HospitalInspections.org

Based on interviews, a review of meeting minutes, Madonna Medical Staff Bylaws Rules and Regulations, Operational Definitions [OD's - facility policies and procedures], contracted services and a review of the physician reappointment process, the governing body of the Long Term Acute Care Hospital (LTACH) failed to establish or maintain a separate and distinct hospital from the other providers encompassing the Madonna Rehabilitation 'System'. The Conditions of Participation were integrated with other certified providers within the Madonna Rehabilitation Hospital 'System'; therefore, the Condition of Participation: Governing Body was not met. Failure to provide independent oversight places all potential patients at risk for receiving poor quality of care.

The facility had 96 certified beds. The facility reported an acute patient census of 47 on the first survey day, 3/4/2014 and the total sample size was 31.

See also:

482.13 Condition of Participation: Patient's Rights - the facility failed to have patient rights information, admission area and process, and OD's that was independent from the 'System' and exclusive for the patients of this facility.
482.21 Condition of Participation: Quality Assessment and Performance Improvement Program - the facility failed to have it's own exclusive QA program that was independent from the 'System' QA program to ensure the quality of services for the patients of this facility.
482.22 Condition of Participation: Medical Staff - the governing body failed to enforce the medical staff bylaws and failed to ensure that this facility had a group of physicians was exclusive to this facility and independent from the 'System' medical staff to provide patient care.
482.23 Condition of Participation: Nursing Services - the facility failed to have an independent organizational nursing service department separate from other 'System' nursing services to ensure that nursing service needs were met for the patients of this facility.
482.24 Condition of Participation: Medical Record Services - the facility failed to have an independent medical record services department that was exclusive to the facility and independent from the 'System' medical records department.
482.25 Condition of Participation: Pharmaceutical Services - the facility failed to have a pharmacy department that was exclusive to meet the needs of the facility patients that was independent from other providers of the 'System'.
482.26 Condition of Participation: Radiology Services - the facility failed to have separate and independent radiology services exclusively for it's patients that was independent from the 'System' radiology services department.
482.27 Condition of Participation: Laboratory Services - the facility failed to have a distinct and separate laboratory services department to meet the needs of the facility patients that was independent from the 'System' laboratory services department.
482.28 Condition of Participation: Food and Dietetic Services - the facility failed to have a dedicated food service to meet the needs of it's patients that was independent from the 'System' food service.
482.30 Condition of Participation: Utilization Review - the facility failed to have an utilization review [UR]program to ensure the needs of the facility patients were met that was independent from the 'System' UR program.
482.41 Condition of Participation: Physical Environment - the facility failed to demonstrate independence from the 'System' maintenance department in providing for the maintenance and equipment needs of the facility; failed to ensure staff were trained on how to protect patients during potential/actual fire events; and failed to ensure safe mechanisms for exit of the facility during a potential/actual fire event.
482.42 Condition of Participation: Infection Control - the facility failed to have an active, dedicated infection control program that was specifically designed for the facility and it's patients and independent from the 'System' program.
482.43 Condition of Participation: Discharge Planning - the facility failed to have an independent discharge planning services dedicated to meet the needs its patients that was separate from other 'System' providers.
482.45 Condition of Participation: Organ, Tissue and Eye Procurement - the facility failed to have a contract with the Nebraska Organ Recovery System [NORS] and the Lions Eye Bank that was independent from other 'System' providers to meet the needs of it's patients.
482.56 Condition of Participation: Rehabilitation Services - the facility failed to have it's own rehabilitation staff and treatment areas that were exclusive for the patients of the hospital and independent from other 'System' providers.
482.57 Condition of Participation: Respiratory Services - the facility failed to provide respiratory services department and staff that were exclusive to meet the needs of the hospital patients and independent from other 'System' providers.
Findings include:

A. On 2/26/14, at 10:30 AM, an interview conducted with the Chairman of the governing body, revealed that the governing body was responsible for oversight of the Madonna Rehabilitation Hospital, as well as the Long Term Acute Care Hospital (LTACH) and Skilled Nursing Facility (SNF). The Chairman further confirmed, "We do not have three boards."

B. This same interview confirmed that both the Madonna Rehabilitation Hospital and LTACH operated under the same shared set of written governing body bylaws, had one shared medical staff that functioned under one set of medical staff bylaws, and had shared employees that functioned under one set of employee rules.

C. A review of governing body meeting minutes for the time period January 2013 through February 2014, confirmed that business from both the Madonna Rehabilitation Hospital and the LTACH, as well as other Madonna Rehabilitation Hospital 'System' providers were consistently integrated into the meeting minutes. Co-mingle topics routinely included the reappointment of medical staff members, Quality Assessment reports, Infection Surveillance data and financial information from all sources.

D. A review of a selected sample of contracts indicated that these agreements were made with the Madonna Rehabilitation Hospital 'System' and were not for the LTACH exclusively. Examples included services for dietary management, biomedical equipment maintenance, physician services, organ donation and emergency laboratory services.

E. A review of a selected sample of written operational definitions (OD's - facility policies and procedures) confirmed that the governing body/facility failed to establish policies and procedures specific and unique to the LTACH. All OD's followed the same format, included the heading titled "Madonna Rehabilitation Hospital ", a subject, and a scope (which indicated the specific entity the OD was applicable to, i.e., hospital, long term care, etc.)

