit conference 8/18/11. No further documentation was provided.

Based on record review and interviews with hospital staff, the governing body does not ensure that services provided by contract are evaluated through the quality assurance/performance improvement (QAPI) program.

Findings:

1. The hospital did not have a list of all contracted services and their scope.

2. The QAPI program did not include an evaluation of contracted services.

Based on record review and interviews with hospital staff, the governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Services provided to the hospital by contract are not monitored and evaluated by the hospital's quality assessment and performance improvement (QAPI) program to ensure that they are provided in a safe and effective manner. The governing body does not ensure contract services are provided in a safe and effective manner.

1. On the morning of 8/16/11 surveyors reviewed thirteen contract personnel files. Nine out of thirteen did not have documentation of orientation and training. This finding was reviewed at the exit conference and no further documentation was provided.

2. On 8/17/2011 surveyors reviewed Governing Body Meeting Minutes. Not all of the services provided under contract are reviewed and evaluated by the Governing Body to ensure services are provided in a safe and effective manner.

Based on review of hospital documents and interviews with personnel the facility failed to maintain a list of all contracted services with all required elements.

Findings:

1. On 8/16/11 surveyors reviewed a list of contract services provided by Staff A.
2. The contract list did not include services contracted through the separately licensed adjacent facility.
3. The contract list did not include all of the nursing agency contractors.
4. The contract list did not include the current hemodialysis company.
5. The contract list did not include all the agencies utilized for peripherally inserted central catheters (PICC).
6. The contract list did not have scope and nature of services provided documented on all contractors.

Based on review of policies and procedures, inservices, and documentation supplied for review, and interviews with hospital staff, the hospital failed to specify the time frame for review, investigation and response to the complainant.

Findings:

This deficiency was cited at the last survey conducted on 06/20/2011. The policies cited below were in effect at the time of the complaint investigation on 06/20/2011 and no revision had been approved at the time of this recertification survey (08/16 - 18/2011). All inservice of staff were performed according to the policies dated 01/01/2009 and the "Addendum" dated 09/28/2010.

1. Upon arrival on 08/16/2011, the hospital provided the surveyors with two different policies concerning grievances (each with an effective date of 01/01/2009) and an "Addendum" dated 09/28/2010. Attached to the policies were copies with the same effective dates, but had been revised. When asked, Staff B stated the policies were proposed revisions, but had not been approved by the governing body at this time.

2. Staff B, O and Cc told the surveyors on 08/16/2011 that staff had been provided inservice on the grievance procedure. Review of the inservice notebook showed staff were trained on 06/21/2011 on the unrevised policies and addendum. Added to the inservice was the definition of grievances, as specified by CMS (Centers for Medicare and Medicaid Services) regulations. On 08/16/2011 at 1150 and 1225, Staff O and Cc confirmed inservice was performed on the old policies.

3. The policies cited three different time frames for completion of the complaint/grievance.
a. The policy entitled "Patient/Family Concerns of Grievances", found in the Leadership Manual section of the policies, documented that grievances should be resolved within 72 hours by the staff and Department Head, but if not, it would be forwarded to the Quality Manager and resolved within an additional 72 hours.

b. The policy entitled"Complaints/Grievance Procedures", found in the Quality Manual-Risk Management section of the policies, documented the "department director will be responsible for resolution interventions within 5 to 7 working days". Further into the policy, the policy documented a response would be within 30 days after first receiving the grievance.

c. The "Addendum" documented that although "Policy" documented grievances would be resolved within 72 hours, "We resolve our complaints within 24 hours." It implied that only if an "official grievance" was filed, would a written response be sent.

4. The patients' handouts did not specify a timeframe for resolution and response to grievances expressed/filed.

Based on review of medical records, policy and procedure, hospital documents, interviews with staff, and observation, the hospital failed to provide care in a safe setting.

