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Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting patient's rights as evidenced by:

Cross reference A-0144: The hospital failed to ensure patient bedrooms and bathrooms were free from a conditions that could cause patient harm resulting in an Immediate Jeopardy.

Cross reference A0196: The facility failed to ensure all direct care staff receive proper restraint training.

The egregious nature of these deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on a review of documentation and interviews, it was determined the Governing Body failed to implement an effective utilization review plan that provided for review of services provided by the institution and the members of the medical staff to patients.

Findings include:

Cross reference A-0652 The Governing Body failed to convene a utilization review committee consisting of two or more practitioners.

Cross reference A-0654 The governing body failed to implement the utilization review policy for review for Medicare and Medicaid patients.

The cumulative effect of the systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Utilization Review, which poses a potential risk to the health and safety of patients when the facility fails to ensure appropriate utilization evaluation is ongoing for patients and reported to the Governing Body.

Based on observation on tour, review of policy, review of the facility plan of correction, and interview, the Administrator failed to ensure the facility was maintained in a condition that was free from a situation that may cause a patient to suffer physical injury by not maintaining a ligature free environment in patient bedrooms and bathrooms. This deficient practice can result in patient self harm and self asphyxiation resulting in harm or death.

Findings include:

Observation on June 10, 2025, revealed the facility's non-compliance with State licensing requirements for environmental standards and physical plant standards to protect the health and safety of patients receiving treatment at the facility. Ligature risks were identified during the facility tour that included patient bathroom toilets and shower heads not installed flush with the wall, creating a tie off point, protruding screws creating a patient self harm opportunity, elbow joints connecting beds to walls for 16 beds creating a ligature point, and sink faucets not properly maintained creating a tie off point.

The facility provided a plan of correction for the ligatures deficiencies dated September 13, 2024, that states with regards to ligatures, "...Conduct a thorough risk assessment of all existing areas to identify potential ligature points and other hazards ...Conduct training sessions for staff on recognizing and mitigating ligatures risks ...." The plan further addresses the installation of the new toilets stating "...Establish a regular maintenance schedule to ensure the ongoing functionality and safety of the new anti-ligature toilets ...develop a system for reporting and addressing any issues or repairs needed ...Conduct post-installation inspections to ensure proper installation ...address any issues or defects immediately ...." The facility failed to implement this plan of correction to ensure that ligatures were monitored and addressed in a timely manner.

Interview with Employee #1 and Employee #4 on June 10, 2025, confirmed the findings on tour.

Based on facility policy and procedure, personnel files, and interview, the Department determined that the administrator failed to ensure two personnel members obtained in-service training for seclusion and restraint when required. This poses a potential risk that staff are not appropriately trained.

Findings include:

Policy #HR-160, titled "Employee Orientation, Staff Development and Training" last reviewed 10/02/2023, revealed: "...Administrative and support staff participate in annual continuing education and training to maintain skills and competencies to perform their job ....In-service training for staff is based on program and individual staff needs,...Behavioral Health Professionals, Behavioral Health Technicians and Residential Techs need to maintain current skills and knowledge obtain or enhance skills and knowledge in the behavioral health services the agency is authorized to provide,..."

Employee #1 ' s personnel record revealed the following:

A document titled "Job title HOSPITAL ADMINISTRATOR/CRISIS SERVICES DIRECTOR", which revealed: "...Skills/Abilities Required:...Trained in and effectively manages crisis intervention/behavior management ...."

A certification for "Handle with Care" revealed: "...9/20/2023 This Certification Expires 1 Year From This Date ..."

A certification for "De-escalation, Seclusion and Restraint Training" was completed 12/11/2024.

Employee #6 ' s personnel record revealed the following:

A document titled "Job title Behavioral Health Para-Professional Residential Tech (BHPP)", which revealed: "...Duties and Responsibilities ...Be trained in providing de-escalation, seclusion, and restraints ..."

A certification for "Handle with Care" revealed: "...2/24/2023 This Certification Expires 1 Year From This Date ..."

A certification for "De-escalation, Seclusion and Restraint Training" was completed August 20, 2024.