Based on interviews with administrative staff, record review of Patient Right written information (provided to patients on admission) and observation of the admission area, the facility failed to independently have its own Patient Right information, admission area and process, and its own Operational Directives (OD's - facility policies and procedures). The facility used the Madonna Rehabilitation Hospital 'System' admission staff, common admission area and OD's to protect their patient rights. The Long Term Acute Care Hospital (LTACH) did not have its own grievance process or staff to review grievances. Records of training/education for LTACH staff employees and medical staff related to restraint use revealed that the training is completed and records are maintained by the Madonna Rehabilitation Hospital 'System' and not independently by the hospital. The Madonna Rehabilitation Hospital 'System' included the Madonna Rehabilitation Hospital and LTACH. The Condition of Participation was not met related to the facility's inability to independently provide for the protection of patient rights for their patients. This had the potential to affect all patients of the hospital. See also A00116, A0117, A0118, A0167, A0176 and A0208.

Findings are:

A. A staff interview with the Director of Quality and Risk Management for Madonna Rehabilitation Hospital 'System' on 3/4/14 at 3:30 PM, revealed that all Patient Rights information provided to patients on admission and OD's are not hospital-specific but are system wide. One OD covered all facility types (the Madonna Rehabilitation Hospital, Pediatrics [a unit of the Madonna Rehabilitation Hospital that provides services to patients under the age of 19] and the LTACH). Interview on 3/5/14 at 2:15 PM with the Director confirmed that grievances are reviewed and processed by the Madonna Rehabilitation Hospital 'System' and are not done independently by the LTACH. The Director stated, "you won't find anything separate for individual hospital provider types."

B. Observation of the admissions area on 2/27/14 at 11:30 AM found that both the Madonna Rehabilitation Hospital and the LTACH utilize the same admissions area and staff. Interview with the Director of Admissions on 2/27/14 at 11:30 AM confirmed this finding.

C. A review of the current "Patient Information & Visitor Guide Winter 2014, Madonna Rehabilitation Hospital" provided to patients on admission, included the Patient Rights information. The guide/handbook is written as 1 book for all provider types. Under the section titled "Levels of Care" on page 9, the information is provided for "Acute Rehabilitation (AR), Transitional Care Unit (TCU), Long Term Acute Care (LTACH), Rehabilitation Day Program, and Therapy Plus Outpatient Services."

D. Record review of the OD titled "Madonna Rehabilitation Hospital, Subject: Restraints and Seclusion (1819)" identified the Program Scope: Hospital, Long Term Care Programs. Under the policy purpose the OD states "This policy provides guidance for the appropriate use of restraint. The term patient will be used to refer to all individuals who receive care at Madonna". The policy further states "Employee Education and Training pertaining to safe and appropriate use of restraints will be provided to staff that apply restraints or care for patients in restraint. Education and training will be coordinated by the Education and Staff Development Department." Physician Training is noted as being coordinated by the Credentialing/Contract Review Specialist. The OD's, education and records related to staff training are not kept independently for the LTACH but are integrated with the other providers included in the Madonna Rehabilitation Hospital 'System'.

Based on record review of the Quality Assurance (QA) Plan for the Madonna Rehabilitation Hospital 'System', interview with the QA Manager for the Madonna Rehabilitation Hospital 'System', and review of PI (Performance Improvement) Committee meeting minutes, the facility failed to have its own separate QA program exclusively for the Long Term Acute Care Hospital (LTACH). All QA activities were performed and authorized at the Madonna Rehabilitation Hospital 'System' level. The Madonna Rehabilitation Hospital 'System' included The Madonna Rehabilitation Hospital, LTACH, and the Skilled Nursing Facility. Failure to have its own independent LTACH QA program means the hospital could not independently ensure the quality of services provided to its patients. This failure places all patients of LTACH at risk for negative patient outcomes resulting in the Condition of Participation: Quality Assessment and Performance Improvement not being met. The facility has 96 certified beds. The census was 47 on the day of entrance. The total sample size was 31.

Findings are:

A. A record review of the QA plan provided by the QA Manager for the Madonna Rehabilitation Hospital 'System' on 3/3/14 revealed that the Operational Definition [OD's - facility policies and procedures] titled "Madonna Rehabilitation Hospital 2012", dated 7/7/2013, stated the "Mission of the Quality Management/Risk System was to provide leadership and support for organizational collaboration to achieve and maintain high quality care and service in a safe and secure environment. The Madonna Rehabilitation 'System' facilitated the use of data within a problem solving structure that included the selection of appropriate tools for investigation, problem analysis, reporting, planning, implementing plans and evaluating effectiveness." Under the title "Components of System" the QA plan stated "Integration is intended to maximize the interactions between overlapping and/or related functions for the purpose of improved efficiency and effectiveness is [sic] all areas of the work of the system."

