HospitalInspections.org

Based on review of license and name of faciltiy and in interview with staff there was no evidence to support a change of ownership or change in name of the facility. This requirement was not met as follows:

Findings:

a. The faciliy's name on state licensing documents this faciliy as being " Gulf State of New Braunsfels Hospital". Upon observation the name of the facility that is on the entrance of the facility is "Hill Country Specialty Hospital, LLC." There was no evidence found to conclude there was change of ownership documents submitted or approved by state licensing for the change of ownership of the facility or awareness or approval of the change of name of the facility.

b. Interviewed staff #1, Chief Executive Officer at 10:30am on October 20, 2010 in the administration conference room who confirmed that within the year 2010 the facility went through a change of ownership because of various problems with the prior ownership and that the facility also went through a change of their name from "Gulf States LTAC of New Braunsfels to Hill Country Specialty Hospital, LLC". Staff #1 said that the paperwork for change of ownership and name change are currently being reviewed by management staff and facility lawyers before being sent in to state licensing. The facility is now 100% physician owned. The change of facility name took place in May 2010.

1. Based on review of documents and interview with staff no evidence could be provided to confirm that services performed under a contract are provided in a safe and effective manner. This requirement was not met as follows:

Findings:

a. In review of the list of contracted services at the facility, documentation on how these services were evaluated and services were being provided in a safe and effective manner could not be proven.

b. Interviewed staff #8, Director of Quality at 2:20pm on October 21, 2010 in the administration conference. Staff #8 could not provide evidence that contracted services in the facility were being evaluated to prove that they were being provided in a safe and effective manner.

1. Based on review of 24 medical records (MR) both open and closed and interview with staff it was observed that there was frequent use of verbal order in these medical records. This requirement was not met as follows:

Findings:

a. In reviewing 24 medical records (MR 1-24)) it was observed that in 15 out of the 24 (67%) medical records reviewed (MR# 7, 9,11,12,13,15,16,17,18,19,20,21,22,23 and MR# 24) contained evidence of frequent use (3 -5 per day) of verbal orders.

b. Interviewed staff #8, Director of Quality and staff #7, Director of Nursing at 2:30pm on October 25, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff interviewed explained that they were aware and are currently working on a plan to decrease frequency of verbal orders. Staff could not provided evidence that this requirement was met

1. Based upon review of 24 medical records (MR) both closed and open and interview with staff it was observed that medical records were not promptly completed. This requirement was not met as follows:

Findings:

a. After review of medical records (MR 1-24) it was observed that there were 22 out of 24 (92%) of medical records (MR# 1,2,3,4,5,6,9,10,11,12,13,14,15,16,17,18,19,20,21,22 and MR#24) that were incomplete after 30 days of discharge. These medical records had medical documentation entries that were either not timed, dated or signed by the practitioner this included physician progress notes, physician orders and discharge summaries. There were 11 out of 24 (46%) medical records (MR# 11, 13,14,15,16, 17, 18, 19, 20, 21 and MR #22) that did not contain discharge summaries.

b. Interviewed staff #8, Director of Quality and staff #7, Director of Nursing at 2:30pm on October 25, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staffs explained that they were aware and are currently working on incompleteness in medical records. Staff could not provided evidence that this requirement was met.

1. Based upon review of 24 open and closed medical records and interview with staff it was observed all orders including verbal orders were not dated, timed and authenticated promptly. This requirement was not met as follows:

Findings:

a. In review of these medical records it was observed that 16 out of the 24 medical records reviewed (67%) (MR# 1,2,3,4,6,12,13,15,17,18,19,20,21,22,23 and MR#24) had verbal orders that were either not dated,timed and/or authenticated by the practitioner.

b. Interviewed staff #8, Director of Quality and staff #7, Director of Nursing at 2:30pm on October 25, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff interviewed explained that they were aware and are currently working on these deficiencies. Staff could not provided evidence that this requirement was met.

1. Based upon review of 24 open and closed medical records and interview with staff it was observed that there were medical records who contained verbal orders that were not authenticated within 48 hours.This requirement is not met as follows:

Findings:

a. After reviewing 24 medical records it was observed that 16 out of the 24 medical records (MR# 1,2,3,4,6,12,13,15,17,18,19,20,21,22,23 and MR#24) (67%) reviewed had verbal orders that were either not dated, timed and/or authenticated within 48 hours by the practitioner.

b. Interviewed staff #8, Director of Quality and staff #7, Director of Nursing at 2:30pm on October 25, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staffs explained that they were aware and are currently working on incompleteness in medical records. Staff could not provided evidence that this requirement was met.

1. Based upon review of 24 medical records it was observed that discharge summaries with outcome of hospitalization, disposition of care and provisions for follow-up care was not included in some of the medical records reviewed. This requirement was not met as follows:

Findings:

a. In a review of 24 medical records it was observed that 11 out of the 24 medical records (46%) (MR# 11,13,14,15,16,17,18,19,20,21 and MR#22) reviewed did not contain discharge summaries with outcome of hospitalization, disposition of care and provisions for follow-up care.

b. Interviewed staff #8, Director of Quality and staff #7, Director of Nursing at 2:30pm on October 25, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff could not provided evidence that this requirement was met.

Based on review of minutes and interview with staff it was determined the pharmacist was not an active participant in developing, supervising, and coordinating all the activities of pharmacy services.

Findings include:
1. Review of Performance Improvement Committee minutes from January 2010-September 2010 on October 25, 2010 in the conference room of the facility failed to document the pharmacist attended or provided input into the infection control activities of the facility. Attendance roster for the committee meetings had "absent" in the space allocated for signature at all the meetings for the year of 2010. A form was in the minutes, Hill Country Specialty Hospital Quarter Function Reports Pharmacy & Therapeutics, that contained no information added by the pharmacist or the signature of the pharmacist. Review of Performance Improvement Committee minutes from January 2010-September 2010 on October 25, 2010 in the conference room of the facility failed to document the pharmacist attended or provided input into the performance improvement activities of the facility. Attendance roster for the committee meetings had "absent" in the space allocated for signature at all the meetings for the year of 2010. A form was in the minutes, Hill Country Specialty Hospital Quarter Function Reports Pharmacy & Therapeutics, that contained no information added by the pharmacist or the signature of the pharmacist to indicate their participation in the review of pharmacy services.

2. Interview with Staff #8 , Director of Quality services on 10/25/10 at 1:50 p.m. in the conference room revealed the Infection Control meeting is addressed in the Performance Improvement Committee meeting held monthly. Staff #8 confirmed the pharmacist has not attended any of the Performance Improvement Committee meetings in 2010 and has not turned in a report of information to be discussed at the meeting. Staff #8 could provide no evidence of active participation by the pharmacist in the infection control program. Interview with Staff #8 on 10/25/10 at 1:50 p.m. in the conference room revealed the Pharmacy & Therapeutics meeting is addressed in the Performance Improvement Committee meeting held monthly. Staff #8 confirmed the pharmacist has not attended any of the Performance Improvement Committee meetings in 2010 and has not turned in a report of information to be discussed at the meeting. Staff #8 could provide no evidence of active participation or documentation by the pharmacist in required committees in the facility.