Findings:
1. The hospital's policy titled "risk management-event reporting dated 1/1/2009" stipulates 1. Guidelines-Events may be those involving patient care or those involving the operation of a department/facility. 1.1 patient care-reported via the Quality (incident) report, 1.1.1 Adverse Event (AE) An unplanned or unusual deviation in the patient care process, 1.1.2 Error-an unintended act either of omission or commission, or an act that does not achiev its outcome. 1.1.3 Sentinel event-an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. The policy further provides examples of reportable incidents.
The hospital policy Incident Report stipulates process of reporting patient events and visitor events. The policy further stipulates at "1.6.2-quality incident report must be completed for all unusual occurrences".

On the morning of 8/16/2011 Staff A told surveyors the facility had educated nursing staff (since the initial survey) on "grievances and incident reports". Staff education provided to surveyors included a definition of complaint, grievance, and an incident. An incident was defined in the education as "an occurrence of an action and/or situation, any adverse outcome associated as a direct consequence of treatment". The definition provided on the education sheet did not match the definition provided in the policies. The definition sheet provided to surveyors had a form attached entitled "Specialty Hospital" and referred to complaints. The education did not include the policies cited above. The information provided to surveyors did not include forms to be completed if an incident occurred. There was no documentation provided to surveyors the staff had been trained on the hospital's policies regarding incidents and incident reporting.

2. The hospital has a high observation area. This area is enclosed in glass and has four patient bays. Curtains separate each patient bay. On 8/18/2011 during a tour of the high observation area, a surveyor noted a patient was in contact isolation. There was no hand sanitizer available at the bedside. The only sinks available for all bays was across the observation area. Staff could not sanitize hands without using sinks located at the entrance of the unit. Notification of isolation precautions was not visible on entrance to the high observation area. See tag 0749

3. MR#2,3,8,9 reviewed for restraint use document restraints were used without timely assessment of patients by the licensed independent practitioner. Orders for restraints were not always signed by a licensed independent practitioner. MR#8 and #9 had restraint orders signed by a physician in advance of the 24 hour time frame. Documentation in MR#2,3,8,9 did not indicate the patient was assessed every two hours as required by hospital policy. Documentation in MR#2,3,8, 9 did not stipulate alternatives to the use of restraints had been attempted prior to administering restraints. The restraint policy indicates restraint usage will be tracked and minimized. The restraint data presented in Quality Meeting Minutes or Governing Body Meeting minutes was not analyzed with recommendations to improve compliance with policy. There was no documentation the data was reviewed for usage trends. There was no documentation the committees recommended changes to improve compliance with policy and decrease facility restraint usage.


4. The hospital has two policies on abuse. The policy "Elder Abuse" stipulates Adult Protective Services would be notified with suspected abuse but did not contain any other steps the hospital would take to ensure patient safety or train personnel in recognition of possible abuse or neglect and steps to follow when suspected or reported to them. The policy "Suspected Abuse" stipulates if abuse is suspected the alleged perpetrator would be removed from caring for the patient. The policy does not stipulate how the hospital would ensure safety of the other patients and the alleged perpetrator while the investigation occurred. The policy dld not stipulate how the staff would be trained to recognize possible abuse and neglect while patients were hospitalized. The policy also did not specify steps the staff needed to take if allegations of abuse and neglect were reported. See tag 0122

5. According to facility policy "transfer/transport care and reporting" the policy statement stipulates "patients at this facility may expect their condition/status to be documented prior to and following transport and appropriate monitoring to take place following return to the facility" and a form titled "short term transfer/transport document" was attached

3 of 3 (MR#8, 7,11,) medical records reviewed for transfers to higher level of care or for procedures at nearby facilities did not contain documentation of patient condition prior to transfer out and did not have documentation of patient condition at the time of transfer back into the facility. There was no documentation report was called to the receiving facility. There was no documentation stipulating the condition of the patient when transferred back to the facility.