B. An interview with the QA Manager for the Madonna Rehabilitation Hospital 'System' on 3/3/14 at 1:30 PM, revealed that all staff working with Quality/Risk Management are at the system level. They cover all of the Madonna Rehabilitation Hospital 'System' provider types. The manager confirmed that the system QA based program covered the Madonna Rehabilitation Hospital, LTACH, Skilled Nursing Facility, and Outpatient Therapies. Six staff work with Quality and include the QA manager, an RN (Registered Nurse), an Infection Preventionist, Employee Health and Safety RN and LPN (Licensed Practical Nurse), an LPN data specialist and 1 other staff who is the Coordinator of the Quality/Risk System. The QA manager stated "all of us work as Madonna 'System' not just for the Rehabilitation Hospital or LTACH." The QA manager further reported that all Quality Improvement Projects are established by the Madonna 'System' which sets priorities for projects.

C. A record review of the OD titled " Madonna Rehabilitation Hospital, Subject Performance Improvement (PI) Program (2013)" noted under the section titled "PI Program Objectives" that "The purpose of the Madonna Performance Improvement Program was to provide leadership to and support for a collaborative system of continuous and positive change in (clinical) processes, structure and outcomes throughout Madonna. The PI Program facilitates all activities required for measuring, reporting, assessing and improving quality of care and service." The document also stated "The PI Steering Committee provides leadership, direction, consultation, and coordination to performance improvement efforts throughout the organization. The Committee sponsors all PI related committees and teams and sets the priorities for performance improvement activities."

D. A record review of the document titled "Madonna Rehabilitation Hospital Meeting Notes " , "PI Steering Committee" dated 12/2/13, revealed integrated data reporting for the first quarter of fiscal year 2014 for all of the Madonna Rehabilitation Hospital 'System' providers [the Madonna Rehabilitation Hospital, the LTACH, and the Skilled Nursing Facility].

Based on a review of the Medical Staff Bylaws Rules and Regulations, interview and meeting minutes, The Long Term Acute Care Hospital (LTACH) failed to establish a single, separate medical staff for the purpose of providing care to patients of the LTACH requiring complex medical services. The medical staff was fully integrated into other aspects of the Madonna Rehabilitation Hospital 'System'; therefore, the Condition of Medical Staff was not met. This finding places all patients at risk due to a lack of dedicated medical staff to meet their needs. The facility reported an active medical staff of 33 members. The facility census was 47 on 3/4/14 the day of entrance. The total sample size was 31.

Findings include:

A. The Medical Staff Bylaws Rules and Regulations page 3 revealed that the Madonna Rehabilitation Hospital 'System' provided in-house attending physician coverage for both the LTACH and the Madonna Rehabilitation Hospital as well as other Madonna Rehabilitation Hospital 'System' providers. In-house staff physicians or their designees, would evaluate all patients in these programs for determining rehabilitation potential and would assume medical responsibility, including admission and discharge responsibilities, ordering care and participation in the interdisciplinary team meetings.

B. A review of Medical Staff Meeting minutes for the time period - January 2013 through February 2014, confirmed that discussion of issues from both the Madonna Rehabilitation Hospital and LTACH were intermingled throughout the meeting minutes and there were no individual Medical Staff meeting minutes exclusively for the LTACH.

C. On 2/26/2014, at 9:00 AM, an interview conducted with the Chief Medical Officer, confirmed that one medical staff served both the Madonna Rehabilitation Hospital and the LTACH. The medical staff did not make a distinction between the two hospitals, and one set of written bylaws applied to both hospitals as well. In addition, this same interview, confirmed that during the reappointment process, physicians were reappointed simultaneously to both hospitals and that medical staff privileges granted to physicians, applied to both hospitals and were not exclusively for the LTACH.

Based on interviews with Nursing Administration and staff nurses, review of nursing schedules, and a review of the organizational chart, the Long Term Acute Care Hospital (LTACH) failed to have a separate and independent organizational nursing service department. The LTACH shared the Chief Nursing Officer (CNO) position as well as the operational definitions (OD's - facility policies and procedures) with the Madonna Rehabilitation Hospital. Nursing staff could be asked to work at any of the three Madonna Rehabilitation Hospital 'System' providers (the Madonna Rehabilitation Hospital, LTACH or the Skilled Nursing Facility including the Ventilator Assist Unit). The staffing of the LTACH was provided by a centralized staffing department that also provided staff for the Madonna Rehabilitation Hospital and the Skilled Nursing Facility including the Ventilator Assist Unit. The lack of a separate and independent organizational nursing service department in the LTACH led to a determination that the Condition of Participation: Nursing Services was not met. Failure to have a dedicated CNO to provide oversight and its own nursing staff places all patients receiving nursing services at risk of poor quality of care. See also A 386 and A 393 for additional information.

Findings are:

A. An interview with the CNO on 2/26/14 at 2:25 PM revealed that the CNO was the CNO for both the Madonna Rehabilitation Hospital and the LTACH.

B. A review of the undated Nursing Organizational Structure Chart received 2/26/14 from the Chief Nursing Officer (CNO), demonstrated the lack of independence of the LTACH from the Madonna Rehabilitation Hospital. The Chart revealed that the Director of the Madonna Rehabilitation Hospital and the Director of the Long Term Acute Care Hospital Nursing both report directly to the Vice President/CNO, who reports to the Executive Vice President/Chief Operations Officer (COO) who reports to the President /Chief Executive Officer (CEO).

