HospitalInspections.org

Based on observation, review of policy and procedure, interviews, and document review, it was determined the facility failed to maintain compliance with Federal, State and Local Laws as evidence by failing report an occurrence of fire to hospital licensing director as regulated in (25 TAC) 133.141(b). According to the facility Occurrence Report the alarm system was not operational at the time of the fire as indicated by local fire authority,

Findings were:

According to (25 TAC) 133.141(b) all occurrences of fire shall be reported to the local fire authority and shall be reported in writing to the hospital licensing director as soon as possible but not later than 10 calendar days following the occurrence.

Review of an occurrence report for 1-18-11 noted " Building B filled with smoke code red called. Fire department dispatched. Patients evacuated per policy and procedure. Found motor to the air handler burnt out non repairable. Building inspected by Hospital staff, declared safe by CCFD, Patients returned to building without incident, Found that alarm system was not in working order, monitoring company notified unable to respond to repair system hospital placed on Fire Watch ....There was a minor fire in the air handler in Building B, No injuries. Smoke only. Pts. were safely evaluated from building. " An interview with the Chief Operations Officer on 6-22-11 confirmed this incident of fire was not reported to the hospital licensing director.

The report of a fire alarm not working at the facility during an incident of fire placed the patient population at risk. Without a functional alarm system, the facility is unable to appropriately monitor and respond to incidents involving fire or smoke. This could delay or prevent any evacuation efforts, placing patients at risk of physical harm or death.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on observation and review of documents, it was determined that the governing body failed to demonstrate responsibility for services provided in the hospital in that the facility failed to follow established facility policy and procedure in the care of a patient.

Findings were:

Cross refer to Tags:
A073 Institutional Budget and Plan
A083 Contracted Services
A0431 Medical Record Services.

Facility policy entitled " Transcription Service " stated " It shall be the policy of Padre Behavior Hospital to provide a centralized transcription system for the dictation of certain reports regarding patient care, evaluation, treatment, and aftercare. "

In a telephone interview with, vendor # 3, on 6-22-11 @ 1415, stated that PBH owed approximately $25,000.00 for transcription services and that they were 5-6 months behind in paying. Vendor #3 stated that transcription services had not been terminated yet but that they would be terminated at the end of June 2011 for non-payment.

Cross refer to Tags:
A073 Institutional Budget and Plan
A083 Contracted Services
A0115 Patient Rights
A0700 Physical Environment.

Facility Policy entitled " Policy for Pest Control " stated " A contact is in force with a licensed pest control company. They agree to provide monthly spraying and pest control inspections. "

In a telephone interview on 6-22-11 @ 1340, vendor # 7, stated that pest control services to the facility had been suspended due to non-payment and that their last, monthly service to the facility had been 4-22-11. No pest control services had been provided to the facility since 4-21-11.

Lack of pest control services at the facility placed patients at increased risk of infection. Without appropriate pest control services insects and rodents could become a problem, introducing and spreading disease-causing organisms.

Cross refer to Tag A0469 Content of Record-Discharge.
Facility policy entitled " Padre Behavioral Hospital Medical Staff Rules and Regulations Governing Patient Management " under " Complete Psychiatric Evaluation " stated in part:
" A complete psychiatric evaluation shall be performed and entered into the medical record by the attending physician or designee within 60 hours of admission. "

The following medical staff had not completed psychiatric evaluations within 60 hours of patient admissions for period from 2/1/11 through 6/21/11:
? Staff # 1 had 12 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 9-20).
? Staff # 2 had 25 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 70-94).
? Staff # 3 had 4 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 118-121).
? Staff # 6 had 3 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 213-215).

The " Padre Behavioral Hospital Request for Clinical Privileges-Physician Assistant " indicated Staff # 7, a Physician Assistant was only approved to " Dictate discharge summaries (limited to information extracted form the patient 's medical record)."

? Staff # 7 dictated 4 Psychiatric Evaluations on Patients # 10, 17, 18, and 214 for the period from 2/1/11 through 6/21/11.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on observation, review of records, and interviews it was determined the facility failed to protect and promote each patient's rights as evidence by not filling contracted payment obligations to vendors, delayed maintenance repairs, no monthly pest services provided, and non-reporting of a fire to the hospital licensing director. This affected patient care and safety by putting the patient population at risk of infection related to pests, risk of illness related food storage, and risk of harm related to a non-functional alarm system during an incident of fire.