MR#11 the patient's nurse documented "pt received laying in bed O2 (oxygen) off-no bedside chart made-no MAR-no pt (patient) chart- made bedside chart with nurses notes-made pt chart". There was no "short term transfer/transport document in the chart.

MR#8-the patient's record indicated the patient was transferred three times to a nearby separately licensed hospital for higher level of care services or procedures. There was no documentation in the chart indicating Pt#8's nurse called report to the other facilities prior to transferring the patient to the other facility. There was no documentation in the chart when the patient returned from the nearby hospital the facility had received report.

MR#7-the patient's record indicated the patient was transferred twice to nearby separately licensed hospital for care. There was no documentation in the chart indicating report was called to the receiving facility. There was no short term transfer/transport document completed.

6. Contract staff were not trained and evaluated as competent to provide care in the facility. None of the contract files contained orientation and training to the facility. The facility did not verify licensure on contractors. One contractor's file was requested on 8/16/11, staff A told surveyors she did not know who this person was. Later Staff A told surveyors the contractor in question was subcontracted to the facility from another contractor and there was no information on the contractor. None of the agency nursing files contained an hospital training, competency, or evaluations.

Based on review of the facilities policies and procedures and inservice education, and interviews with hospital staff, the hospital failed to develop and enforce a policy that clearly describes the procedures to follow when a patient alleges abuse or neglect by a hospital employee.

Findings:

1. The hospital had two policies on abuse.

2. The policy, entitled "Elder Abuse, #CM-PC-H-0039, recorded the hospital staff would notify APS (Adult Protective Services) and they would decide what needed to be done and do any investigation required. The policy did not contain any other steps the hospital would take to ensure patient safety or train personnel in recognition of possible abuse or neglect and steps to follow when suspected or reported to them.

3. The other policy, found in the leadership division of policies, entitled "Suspected Abuse", #LM-RI-H-0027, recorded if the "alleged perpetrator is a staff member, that person shall be removed from caring for the patient in question."
a. The policy did not stipulate how the hospital would ensure the safety of other patients and the "alleged perpetrator" while the hospital investigated the allegation.
b. The policy did not specify how staff would be trained to recognize possible abuse or neglect while the patient was hospitalized.
c. The policy did not specify how staff would be trained on the steps/procedure to follow when allegations of suspected abuse or neglect was identified by or reported to them.

4. This was confirmed with Staff B and Staff O on 08/16/2011 at 1225. The finding was also reviewed with administrative staff during the exit conference on the afternoon of 08/18/2011.

Based on review of policy and procedure, medical records, and meeting minutes the facility failed to implement a restraint policy which includes measures to reduce the use of restraints.

Findings:

1. Pt #2,3,8,9 medical records indicated each patient had been placed in restraints. Hospital policy "restraint use" stipulates at 3.2.5 (c) "the following will also be performed by the Nurse or designee and will be documented at a minimum every 2 hours and as needed; a.clinical justification, b. determine if a less restrictive alternative is applicable; c. restraint effectiveness; d. sensation, pulse skin temp, color, movement of part restrained; e. site skin inspection; f. skin care, if indicated; g. ROM (range of motion) to extremities or when condition warrants, ambulation; h. offer: toileting fluids, nourishment, and oral care, unless contraindicated; i. call bell is within reach. In an interview with Staff O surveyors were told when restraints are applied the nursing staff should complete a restraint flowsheet. Four (2,3,8,9) records reviewed for restraint usage did not have restraint flowsheets or documentation in the narrative as required by policy.