C. An interview with the Director of the Nurse Staffing Department on 2/27/14 at 10 AM, revealed there was a centralized nurse staffing office that provided staff to all 3 providers of the Madonna Rehabilitation Hospital 'System' (the LTACH, the Madonna Rehabilitation Hospital and the Skilled Nursing Facility including the Ventilator Assist Unit). The staff members were provided either from the core group of staff hired for each specific hospital or by floating staff from other areas within the Madonna Rehabilitation Hospital 'System' (the LTACH, the Madonna Rehabilitation Hospital and the Skilled Nursing Facility including the Ventilator Assist Unit).

Based on staff interviews, review of Operational Definitions [OD's - facility policies and procedures], medical records, and observation of the Health Information Management [HIM] department staff and space, the Madonna Long Term Acute Care Hospital [LTACH] failed to have a separate and independent medical record service as evidenced by the sharing of employees, space, and medical record electronic and storage systems with the other providers of the Madonna Rehabilitation Hospital 'System'. The LTACH was not able to demonstrate the ability to have an independent department for medical record services, therefore, placing the Condition of Participation for Medical Record Services out of compliance. This had the potential to affect the medical records information needs of all patients of the Long Term Acute Care Hospital. Census on entrance was 47, Sample size was 31.

Findings are:

A. On 2/25/2014 at 1:50 PM, the Director of HIM [Health Information Management] was interviewed regarding the services provided by the HIM department. Interview revealed that the facility's medical record was a combination of an electronic system and paper documentation. The electronic system used is a 3M program. At that time, the paper part of the record was filed in the HIM Department files.
The HIM Director revealed that when a patient is admitted to the Madonna Rehabilitation Hospital 'System', the patient is assigned a medical record number [MRN] and an account number. The patient retains the MRN as long as they are a patient of the Madonna Rehabilitation Hospital 'System', no matter what provider type they are being treated at (The Madonna Rehabilitation Hospital, the LTACH or the Skilled Nursing Facility). A MRN is assigned in numeric order, no matter which provider is admitting the patient as they do not have separate MRN's for each of the provider types. The account number will change with each admission, but the MRN remains the same. The records of the Madonna Rehabilitation Hospital, the LTACH and the Skilled Nursing Facility [SNF] are all maintained in the HIM department, and are filed by the patient's MRN. The electronic system is the same for all of the providers and the user name and password system for access to the electronic system is not differentiated. The Madonna Rehabilitation Hospital and the LTACH share transcription services and department staff.

B. A tour of the department on 2/25/2014 was conducted. An interview with one of the staff during the tour, found that this particular staff primarily did input for the Madonna Rehabilitation Hospital, but also helped with the LTACH. Interview revealed that each staff liked doing certain parts of the record and so they each did that part of the record, no matter which provider type the record was for. They also covered for each other on days off. During the tour of the department there was a large central work space and it was noted that this space was utilized by all provider types to sort through records for copying, review, etc. Rolling shelves were observed and interview with the HIM director during the tour revealed that records were filed by MRN and therefore intermixed for all of the Madonna Rehabilitation Hospital 'System' providers. The HIM Director revealed that they keep records for 2 years on site, and then they are boxed up and moved to a secure off-site location through a contracted service. The records are intermixed in the boxes and are not differentiated by provider type.

C. Review of the OD's for the HIM department found they encompassed all of the Madonna Rehabilitation Hospital 'System' provider types and were not exclusive to the LTACH. This was verified by the HIM Director.

Based on staff interviews, reviews of Operational Definitions[OD's - facility policies and procedures]; review of department records and observation of the department, the Madonna Long Term Acute Care Hospital [LTACH] failed to have a separate and independent diagnostic radiologic service from the Madonna Rehabilitation Hospital 'System'. The Madonna LTACH was unable to demonstrate the ability to independently meet the radiologic needs of its patients placing the Condition of Participation for Radiologic Services out of compliance. This finding places all patients needing Radiology Services at risk of receiving inadequate service. The facility census on entrance was 47 and the sample size was 31.

Findings are:

A. An interview with the Supervisor of Radiology [RT Supervisor] was completed on 3/3/2014 at 10:00 AM. Also participating in the interview was the full time Radiology Technician [RT] A. The Supervisor revealed that they have 2 full time staff as well as 4 other RT's including the RT Supervisor. Interview revealed that the only radiology equipment they have to provide the radiology services is 1 portable x-ray machine and 1 CR Reader [a machine that the x-ray plate ir cartridge is slid into and scans the image into a computer for viewing and reading]. The Supervisor verified that radiology services are provided Monday through Friday from 8:00 AM to 5:00 PM, and on-call from 5:00 PM to 9:00 PM. After 9:00 PM, the physician giving the order decides if it can wait until the morning or if the patient needs to be taken to another facility for the x-ray. Madonna Rehabilitation Hospital 'System' did have a contract with a local imaging company to come and do ultrasounds, and venous Doppler's [tests that look at soft tissue using ultrasound and blood flow in blood vessels] . They also contracted with a local hospital to perform EKG's, cardiac echograms, venous Doppler's [tests for cardiac function], and sleep studies [tests for sleep and breathing problems that occur during sleep]. The contracted acute care hospital would also perform ultrasounds if the local imaging company could not complete the test when needed. They did have to schedule some tests to be done at the local hospital, but they would complete the prep for the test(s) at the LTACH.