Findings were:

In a telephone interview on 6-22-11 @ 1340, vendor # 7, stated that pest control services to the facility had been suspended due to non-payment and that their last, monthly service to the facility had been 4-22-11. No pest control services had been provided to the facility since 4-21-11.

Lack of pest control services at the facility placed patients at increased risk of infection. Without appropriate pest control services insects and rodents could become a problem, introducing and spreading disease-causing organisms.

According to in interviews with staff members #8, 10, and 17 the dining room of the facility had been without air conditioning for over two months before a repair occurred. Per interview with staff members # 8, 9, and 17 the air conditioning in the kitchen had been non-functioning for 6 days (since 6-16-11).

Tour of the patient dining room, kitchen and food preparation and storage area on 6-21-11 revealed the following:

? The air conditioning in the kitchen area was not working at the time the surveyors toured the facility.
? Stored canned food was registering a temperature of 92.5 degrees Fahrenheit, measured using an infrared temperature gun.
? The thermostat on the wall in the kitchen registered 93 degrees Fahrenheit.

The lack of temperature control in areas where food is prepared, stored, and served presented an increased risk of food borne illness for patients and staff.

Review of an occurrence report for 1-18-11 noted " Building B filled with smoke code red called. Fire department dispatched. Patients evacuated per policy and procedure. Found motor to the air handler burnt out non repairable. Building inspected by Hospital staff, declared safe by CCFD, Patients returned to building without incident, Found that alarm system was not in working order, monitoring company notified unable to respond to repair system hospital placed on Fire Watch ....There was a minor fire in the air handler in Building B, No injuries. Smoke only. Pts. were safely evaluated from building. "

The report of a fire alarm not working at the facility during an incident of fire placed the patient population at risk. Without a functional alarm system, the facility is unable to appropriately monitor and respond to incidents involving fire or smoke. This could delay or prevent any evacuation efforts, placing patients at risk of physical harm or death.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on review of documentation it was determined that the facility failed to appropriately complete psychiatric evaluations, discharge summaries, countersign orders and progress notes. The facility failed to complete medical records within 30 days following discharge as evidenced by a review of charts which were incomplete as of survey date 6/22/11. The charts remained incomplete, missing necessary signatures and forms had not been completed. 207 out of 215 records reviewed were delinquent. The charts were considered by the facility to be closed and complete records.

Findings were:

Review of 215 clinic records revealed incomplete medical records.

Cross refer to Tag:
A0450 Medical Record Services

? Patient # 3 had a Medication Consent for Orajel, dated 1/19/11, with no MD signature or date noted.
? Patient # 4 had a Physician Progress note dated 2/17/11 with no MD signature or date noted.
? Patient # 98 had a Physician Progress note dated 1/24/11 with no MD signature or date noted.
? Pt. # 18 had no Psychiatric Evaluation for his 4-27-11 through 5-27-11 admission.

Cross refer to Tag
A0469 Content of record-Discharge Diagnosis

The following medical staff had not completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 5 had 16 out of 215 discharge summaries reviewed that had not been completed within 30 days of discharge (Patients # 122-137).
? Staff # 4 had 13 out of 215 discharge summaries reviewed that had not been completed within 30 days of discharge (Patients # 174-186).

The following medical staff had not signed completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 1 had 50 unsigned discharge summaries out of 215 records reviewed (Patients # 17-63).
? Staff # 2 had 7 unsigned discharge summaries out of 215 records reviewed (Patients # 64-69).
? Staff # 3 had 24 unsigned discharge summaries out of 215 records reviewed (Patients # 95-117).
? Staff # 5 had 36 unsigned discharge summaries out of 212 records reviewed (Patients # 138-173).
? Staff # 6 had 27 unsigned discharge summaries out of 215 records reviewed (Patients # 187-213).

Facility policy entitled " Padre Behavioral Hospital Medical Staff Rules and Regulations Governing Patient Management " under " Complete Psychiatric Evaluation " stated in part:
" A complete psychiatric evaluation shall be performed and entered into the medical record by the attending physician or designee within 60 hours of admission. "

The following medical staff had not completed psychiatric evaluations within 60 hours of patient admissions for period from 2/1/11 through 6/21/11:
? Staff # 1 had 12 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 9-20).
? Staff # 2 had 25 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 70-94).
? Staff # 3 had 4 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 118-121).
? Staff # 6 had 3 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 213-215).