2. Patient #8 is a 74 year old male admitted to the facility on 6/15/11. On 6/23/2011 nursing documentation stipulates the patient became agitated and was given one milligram of ativan intramuscularly. No physician order for the ativan was on chart. None of the nursing documentation stipulated any measures were used to reorient or redirect Patient #8. There was no documentation there had been an assessment of the patient's condition which might be triggering the abnormal behavior. On 7/16 the nurse documented "hitting staff, screaming out, slid to ground, trying to get out of bed." Patient #8 was administered 2mg Haldol IM. A verbal order stipulated "2 mg Haldol IM may repeat if not improvement. There was no documentation there had been an assessment of the patient's condition which might be triggering the behavior. The Haldol was not listed as a routine medication for this patient. Restraint use was documented in Patient #8's nursing narrative 24 days of a 30 day stay. 22 of the 24 occurrences of restraints did not have restraint flowsheets with documentation per policy. Five of the restraint orders did not have a physician signature. Two of the 24 restraint order sheets were signed in advance of the date of use. One restraint order was written "ok to place pt on restraints until Dr (name withheld) sees patient)". The physician listed in the order was the patient's attending physician.

Based on review of medical records, review of policy and procedure, and staff interviews the hospital failed to identify the use of medication to manage patient's behavior as a chemical restraint.

Findings:

1. Patient #8 is a 74 year old male admitted to the facility on 6/15/11. On 6/23/2011 nursing documentation stipulates the patient became agitated and was given one milligram of ativan intramuscularly. No physician order for the ativan was on chart. None of the nursing documentation stipulated any measures were used to reorient or redirect Patient #8. There was no documentation there had been an assessment of the patient's condition which might be triggering the abnormal behavior. On 7/16 the nurse documented "hitting staff, screaming out, slid to ground, trying to get out of bed." Patient #8 was administered 2mg Haldol IM. A verbal order stipulated "2 mg Haldol IM may repeat if no improvement. There was no documentation there had been an assessment of the patient's condition which might be triggering the behavior. The Haldol was not listed as a routine medication for this patient. The hospital failed to identify the use of the medication as a chemical restraint.

2. In the morning on 8/17/2011 surveyors reviewed the restraint policy. There was no policy for use of medications as a restraint. Later that morning, surveyors met with Staff B. Staff B stated the facility did not train staff on the use of chemical restraint. The above findings were reviewed with Staff B. This information was also reviewed on the afternoon of 8/18/2011 during the exit conference. No further documentation was provided.

Based on review of hospital hospital documents and training documentation provided, and interviews with hospital staff, the hospital failed to ensure all staff who have direct patient contact are trained and kept current in the proper and safe use of restraints. Contract agency nurses providing direct patient care did not have hospital restraint training. None of the contract agency nursing staff had files specific to the facility.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Director of Nursing (DON), or designee, provided orientation and evaluation of agency personnel.

Findings:

1. On 8/16/11 the surveyors requested agency nurses personnel files. Staff A told surveyors that information was kept at the agency. No documents were provided to surveyors on any agency nursing personnel orientation, training, competency, or evaluation originating from the facility. Faxed copies of records provided on 8/17/11 consisted of Staff K and Staff L which contained no orientation to the facility, oversight on adherence to policies and procedures, supervision, or evaluations that are unit and facility specific.

2. On 8/16/2011 the surveyors requested a registered nurses file who contracted with the hospital to provide peripherally inserted central line catheters (PICC) lines. Staff B told surveyors the facility did not have information on the contracted nurse Staff Y.


3. On 8/17/2011 Surveyors were given faxed information on Staff K and Staff L. The facility had no previous records pertaining to Staff K and Staff L's orientation to the facility, review of policies and procedures, supervision, or evaluation of clinical activities.

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, documentation of care provided, medication administration, and vital signs monitoring.

Findings:

1. Patient#'s 5, 7,8, 11 medical records did not contain documentation of patient condition prior to transfer out and did not have documentation of patient condition at the time of transfer into the facility. According to facility policy "transfer/transport care and reporting" the policy statement stipulates "patients at this facility may expect their condition/status to be documented prior to and following transport and appropriate monitoring to take place following return to the facility" and a form titled "short term transfer/transport document" was attached. In an interview with Staff O surveyors were told transfer and transport documentation should be documented in the chart. Staff O provided surveyors with a form titled "patient transfer form". This form did not match the form attached to the transfer/transport care and reporting policy.