B. The Supervisor revealed that all tests done' on site' are completed in the patient's room. When the order was received for a test, staff took the portable x-ray machine to the patient's room and completed the test. The radiology department office and storage space was physically located on the LTACH hospital area. The Supervisor said radiology staff do not differentiate between the "units". They cover the Madonna Rehabilitation Hospital, the LTACH, and all the Skilled Nursing Facility [SNF] units. They treat all of the Madonna 'System' providers the same, whoever needs their services will get them to the best of their ability and as timely as possible. The Supervisor said they are employed by the Madonna Rehabilitation Hospital 'System' and are not individually employed by the LTACH.
B. The Supervisor revealed that since images are now electronic they do not require storage space for them. Prior to becoming an electronic imaging system, the films were stored in the Health Information Management department, but are at the off-site storage facility now. The storage does not separate images by provider, but by medical record number [MRN]. The MRN is not distinct by provider; all reports are filed in the medical record of the patient.

C. The review of the OD's related to the radiology services found them labeled with 'Madonna Rehabilitation Hospital', but the Supervisor revealed that all of the providers in the 'system' including the Madonna Rehabilitation Hospital, the Madonna LTACH, and the SNF use the same label.

D. Review of one of the OD's for the radiology department revealed that the subject was "Scheduling External Procedure, Scope: Hospital and Long Term Care".

E. Review of a contract with the imaging company found the contract covered all of the providers that are inclusive of the Madonna Rehabilitation Hospital 'System' as noted and written: "A. Hospital located at 5401 South Street, Lincoln, Nebraska 68506-2134, licensed to provide medical care in its Acute Rehabilitation Hospital ("AR"), Long Term Care Hospital (" LTCH" ), Sub-Acute Medicare certified skilled nursing facility ("SAR "), and nursing home ("NH") units desires to contract with a provider of medical imaging services for the purpose of furnishing certain diagnostic imaging and other health care services to inpatients of Hospital .." The Madonna LTACH did not have a separate independent contract for these services exclusively for its patients.

D. The Supervisor provided the information that the Radiologist for department handles the entire radiology department for all of the Madonna Rehabilitation Hospital 'System' providers. The Radiologist was a member of the combined Medical Staff of the Madonna Rehabilitation Hospital 'System' and was not an employee of the Madonna LTACH.

Based on staff interview and a review of a selected sample of laboratory Operational Definitions (OD ' s- facility policies and procedures), the Long Term Acute Care Hospital (LTACH) failed to establish a distinct, separate laboratory department with separate OD's dedicated to the LTACH, therefore, the Condition of Participation: Laboratory Services was not met. This finding places all patients requiring Laboratory Services at risk. The facility reported a census of 47 on the first survey day, 3/4/2014. The sample size was 31.

Findings include:

A. On 3/4/2014, at 3:00 PM, an interview with the Laboratory Manager revealed that the laboratory served not only the LTACH, but also served the Madonna Rehabilitation Hospital, as well as the Ventilator Assisted Unit of the Skilled Nursing Facility.

B. A review of the OD for blood transfusion ,labeled "Madonna Rehabilitation Hospital ", Operational Definition, " Scope: Hospital and Long Term Care" revealed that if the lab was not open, you needed to call the LTACH Supervisor."

C. The written OD for the transfusion of blood products, labeled, "Madonna Rehabilitation Hospital Subject Transfusion of Blood Products", stated "For orders received after 15:00 on ARU (Acute Rehabilitation Hospital), LTACH (Long Term Acute Care Hospital)...the transfusion will be ordered for the following morning."

Based on a review of the contracted food service agreement and an interview with the Director of Food Services, the Long Term Acute Care Hospital (LTACH) failed to establish an agreement for a dedicated food service independent from the other providers of the Madonna Rehabilitation Hospital 'System', therefore, the Condition of Participation: Food and Dietetic Services was not met. This finding had the potential to place all patients receiving Food and Dietetic services at risk. The facility reported a census of 47 on the first survey day, 3/4/2014. the sample size was 31.

Findings include:

A. On 3/5/2014, at 10:30 AM an interview with the Registered Dietician, who served as the Director of Food and Nutritional Services for the LTACH, revealed that the food service was a contracted service that was integrated into all the areas of the Madonna Rehabilitation Hospital 'System'. The food service department did not distinguish between the Madonna Rehabilitation Hospital and LTACH, but rather the entire food service department was co-mingled with all the other providers of the Madonna Rehabilitation Hospital 'System'.

B. The contract with the food service management company, signed by the President and Chief Executive Officer dated, 2/25/2014, referred to the Madonna Rehabilitation Hospital as 'client'. The Director of Food and Nutritional Services confirmed the contract applied to the entire Madonna Rehabilitation 'System', which included the LTACH and the Madonna Rehabilitation Hospital, as well as, other providers on the same campus.