Cross refer to Tags:
A073 Institutional Budget and Plan
A083 Contracted Services

Facility policy entitled " Transcription Service " stated " It shall be the policy of Padre Behavior Hospital to provide a centralized transcription system for the dictation of certain reports regarding patient care, evaluation, treatment, and aftercare. "

In a telephone interview with, vendor # 3, on 6-22-11 @ 1415, stated that PBH owed approximately $25,000.00 for transcription services and that they were 5-6 months behind in paying. Vendor #3 stated that transcription services had not been terminated yet but that they would be terminated at the end of June 2011 for non-payment.


The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Base on a review of facility contract and interviews, it was determined the facility failed to ensure continuous 24 hour laboratory services for patient as evidence by an electronic mail from the contracted laboratory stating service to the facility will be suspended 6-30-11 for non-payment.

Findings were:

An electronic mail from contracted Laboratory services on 6-21-11 stated " We will suspend our service agreement June 30, 2011 for non-payment. " Another electronic mail from the contracted Laboratory services dated 6-6-11 stated " The account balance is back over $10,000.00. The invoices for February and March over due. " Laboratory services to the facility were to be suspended 6-30-11 related to this non-payment.

A lack of laboratory services would impact patient care due to the inability to obtain both routine and emergency laboratory values. In a psychiatric setting, access to current laboratory values related to therapeutic range of psychiatric medication is important to monitor due to the risk for toxicity and adverse reactions.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.
.

Based on review of correspondence and interviews it was determined the facility failed to provide a qualified dietician who works full-time, part-time, or on a consultant basis. The facility dietician suspended her services at the facility on 6-6-11.

Findings were:

Review of the document entitled " Agreement for Nutritional Services " dated 6-23-06 by the facility with dietician stated in part: "Contractor Invoicing. In consideration for services provided, Hospital agrees to reimburse Contractor within thirty (30) days of receipt of Contractor's complete and accurate invoice, which shall include dates, hours and description of services provided."

Review of an electronic mail message dated 5-22-11 from the contracted Dietician, vendor # 8, stated "Once I receive the check for February 2011, I will reinstate services as scheduled. However, I will need to be paid for March 2011 (Invoice PBHSI0311) by Friday June 3, 2011. Please note an invoice for May 2011 will be submitted on June 1, 2011 and payment will be due by Friday, July 1. 2011. If I am not paid by these dates I will suspend my services again." Another electronic mail message dated 6-6-11 from the contracted Dietician stated "Consultant dietician services have been suspended."

In a telephone interview on 6-21-11 @ 1340, the dietician stated that dietary consultant services were still suspended and had only been paid for services rendered through February 2011.

With no dietician services available, the dietary and nutritional needs of patients are not properly monitored. Proper nutrition is important to maintain health and promote healing. With no full time dietician available, the patients lack appropriate dietary monitoring, education, and recommendation for dietary changes. This places the patients at risk for inadequate nutritional support.

Tour of the patient dining room, kitchen and food preparation and storage area on 6-21-11 revealed the following:

? The air conditioning in the kitchen area was not working at the time the surveyors toured the facility.
? Stored canned food was registering a temperature of 92.5 degrees Fahrenheit, measured using an infrared temperature gun.
? The thermostat on the wall in the kitchen registered 93 degrees Fahrenheit.

The lack of temperature control in areas where food is prepared, stored, and served presented an increased risk of food borne illness for patients and staff.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on observations, review of facility policy and procedure, as well as interviews it was determined the facility was not properly maintained to ensure the safety of the patients.

Findings were:

In a telephone interview on 6-22-11 @ 1340, vendor # 7, stated that pest control services to the facility had been suspended due to non-payment and that their last, monthly service to the facility had been 4-22-11. No pest control services had been provided to the facility since 4-21-11.

Lack of pest control services at the facility placed patients at increased risk of infection. Without appropriate pest control services insects and rodents could become a problem, introducing and spreading disease-causing organisms.

According to in interviews with staff members #8, 10, and 17 the dining room of the facility had been without air conditioning for over two months before a repair occurred. Per interview with staff members # 8, 9, and 17 the air conditioning in the kitchen had been non-functioning for 6 days (since 6-16-11).

Tour of the patient dining room, kitchen and food preparation and storage area on 6-21-11 revealed the following:

? The air conditioning in the kitchen area was not working at the time the surveyors toured the facility.
? Stored canned food was registering a temperature of 92.5 degrees Fahrenheit, measured using an infrared temperature gun.
? The thermostat on the wall in the kitchen registered 93 degrees Fahrenheit.