2. Patient's #2,3,8,9 medical records reviewed for restraint usage did not contain documentation the patient was monitored as required by the facility policy. Restraint orders were not always signed by a physician or licensed independent practitioner. Alternatives to restraints were not always documented. Assessments by the registered nurse applying the restraints did not match attending physician documentation.

3. Patient record #5 did not have a signed history and physical or signed consultation note.

4. Patient records #8,9 had incomplete initial nursing assessments.

5. Patient records #1,3,8,9 reviewed for intravenous infusions did not have documentation regarding date of insertion, time of insertion, clinician initiating, type/gauge of device initiated.

6. Patient records #1,2,3,4,5,7,8,9 did not always have verbal orders dated, signed, and timed.

Based on review of medical records and interviews with staff, the facility failed to provide radiologic services on the order of an authorized practitioner.

Findings:

1. On 8/16/2011 surveyors requested radiology policies. Staff A and B told surveyors the facility did not have policies only a contract.

2. Two medical records reviewed for radiology orders did not include orders for x-ray. Pt#9's nursing narrative indicated the patient received a peripherally inserted central catheter (PICC) on 6/7/11. There was no order for the x-ray. There was no report on the x-ray. Nursing documented "x-ray PICC line confirmed".

Pt #11's nursing narrative indicated a PICC line was placed and a call to the contractor was placed to get confirmation of the PICC line placement. Pt#11's chart did not have an order for the x-ray. There was no report of confirmation on the chart.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services, only personnel designated as qualified by the medical staff used the radiologic equipment and administered procedures; and all personnel regularly exposed to radiation are checked for radiation exposure periodically.

Findings:

1. On the morning of 8/16/11 Staff A told surveyors the facility had a contract with a mobile x-ray company and radiologists read the xrays via a digital pacs system.

2. Review of hospital documents did not indicate a radiologist oversaw the radiology services.
3. There were no policies developed and approved by the medical staff to designate which personnel are qualified to use the radiological equipment and administer procedures.

Based on review of policy and procedure, medical records, and interviews with staff, the hospital failed to maintain records for all radiology procedures performed.

Findings:

1. On 8/16/2011 surveyors requested radiology policies. According to Staff B, radiology services are provided under contract. The facility did not have policies and procedures reviewed and approved through the medical staff on how x-ray films will be stored and retrieved.

2. On 8/16/2011 this finding was reviewed with Staff B. No further documentation was provided.

Based on surveyor observations, review of hospital documents, meeting minutes, infection control data, policies, and patient medical records, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed, implemented, and maintained an ongoing infection control program designed to identify, prevent, control and investigate infections and communicable diseases of patients and personnel and provide a sanitary and safe environment for patient care. The infection control practitioner failed to ensure the program maintained a comprehensive system for reporting, analyzing, preventing and controlling infections and communicable diseases.

Findings:

1. On the morning of 08/16/2011, the surveyors requested all surveillance/monitoring activities performed for 2011. With the exception of the infection control log in the meeting minutes, the only surveillance/monitoring activity brought to the surveyors was handwashing surveillance.

2. Although the infection control plan documented evaluation of protective equipment and "garb", isolation precautions and techniques were not monitored as part of infection control program.
a. On the bottom of multiple hand surveillance forms staff performing the observations documented occurrences where staff and contractors did not follow the isolation precautions.

b. On tour on the morning of 08/18/2011, one surveyor observed a 4-bed unit. The only separation between the patients were curtains. The hand washing facilities were at the opposite side of the room. The surveyor observed two staff at 501B's (Patient #6's) bedside wearing isolation gowns. Staff B and Ee told the surveyor that only Patient #6 was in isolation and called the surveyor's attention to the television monitor on which hung the notification and type of isolation.

c. On tour on the morning of 08/18/2011 with Staff B and Ee, the surveyor also observed isolation gloves and gowns hanging on the door outside Room 506, but no sign designation the patient was on isolation or the type of isolation. The surveyor was told the patient was not on isolation because no sign was present. When the medical record was reviewed, it showed Patient #10 had been on contact isolation since admission.