Based on staff interview, medical record review, and facility document review, the Madonna Long Term Acute Care Hospital [LTACH] failed to have a separate and independent Utilization Review Plan, and failed to have a Utilization Review Committee that met requirements resulting in the Condition of Participation not being met. The census on entrance was 47, and the sample size was 31. This finding had the potential to impact the covered length of stay/decision making for all patients needing or requiesting a Utilization Review of their hospital stay.
Findings are:
A. An interview was completed on 2/26/2014 at 1:15 PM with the Case Manager Director [Manager] who was identified as the person responsible for the Utilization Review [UR] process for the facility. The Manager revealed the facility does its own UR. She also revealed she manages the UR process for both the Madonna Rehabilitation Hospital and the LTACH. The supervisor described the UR committee as being the interdisciplinary team that assesses and plans the care for each patient. She identified that the outliers are not based on length of stay [LOS] but on costs. She provided a paper with columns that were titled patient ' s name, type of coverage, LOS, CMG/DRG [Diagnosis codes], Medicare Exhaust Date, Count Down, Medicare Standard Reimbursement, Cumulate Costs, Daily Reimbursement, Average Daily Cost, etc. The Case Management staff and Social Work staff watch this for patients that are reaching the maximum benefits they are allowed. This is how the facility determines their outliers since patients' LOS is longer in this facility type. Patients are discussed by the interdisciplinary team on a weekly basis to evaluate their progress towards goals, make changes to the plan of care as needed, and look at the appropriateness of the discharge plans related to predetermined discharge criteria. The Manager confirmed the facility does not discharge patients that have reached their cost limits as long as the medical necessity for the level of care they are receiving continues.
B. Review of their UR Operational Definition [OD's - facility policies and procedures] began with " SUBJECT: UTILIZATION REVIEW OF MEDICARE PATIENTS ON HOSPITAL UNITS (1715) SCOPE: Acute Rehabilitation Hospital and Long Term Acute Care Hospital ." The OD identified the interdisciplinary team as responsible for the UR process. It directed that if a patient was reaching their cost limits or becoming a high cost outlier, the Manager was to be notified. If there were questions regarding continued medical necessity, the Manager would request the Vice President of Medical Affairs to review the patient ' s record. The facility was not able to demonstrate it had a UR Committee that independently met the needs of the LTACH patients, independent of the other Madonna Rehabilitation Hospital 'System' provider types.

Based on interviews, record reviews, and observations, the facility failed to:
1) independently provide for the equipment, maintenance and repair needs of the Long Term Acute Care Hospital [LTACH]. General maintenance is performed by the Madonna Rehabilitation Hospital 'System' for both the Madonna Rehabilitation Hospital and the LTACH. The contract for Biomed 360 to provide for the biomedical services is with Madonna Rehabilitation Hospital 'System' and is not an independent agreement with the LTACH. The LTACH was unable to independently ensure the facility and clinical equipment was maintained to ensure the safety of all patients. This lack of a dedicated maintenance program to the facility has the potential to affect the repair and maintenance needs of any patients requiring the use of equipment, and any patients who receive care and services in the facility.

These findings result in the Condition of Participation: Physical Environment is not met. The facility has 87 certified beds. The census was 60 on entrance 2/24/24. The total sample size was 39. See also A0709, A0714 and A0722.
Findings are:
A. Record Review of the document titled "Biomed360 Agreement" also identified as "Agreement # [name of company] -2321" was signed by the President and Chief Executive Officer for Madonna Health 'System' on 8/3/11. The document states the contract is in effect for 3 years. Services provided include electrical safety, preventative maintenance, repairs, and management services to "assist Customer with the management of its equipment maintenance program." An administrative interview with the Director of the LTACH on 3/5/14 at 1:30 PM confirmed the Biomed 360 contract agreement is for the Madonna Rehabilitation Hospital 'System' and includes both the LTACH and Madonna Rehabilitation Hospital. The Director revealed that the maintenance services provided were provided for the Madonna Rehabilitation Hospital 'System' and not specifically for the Madonna Rehabilitation Hospital.

Based on staff interview, meeting minutes and a review of infection surveillance data, the facility failed to establish an active, dedicated infection control program specifically designed for the Long Term Acute Care Hospital (LTACH), therefore, the Condition of Participation: Infection Control was not met. This finding resulted in placing all patients of the Long Term Acute Care Hospital at risk for potential infection. The facility reported a census of 47 on the first survey day, 3/4/2014. The sample size was 31.

Findings include:

A. On 3/5/2014 at 11:00 AM an interview conducted with the Infection Prevention Coordinator, revealed infection surveillance that included, 'the whole house', referring to the Madonna Rehabilitation Hospital, Long Term Acute Care Hospital and Skilled Nursing Facility. Interview further revealed that staff time spent in each area was not split out by provider, but was fully merged into the overall budget for the department.

B. A review of meeting minutes including the health care acquired infections reported for the time period October, 2012 through December 2013, confirmed the reports co-mingled infection data between the Madonna Rehabilitation Hospital and the LTACH, as well as data from the Ventilator Assisted Unit of a Skilled Nursing Facility. All reports included a summary report labeled, "Facility HAI"(Healthcare Associated Infections), which further demonstrated co-mingling patient data from both the Madonna Rehabilitation Hospital and the LTACH.