The lack of temperature control in areas where food is prepared, stored, and served presented an increased risk of food borne illness for patients and staff.

Review of an occurrence report for 1-18-11 noted " Building B filled with smoke code red called. Fire department dispatched. Patients evacuated per policy and procedure. Found motor to the air handler burnt out non repairable. Building inspected by Hospital staff, declared safe by CCFD, Patients returned to building without incident, Found that alarm system was not in working order, monitoring company notified unable to respond to repair system hospital placed on Fire Watch ....There was a minor fire in the air handler in Building B, No injuries. Smoke only. Pts. were safely evaluated from building. "

The report of a fire alarm not working at the facility during an incident of fire placed the patient population at risk. Without a functional alarm system, the facility is unable to appropriately monitor and respond to incidents involving fire or smoke. This could delay or prevent any evacuation efforts, placing patients at risk of physical harm or death.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on review of documentation it was determined that the facility failed to appropriately complete psychiatric evaluations, discharge summaries, countersign orders and progress notes. The facility failed to complete medical records within 30 days following discharge as evidenced by a review of charts which were incomplete as of survey date 6/22/11. The charts remained incomplete, missing necessary signatures and forms had not been completed. The charts were considered by the facility to be closed and complete record. The facility also failed to follow policy that psychiatric evaluations are to be completed within 60 hours of admission with 44 out of 215 charts reviewed not meeting this standard.

Findings were:

Review of 215 clinic records revealed incomplete medical records.

? Patient # 3 had a Medication Consent for Orajel, dated 1/19/11, with no MD signature or date noted.
? Patient # 4 had a Physician Progress note dated 2/17/11 with no MD signature or date noted.
? Patient # 98 had a Physician Progress note dated 1/24/11 with no MD signature or date noted.
? Pt. # 18 had no Psychiatric Evaluation for his 4-27-11 through 5-27-11 admission.

The following medical staff had not completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 5 had 16 out of 215 discharge summaries reviewed that had not been completed within 30 days of discharge (Patients # 122-137).
? Staff # 4 had 13 out of 215 discharge summaries reviewed that had not been completed within 30 days of discharge (Patients # 174-186).

The following medical staff had not signed completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 1 had 50 unsigned discharge summaries out of 215 records reviewed (Patients # 17-63).
? Staff # 2 had 7 unsigned discharge summaries out of 215 records reviewed (Patients # 64-69).
? Staff # 3 had 24 unsigned discharge summaries out of 215 records reviewed (Patients # 95-117).
? Staff # 5 had 36 unsigned discharge summaries out of 212 records reviewed (Patients # 138-173).
? Staff # 6 had 27 unsigned discharge summaries out of 215 records reviewed (Patients # 187-213).

Facility policy entitled " Padre Behavioral Hospital Medical Staff Rules and Regulations Governing Patient Management " under " Complete Psychiatric Evaluation " stated in part:
" A complete psychiatric evaluation shall be performed and entered into the medical record by the attending physician or designee within 60 hours of admission. "

The following medical staff had not completed psychiatric evaluations within 60 hours of patient admissions for period from 2/1/11 through 6/21/11:
? Staff # 1 had 12 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 9-20).
? Staff # 2 had 25 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 70-94).
? Staff # 3 had 4 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 118-121).
? Staff # 6 had 3 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 213-215).

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on a review of documentation, facility policy and procedure, and interviews it was determined the facility failed to ensure the current rules and regulations were implemented and enforced to carry out its responsibilities.

Findings were:

The " Padre Behavioral Hospital Request for Clinical Privileges-Physician Assistant " indicated Staff # 7, a Physician Assistant was only approved to " Dictate discharge summaries (limited to information extracted form the patient ' s medical record " .

? Staff # 7 dictated 4 Psychiatric Evaluations on Patients # 10, 17, 18, and 214 for the period from 2/1/11 through 6/21/11.

Facility policy entitled " Padre Behavioral Hospital Medical Staff Rules and Regulations Governing Patient Management " under " Complete Psychiatric Evaluation " stated in part:
" A complete psychiatric evaluation shall be performed and entered into the medical record by the attending physician or designee within 60 hours of admission. "

The following medical staff had not completed psychiatric evaluations within 60 hours of patient admissions for period from 2/1/11 through 6/21/11:
? Staff # 1 had 12 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 9-20).
? Staff # 2 had 25 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 70-94).
? Staff # 3 had 4 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 118-121).
? Staff # 6 had 3 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 213-215).