These problems were not addressed in the monthly infection control meeting minutes with corrective actions. On the afternoon of 08/18/2011, Staff C stated he tried to address the problems as soon as he became aware of the situations, but did not track or monitor isolation precautions and report to the infection control committee.

3. Although the infection control plan documented employee health and immunizations would be followed as part of the infection control program, the committee meeting minutes did not reflect immunizations of contract staff and physicians had been review, evaluated and corrective actions taken. Review of health files showed nine of nine physicians and all of contract staff did not have complete immunization histories. Staff B and Staff Aa confirmed on 08/18/2011 that the hospital did not keep files on the contract staff.

4. Meeting minutes did not demonstrate the infection control practitioner/infection control program monitored/conducted surveillance to ensure policies and procedures concerning infection control were followed. This included all departments of the hospital, including contract services that had infection control policies in the infection control manual.

5. One surveyor observed four different disinfectants being used throughout the hospital. The manufacture guidelines for wet times ranged from 2 minutes to 10 minutes. Housekeeping staff stated they sprayed the surfaces and allowed the products to remain on the surface for 10 minutes. One or two physical therapy staff interviewed did not know the manufacture guidelines for time the product needed to remain wet on the surface to be effective. The infection control practitioner did not conduct monitoring/surveillance to ensure manufacture guidelines were followed.

6. Review of meeting minutes did not reflect the hospital's infection control program had reviewed the disinfectants used by the hospital or been involved in selecting and approving the disinfectants to be used in the hospital.

7. Meeting minutes for December 2010 through July 2011 reported hand hygiene surveillance non-compliance with appropriate hand hygiene. Meeting minutes did not reflect the information was processed with corrective actions and follow-up showing whether corrective actions were instituted or effective.

8. Meeting minutes for December 2010 through July 2011 did not demonstrate that concerns/problems documented were reviewed, analyzed with corrective actions and follow-up when needed.

Attached to the meeting minutes were documents, identified on the afternoon of 08/18/2011 by Staff C as his notes, were concerns/problems. The concern/problems were not addressed with analysis or corrective action or follow-up in the meeting minutes, including:
a. Ensure staff is using aseptic technique with all central line dressing and cap changes.
b. Continue to ensure and educate staff, patients, and visitors on proper isolation techniques.
c. Continue with a daily full clean plus every 2-hour wipedowns of commonly touched surfaces in the High Ops Unit.
d. Influenza vaccines - acceptance or declination.

Based on review of rehabilitation policy and procedure, hospital documents, personnel files and interviews with staff, the facility failed to ensure the scope of rehabilitative services meet the needs of the patients.

Findings:
1. On the morning of August 16, 2011, Staff A provided surveyors Rehabilitation Services Policy. The policy addressed the scope of occupational therapy, physical therapy, and speech language therapy. There were no other policies for rehabilitative services.
a. There were no policies specific to the equipment used in occupational therapy, physical therapy, and speech therapy and the staff qualified by education and training to use the equipment.
b. There were no policies specific to therapeutic interventions utilized in occupational therapy, physical therapy, or speech therapy and the staff responsible for the activities.
c. There were no policies addressing infection control in the rehabilitation area.

2. In an interview with Staff A on the morning of August 16, 2011 surveyors were told rehabilitation services were provided by contract therapists and therapy assistants. Two of three contract therapy personnel selected for review did not have department specific orientation and training, competencies, or evaluations.

3. Medical Staff Meeting minutes for 2010 and 2011 did not include a of review of the rehabilitation services. Quality Assurance Meeting Minutes did not include a review of the rehabilitation services. There was no evaluation the rehabilitative services provided met the needs of the patient.