Employee #15 confirmed in an interview conducted on June 11, 2025, that Employee #1 and Employee #6 did not obtain in-service training when it was required.

Based on facility policy and procedure, provider files, and staff interviews, the Department determined that the hospital failed to complete peer reviews of medical personnel. This deficient practice poses a risk to the health and safety of patients if the hospital does not ensure proper oversight of medical decision making.

Findings Include:

Policy #PI-102, titled "Focused Professional Practice Evaluations and Ongoing Professional Practice Evaluations for Changepoint Psychiatric Hospital" last reviewed 09/18/2023, revealed: "...Professional Practice Evaluation 1. Ongoing Professional Practice Evaluation (OPPE) is a program that allows the medical staff to identify professional practice trends that impact quality of care and patient safety on a continuous basis ...." Further review of Policy #PI-102 revealed no evidence of a timeframe to complete OPPE ' s for medical staff.

Ongoing Professional Practice Evaluations for the past year were requested for Employee #9, #10, and #11 since 2022. None were provided by the end of the survey.

Employee #2 confirmed in an interview conducted on June 11, 2025, that there was no documented Ongoing Professional Practice Evaluations for Employee #9, #10, or #11 for the past year to provide by the end of the survey.

Based on observation on tour, facility documents and interview, the Administrator failed to ensure there is at least one registered nurse present in the unit for the designated intake area. This deficient practice can result in insufficient personnel available to deal with an emergency.

Findings include:

Observation on tour revealed an observation stabilization unit which requires a registered nurse is present and provides direction for behavioral health observation/stabilization services in the designated area.

Review of facility schedule for April and May 2025, revealed one RN on shift for each shift for the observation stabilization area. Interview with Employee #1 on June 10, 2025, confirmed that the RN for the observation stabilization area is the RN that completes intakes. This would require the RN to leave their duties as the RN assigned to the observation stabilization area, leaving it without an RN present any time there was an admission during the months of April and May 2025.

Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to have a Utilization Review committee with two or more practitioners. This deficient practice poses a risk to the health and safety of the patients, when there are not at least two doctors on the Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

Findings include:

Policy #QM-100, titled "Quality Management Plan 2024-2025" last reviewed 08/21/2024, revealed: "...Organization The Governing Board has ultimate authority and responsibility through the collaboration of the Chief Executive Officer, Chief Financial Officer, and Quality Management Manager for overseeing ..."

Documents titled "Quality/Patient Safety (Utilization Management) Committee Meeting Minutes" for the past year were presented on June 12, 2025.

Quality/Patient Safety (Utilization Management) Committee Meeting attendees for May 14, 2025, March 18, 2025, January 21, 2025, September 17, 2025, and June 12, 2025, included a list of "Attendees" which included no doctors of medicine or osteopathy.

Employee #2 confirmed in an interview conducted on June 12, 2025, that there were no doctors of medicine or osteopathy present during the Quality/Patient Safety (Utilization Management) Committee Meetings for the past year.

Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to implement a Utilization Review process. This deficient practice poses a risk to the health and safety of the patients, when there is not a Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

Findings include:

Policy #QM-100, titled "Quality Management Plan 2024-2025" last reviewed 08/21/2024, revealed: "...Our Performance Improvement system is an integrated process that combines the review functions associated with quality assessment. These activities are enhanced by an information system that strives to streamline and coordinate at a minimum the following functions: Utilization Management involving a process improvement indicator and payor utilization,...The priorities, scope, design, and documentation of effectiveness of the PI system are evaluated and revised at least annually, or more frequently if the need is identified. Activities include but is not limited to:...Utilization Review ..."

Documents titled "Quality/Patient Safety (Utilization Management) Committee Meeting Minutes" for the past year were presented on June 12, 2025.

Evidence of review of admissions and durations of stay, professional services furnished including drugs and biologicals, or of admissions may be performed before, at, or after hospital admission were requested on June 12, 2025. None were provided by the end of the survey.

Employee #2 confirmed in an interview conducted on June 12, 2025, that there was no evidence of review of admissions and durations of stay, professional services furnished including drugs and biologicals, or of admissions may be performed before, at, or after hospital admission documented in the Quality/Patient Safety (Utilization Management) Committee Meeting Minutes.