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Base on observation, review of contracts, and vendor interviews it was determined the facility budget did not adequately anticipated income and expenses as evidence by several contracted vendor services suspended and not making contracted payments to vendors.

Findings were:
Cross refer to Tags:
A0083 Contracted Services
A0431 Medical Record Services
A0576 Laboratory Services
A0618 Food and Dietetic Services
A0700 Physical Environment

Facility policy entitled " Transcription Service " stated " It shall be the policy of Padre Behavior Hospital to provide a centralized transcription system for the dictation of certain reports regarding patient care, evaluation, treatment, and aftercare. "

In a telephone interview with, vendor # 3 6-22-11 @ 1415, stated that PBH owed approximately $25,000.00 for transcription services and that they were 5-6 months behind in paying. Vendor #3 stated that transcription services had not been terminated yet but that they would be terminated at the end of June 2011 for non-payment.

Facility Policy entitled " Policy for Pest Control " stated " A contact is in force with a licensed pest control company. They agree to provide monthly spraying and pest control inspections. "

In a telephone interview on 6-22-11 @ 1340, vendor # 7, stated that pest control services to the facility had been suspended due to non-payment and that their last, monthly service to the facility had been 4-22-11. No pest control services had been provided to the facility since 4-21-11. The facility has an outstanding balance with them of $875.08. The last payment received from the facility was received March 1st and was for a December 2010 invoice.

Lack of pest control services at the facility placed patients at increased risk of infection. Without appropriate pest control services insects and rodents could become a problem, introducing and spreading disease-causing organisms.

Contract entitled " Agreement for Nutritional Services " entered into 6-23-06 by the facility with dietician stated in part: "Contractor Invoicing. In consideration for services provided, Hospital agrees to reimburse Contractor within thirty (30) days of receipt of Contractor ' s complete and accurate invoice, which shall include dates, hours and description of services provided. "

An electronic mail message dated 5-22-11 from the contracted Dietician, vendor # 8, stated " Once I receive the check for February 2011, I will reinstate services as scheduled. However, I will need to be paid for March 2011 (Invoice PBHSI0311) by Friday June 3, 2011. Please note an invoice for May 2011 will be submitted on June 1, 2011 and payment will be due by Friday, July 1. 2011. If I am not paid by these dates I will suspend my services again. " Another electronic mail message dated 6-6-11 from the contracted Dietician stated " Consultant dietician services have been suspended. "

In a telephone interview on 6-21-11 @ 1340, the dietician stated that services were still suspended and had only been paid for services rendered through February 2011.

With no dietician services available the patient population dietary and nutritional needs are not properly monitored. Proper nutrition is important to maintain health and promote healing. With no full time dietician available the patients lack appropriate dietary monitoring, education, and recommendation for dietary changes. This places the population at risk for infection and poor nutrition.

An electronic mail from contracted Laboratory services on 6-21-11 stated " We will suspend our service agreement June 30, 2011 for non-payment. " Another electronic mail from the contracted Laboratory services dated 6-6-11 stated " The account balance is back over $10,000.00. The invoices for February and March over due. " Laboratory services to the facility were to be suspended 6-30-11 related to this non-payment.

A lack of laboratory services would impact patient care due to the inability to obtain both routine and emergency laboratory values. In a psychiatric setting, access to current laboratory values related to therapeutic range of psychiatric medication is important to monitor due to the risk for toxicity and adverse reactions.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on observation and review of documents, it was determined that the governing body did not effectively maintain responsibility and ensure that contractors of services provided services to permitted the hospital to comply with all applicable conditions of participation and standards for the contracted services.

Findings were:

Cross refer to Tags:
A0073 Institutional Plan and Budget
A0431 Medical Record Services
A0576 Laboratory Services
A0618 Food and Dietetic Services
A0700 Physical Environment

Facility policy entitled " Transcription Service " stated " It shall be the policy of Padre Behavior Hospital to provide a centralized transcription system for the dictation of certain reports regarding patient care, evaluation, treatment, and aftercare. "

In a telephone interview with, vendor # 3 on 6-22-11 @ 1415, stated that PBH owed approximately $25,000.00 for transcription services and that they were 5-6 months behind in paying. Vendor #3 stated that transcription services had not been terminated yet but that they would be terminated at the end of June 2011 for non-payment.