Based on staff interview and review of operational definitions (OD 's - facility policy and procedures), the Madonna Long Term Acute Care Hospital [LTACH] failed to have an independent discharge planning service to meet the needs of it's patients exclusive from the Madonna Rehabilitation Hospital 'System'. A Case Manager Supervisor oversees both the Madonna Rehabilitation Hospital and the LTACH discharge planners. The discharge planning OD's are at the Madonna Rehabilitation Hospital 'System' level. The lack of an independent discharge planning department in the LTACH led to the determination that the Condition of Participation: Discharge Planning was not met. This finding had the potential to place all patients needing Discharge Planning services at risk for readmission and/or poor outcomes after discharge. The facility census was 47 on entrance on 3/4/14, sample size was 31.
Findings include:
A. An interview with the Case Manager Supervisor on 3/5/14, at 8:45 AM revealed that [gender] reported to the CNO (Chief Nursing Officer) of the Madonna Rehabilitation Hospital 'System' and this position supervised both the Madonna Rehabilitation Hospital and the LTACH discharge planners.
B. Review of the OD effective date (4/10/09) titled Madonna Rehabilitation Hospital ...Admission, Continued Stay and Discharge Criteria for the Short Term Inpatient Rehabilitation Programs with scope defined as Acute Rehabilitation, Subacute Rehabilitation, and Long Term Acute Care (LTACH), contained the following Scope of Care Statement: "The short term inpatient rehabilitation program exists to provide medical and rehabilitation services to children (0-18) and young adults with physical disabilities. An integrated care continuum, consisting of three short term inpatient rehabilitation levels of care, has been established so that services are tailored to the individual needs of those served. These include: Acute, LTACH [Long Term Acute Care Hospital], and Subacute Rehabilitation Programs. An interdisciplinary team approach which includes the patient and their families/significant others, provide a culturally diverse framework for service delivery. Inpatient rehabilitation programming is needed for individuals who not require services of an acute care hospital yet need medical and/or rehabilitation services which cannot be met at home or on an outpatient basis."
C. An interview with the Case Manager Supervisor on 3/5/14, at 8:45 AM confirmed that the OD's related to discharge planning are "specific to the hospital side; they cover all of the Rehab [Madonna Rehabilitation Hospital], LTACH [Long Term Acute Hospital] and peds [pediatrics]".

Based on staff interview and review of the Nebraska Organ Recovery System (NORS) and Lions Eye Bank contracts, revealed they were for the Madonna Rehabilitation Hospital and the Long Term Acute Care Hospital (LTACH). The LTACH failed to maintain separate contracts, apart from the Madonna Rehabilitation Hospital with the Lions Eye Bank and Nebraska Organ Recovery System for organ, tissue and eye procurement. The lack of independent contracts for the LTACH led to a determination that the Condition of Participation: Organ, Tissue and Eye Procurement was not met. This finding potentially could cause the facility to fail to identify/allow potential organ donations in reponse to patient and/or family/responsible party wishes. See A886 for additional information.

Findings are:

A. An interview with RN (Registered Nurse)-C on 2/27/14, at 8:25 AM revealed, "Yes this is the contract with NORS and the Lions Eye Bank for the Madonna Hospitals (LTACH and Madonna Rehabilitation Hospital). "
B. A review of the Lions Eye Bank of Nebraska, Inc. Donor Institution Agreement and the NORS Agreement identified the agreements were with the Madonna Rehabilitation Hospital and the LTACH simultaneously.

Based on record review of rehabilitation services staffing (includes Physical Therapists (PT), Occupational Therapists (OT), and Speech Therapists (ST) and Recreation Therapists (RT), interview with Administrative staff for Rehabilitation Services, and observation of patient treatment areas providing service to LTACH patients, the facility failed to have its own independent staff and treatment areas. The Madonna Rehabilitation 'System' main gym with specialized equipment and therapy pool are used by all patients within the Madonna Rehabilitation 'System' including the LTACH. The Madonna LTACH was unable to independently meet the Condition of Participation for Rehabilitation Services. This places all Long Term Acute Care Hospital patients at risk while receiving rehabilitation services. The LTACH has 96 certified beds. The census was 47 on the day of entrance. The total sample size was 31.
Findings are:
A. Interview on 2/27/14 at 10:30 AM with the Vice President of Rehabilitation revealed the Inpatient side of the Organizational Chart for Rehabilitation Services applied to all of the Madonna Rehabilitation Hospital 'System' levels/providers of care. The Vice President stated the Main central gym is used by Madonna Rehabilitation Hospital, the LTACH, and the Skilled Nursing Facility (SNF) patients. The Vice President confirmed inpatient staffing for PT, OT, ST and RT include all provider types for the Madonna Rehabilitation Hospital 'System'. Staff is floated "as necessary."
B. Staff interview with the Director of Inpatient Therapies for the Madonna Rehabilitation Hospital 'System' (includes PT, OT, RT) on 3/3/14 at 11:00 AM confirmed that staff float between the LTACH, the Madonna Rehabilitation Hospital and the SNF and may cover any area. The Director further confirmed the Therapy Pool can be used by any patient in the Madonna Rehabilitation Hospital 'System'. All provider types have access anytime the equipment is available.
C. An interview with the Director of Speech Therapy for the Madonna Rehabilitation Hospital 'System' on 3/3/14 at 11:45 AM revealed that 3 staff are assigned to the LTACH, but also "help cover the Rehab [Madonna Rehabilitation Hospital] as needed. 11 staff are assigned to the Madonna Rehabilitation Hospital but "also float to other provider types." The Director stated FEES (Fiberoptic Endoscopic Evaluation of Swallow) testing is done in the procedure room in LTACH or in the patient's room. FEES testing is done on all provider types using the procedure room on the LTACH.
D. Observations of the main central gym on 2/26/14 from 2:30 PM until 3:00 PM revealed the gym has specialized therapy equipment such as the Locomat Robotic gait training device, Body Weight Support device and Electrical Stimulator Bikes. The area also includes a partial car used for transfer training.
E. Interview with the Director of Inpatient Therapies on 3/6/14 at 10:30 AM revealed the use of the gym and therapy pool are coordinated through the scheduling process of Madonna Rehabilitation Hospital 'System'. All equipment is owned and maintained by the Madonna Rehabilitation Hospital 'System'.