4. The above findings were reviewed with administration in the exit conference. No further information was provided.

Based on review of hospital documents, policy and procedure, meeting minutes, medical records, and interviews the hospital failed to ensure the director of rehabilitation services was qualified, trained, and available to supervise therapy services.

Findings:

1. On the morning of August 16, 2011 Staff A told surveyors rehabilitation (physical therapy, occupational therapy) services were provided under contract. Hospital documents stipulated Staff F was the Director of Rehabilitation services. Documents in Staff F's file indicate she is a certified occupational therapy assistant (COTA). A COTA is not qualified to supervise a occupational therapist, physical therapist, or speech therapist.

2. On the August 17, 2011 review of Staff F's personnel file did not have evidence of a job description. On August 18, 2011 after multiple requests for job descriptions, Staff A provided surveyors a job description titled "Director of Rehabilitation. Supervisory responsibilities listed in the job description stipulate "currently supervises all members of the rehabilitation staff. Minimum education requirements stipulates the Director of Rehabilitation is a graduate of an accredited professional therapy school. COTA's are not independent therapists and are not graduates of a professional therapy school.

3. This information was reviewed with administration during the exit conference. No further documentation was provided.

Based on review of records and interviews with staff the hospital does not ensure that data collected for performance improvement is measured after action is taken. Review of performance improvement, medical staff and governing body meeting minutes for 2010 and 2011 did not have evidence of actions taken to address quality problems identified in analysis of the data and to determine if the corrective actions were effective.

Findings:

1. Medical Staff and Governing Body meeting minutes documented that performance improvement (PI) was presented via the PI Report Card.

2. The PI Report Card had number data and percentages only for each category listed.

3. PI meeting minutes had five categories and the fifth category was labeled Outcome/Followup. The only outcomes documented were either open or closed.

Based on policy and procedure, interviews, and review of personnel files the facility does not ensure personnel providing radiology services are appropriately trained and competent to provide services to patients.

Findings:

1. On the morning of 8/16/2011 surveyors were told diagnostic radiology services were provided to the hospital through a contract.

2. Surveyors requested personnel records for contracted services. None were provided. The hospital did not have a list of personnel qualified to run the equipment or provide services to patients. The hospital failed to ensure the contract personnel providing services to patients were appropriately trained, competent, and qualified to provide radiology services to patients. Staff I and Staff J were the requested files for radiology personnel review. On 8/16/2011 surveyors were handed faxed copies of information that was sent to the facility from the contracted company. The facility had no previous record pertaining to Staff I and Staff J's orientation to the facility, competencies, qualifications, evaluations, or completed health and immunization history.

3. The above findings were reviewed with administration in the exit conference. No further documentation was provided.

Based on review of medical records the facility failed to have a signed report of the radiologic image interpretation. Patient #9 and #11 had documentation in the record a contract mobile x-ray company had been called for a diagnostic study to determine peripherally inserted central line catheter was correctly placed. There was no x-ray report. There was no documentation the radiologist interpreted the image and signed a report.

Based on medical record reviews, policies and procedures, and interviews with staff the facility failed to develop a process for maintaining reports and images.

Findings:

1. On 8/16/11 surveyors requested radiology policies. Staff A and B told surveyors the radiology contract was the policy. According to Staff A a mobile imaging company performs some of the radiology imaging. A separately licensed facility nearby the hospital provides other types of imaging. There was no policy indicating how the facility would store and retrieve reports, images, or scans.

2. Patient #11 required peripheral intravenous central line (PICC) placement. The nurse documented in the chart "called contractor (name withheld) to get confirmation of PICC line placement-PICC line nurse left facility stated does not have time to wait for results-to call if not in place". There was no documentation in Patient #3's chart from the contractor regarding the x-ray.

3. Patient #9 required PICC line placement. The nurse documented "x-ray confirmation of placement at 0200". There was no x-ray report of PICC line confirmation in the chart.