Facility Policy entitled " Policy for Pest Control " stated " A contact is in force with a licensed pest control company. They agree to provide monthly spraying and pest control inspections. "

In a telephone interview on 6-22-11 @ 1340, vendor # 7, stated that pest control services to the facility had been suspended due to non-payment and that their last, monthly service to the facility had been 4-22-11. No pest control services had been provided to the facility since 4-21-11. The facility has an outstanding balance with them of $875.08. The last payment received from the facility was received March 1st and was for a December 2010 invoice.

Lack of pest control services at the facility placed patients at increased risk of infection. Without appropriate pest control services insects and rodents could become a problem, introducing and spreading disease-causing organisms.

Contract entitled " Agreement for Nutritional Services " entered into 6-23-06 by the facility with dietician stated in part: "Contractor Invoicing. In consideration for services provided, Hospital agrees to reimburse Contractor within thirty (30) days of receipt of Contractor ' s complete and accurate invoice, which shall include dates, hours and description of services provided. "

An electronic mail message dated 5-22-11 from the contracted Dietician, vendor # 8, stated " Once I receive the check for February 2011, I will reinstate services as scheduled. However, I will need to be paid for March 2011 (Invoice PBHSI0311) by Friday June 3, 2011. Please note an invoice for May 2011 will be submitted on June 1, 2011 and payment will be due by Friday, July 1. 2011. If I am not paid by these dates I will suspend my services again. " Another electronic mail message dated 6-6-11 from the contracted Dietician stated " Consultant dietician services have been suspended. "

In a telephone interview on 6-21-11 @ 1340, the dietician stated that services were still suspended and had only been paid for services rendered through February 2011.

Base on a review of clinical records and facility policies it was determined that the facility failed to enforce applicable criteria regarding privileges granted to individual practitioners as evidence by a Physician Assistant completing Psychiatric Evaluations without corresponding privileges.

Findings were:

The " Padre Behavioral Hospital Request for Clinical Privileges-Physician Assistant " indicated that Staff # 7, a Physician Assistant was only approved to " Dictate discharge summaries (limited to information extracted from the patient's medical record " .

? Staff # 7 dictated 4 Psychiatric Evaluations on Patients # 10, 17, 18, and 214 for the period from 2/1/11 through 6/21/11, therefore this Physician Assistant was operating outside of the scope of his/her privileges as granted him/her by the governing body.

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on review of documentation it was determined that the facility failed to appropriately complete patient medical records evidenced by a review of charts which were incomplete as of survey date 6/22/11. The charts remained incomplete, missing necessary signatures and dates. 207 out of 215 records reviewed were delinquent. The charts were considered by the facility to be closed and complete records.

Findings were:

Review of 215 clinic records revealed incomplete medical records.

? Patient # 3 had a Medication Consent for Orajel, dated 1/19/11, with no MD signature or date noted.
? Patient # 4 had a Physician Progress note dated 2/17/11 with no MD signature or date noted.
? Patient # 98 had a Physician Progress note dated 1/24/11 with no MD signature or date noted.
? Pt. # 18 had no Psychiatric Evaluation for his 4-27-11 through 5-27-11 admission.

The following medical staff had not signed completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 1 had 50 unsigned discharge summaries out of 215 records reviewed (Patients # 17-63).
? Staff # 2 had 7 unsigned discharge summaries out of 215 records reviewed (Patients # 64-69).
? Staff # 3 had 24 unsigned discharge summaries out of 215 records reviewed (Patients # 95-117).
? Staff # 5 had 36 unsigned discharge summaries out of 212 records reviewed (Patients # 138-173).
? Staff # 6 had 27 unsigned discharge summaries out of 215 records reviewed (Patients # 187-213).

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on a review of documentation, it was determined that the facility physicians failed authenticate or countersign all verbal or telephone orders within 48 hours.

Findings were:

? Clinical record for Patient # 4 revealed one verbal order with no MD signature present.
On 3-8-11 at 1245 to " Place pt. in seclusion " with no MD signature present
? Clinical record for Patient # 5 revealed three verbal orders with no MD signature:
On 5-18-11 at 2005 " D/C Benadryl 15 mg PO BID, Benadryl 50 mg PO BID, Zyprexa 5 mg PO/IM now self-harm, Ativan 2 mg PO/IM now self-harm/aggression " .
On 5-19-11 at 1300 " 1. LOS 2. If you need to put pt. on 1:1 call MD. "
On 5-20-11 at 2235 " Zyprexa 5 mg PO/IM Q 4 hours PRN violent agitation,
Ativan 2 mg PO/IM Q 4 hours PRN anxiety or agitation. May give in 15 minutes. "
? Clinical Record for Patient # 17 revealed one verbal order with no MD signature present:
On 3-31-11 at 1100 " Klonopin 2 mg PO STAT aggression. Klonopin 2 mg PO Q 6 hours PRN aggression. "

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Base on a review of documentation, it was determined that the facility failed to complete medical records within 30 days following discharge as evidenced by a chart reviews which were incomplete as of survey date 6/22/11. The charts remained incomplete as they were missing necessary signatures and forms had not been completed. 207 out of 215 records reviewed were delinquent. The charts were considered by the facility to be closed and complete record.

Findings were:
Cross refer to Tag:
A0431 Medical Record Services (Condition)
A0450 Medical Record Services
A0457 Verbal Orders Authenticated Based on Law

The following medical staff had not completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 5 had 16 out of 215 discharge summaries reviewed that had not been completed within 30 days of discharge (Patients # 122-137).
? Staff # 4 had 13 out of 215 discharge summaries reviewed that had not been completed within 30 days of discharge (Patients # 174-186).

The following medical staff had not signed completed discharge summaries within 30 days of patient discharge for period from 2/1/11 through 6/22/11:
? Staff # 1 had 50 unsigned discharge summaries out of 215 records reviewed (Patients # 17-63).
? Staff # 2 had 7 unsigned discharge summaries out of 215 records reviewed (Patients # 64-69).
? Staff # 3 had 24 unsigned discharge summaries out of 215 records reviewed (Patients # 95-117).
? Staff # 5 had 36 unsigned discharge summaries out of 212 records reviewed (Patients # 138-173).
? Staff # 6 had 27 unsigned discharge summaries out of 215 records reviewed (Patients # 187-213).

Facility policy entitled " Padre Behavioral Hospital Medical Staff Rules and Regulations Governing Patient Management " under " Complete Psychiatric Evaluation " stated in part:
" A complete psychiatric evaluation shall be performed and entered into the medical record by the attending physician or designee within 60 hours of admission. "

The following medical staff had not completed psychiatric evaluations within 60 hours of patient admissions for period from 2/1/11 through 6/21/11:
? Staff # 1 had 12 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 9-20).
? Staff # 2 had 25 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 70-94).
? Staff # 3 had 4 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 118-121).
? Staff # 6 had 3 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 213-215).

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.

Based on a review of documentation it was determined the facility failed to appropriately complete psychiatric evaluations within 60 hours of patient admission.

Findings were:

The " Padre Behavioral Hospital Request for Clinical Privileges-Physician Assistant " indicated Staff # 7, a Physician Assistant was only approved to " Dictate discharge summaries (limited to information extracted form the patient 's medical record " .

? Staff # 7 dictated 4 Psychiatric Evaluations on Patients # 10, 17, 18, and 214 for the period from 2/1/11 through 6/21/11.

By the Physician Assistant completing Psychiatric evaluations without privileges in patient charts there is a risk that vital information may not be included on this form, effecting patient care. Physicians possess an education background best suited to obtain information and make determinations regarding patient diagnosis and care contained in a Psychiatric Evaluation. By a Physician Assistant completing the Psychiatric Evaluations, patients are at increased risk for treatment errors related to this documentation.

Facility policy entitled " Padre Behavioral Hospital Medical Staff Rules and Regulations Governing Patient Management " under " Complete Psychiatric Evaluation " stated in part:
" A complete psychiatric evaluation shall be performed and entered into the medical record by the attending physician or designee within 60 hours of admission. "

The following medical staff had not completed psychiatric evaluations within 60 hours of patient admissions for period from 2/1/11 through 6/21/11:
? Staff # 1 had 12 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 9-20).
? Staff # 2 had 25 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 70-94).
? Staff # 3 had 4 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 118-121).
? Staff # 6 had 3 psychiatric evaluations that had not been completed within 60 hours of admission out of 215 records reviewed (Patients # 213-215).

The above was confirmed in an interview with the Chief Executive Officer, Vice President of Regulatory Compliance, and Human Resource Officer the afternoon of 6-22-11 in a facility conference room.