Based on staff interview, review of daily assignment sheets, review of operational definition [OD's - facility policy and procedures] and review of a Letter of Agreement, the Long Term Acute Care Hospital [LTACH] failed to provide independent respiratory services for its patients. A review of staffing schedules (dated 2/19/14-3/7/14) and interview with the Respiratory Manager confirmed that respiratory services are provided at the Madonna Rehabiltation Hospital 'System' level as are respiratory operational definitions, equipment and staff. The Madonna Rehabilitation 'System' also contracted the Director of Respiratory Services and equipment maintenance, but these services are not contracted independently to provide exclusive services to the LTACH. Respiratory staff was assigned to work throughout the Madonna Rehabilitation Hospital 'System', including the LTACH and the Ventilator Assist Unit (part of the Skilled Nursing Facility). The LTACH respiratory department was unable to demonstrate that it could independently provide for the respiratory needs of its patients, leading to the determination that the Condition of Participation: Respiratory Services was not met. This finding had the potential to affect all Long Term Acute Care Hospital patients receiving Respiratory Services at risk for poor quality of care and service regarding their respiratory needs. The facility census was 47 on entrance 3/4/14.
See A-1152
See A-1153
For additional information.

Based on a review of the Madonna Medical Staff Bylaws Rules and Regulations (Bylaws), a review of documentation in 9 out of 9 physicians' reappointment files [Physicians 1, 2, 3, 4, 5, 6, 7, 8 and 9), and interviews, the governing body failed to enforce the bylaws during the medical staff reappointment process. The facility reported 33 active medical staff. This finding places all patients at risk of receiving poor quality medical care services. The facility reported an acute patient census of 47 on the first survey day, 3/4/2014 and the total sample size was 31. The facility reported 33 active medical staff.

Findings include:

A. The Medical Staff Bylaws, Rules and Regulations, Credentialing Policy, Article IV, Section 2, revealed that Requests for Clinical Privileges would be considered and approved based on the following: information resulting from ongoing professional evaluation, performance improvement and other peer review activities... and Practitioner-specific data as compared to aggregate data.

B. The Medical Staff Bylaws, Rules and Regulations, Credentialing Policy, Article V Reappointment Process, Section 2, revealed that Peer evaluations and timely and accurate completion of medical records would be evaluated as part of the reappointment process.

C. A review of the credential files of 9 active medical staff, who were reappointed within the past two years, revealed that 9 of 9 lacked evidence of peer review evaluations, performance improvement measures, practitioner specific data compared to the aggregate date and/or medical record completion, as specified in the bylaws (Physicians 1, 2, 3, 4, 5, 6, 7, 8 and 9).

D. On 2/26/2014 at 9:00 AM an interview with the Chief Medical Officer further confirmed peer review data, performance improvement information and medical record completion results were not used at the time of reappointment, to evaluate physician performance, as specified in the bylaws.

Based on a review of the Madonna Medical Staff Bylaws Rules and Regulations (bylaws), physician credentialing and reappointment files and staff interview, the medical staff failed to follow the bylaws for a physician who requested an expansion of privileges. This finding places all patients receiving lumbar punctures by Physician 3 at potential risk. The facility reported an acute patient census of 47 on the first survey day, 3/4/2014 and the total sample size was 31. The facility reported 33 active medical staff members.

Findings include:

A. Medical Staff Bylaws Rules and Regulations, Credentialing Policy, Article IV Section 1 Clinical Privilege, stated, "Each individual who has been appointed to the Medical Staff shall perform only those clinical privileges granted by the governing body. The individual must demonstrate his or her background, experience, training, current competence, knowledge, judgment, and ability to perform all privileges requested."

B. Physician 3 requested an expansion of privileges to include lumbar puncture (a procedure where a long needle is inserted between the bones of the spine to extract fluid for testing and diagnosis of various conditions). A review of Physician 3's file revealed a lack of any evidence of prior performance of lumbar punctures at other hospitals, nor was there any documentation regarding the physician's proficiency at performing the procedure, including negative (if any) patient outcomes.

C. On 2/26/2014, at 9:00 AM, an interview conducted with the Chief Medical Officer, confirmed that the decision to grant Physician 3 privileges to perform lumbar punctures was based solely on the physicians' residency program and board certification, rather than determining the physician's current clinical competence, as specified in the bylaws.

Based on interview, and a review of the facility-provided organizational chart, the governing body failed to appoint a Chief Executive Officer who was responsible exclusively for the management of the Long Term Care Hospital (LTACH). The lack of an individual dedicated to facility oversight had the potential to affect the quality of care for all of the patients of the Long Term Acute Care Hospital. The facility census was 47 on entrance 3/4/14. The sample size was 31.

Findings include:

A. An interview with the Chairman of the governing body on 2/26/2014, at 10:30 AM revealed that the Madonna Rehabilitation Hospital 'System' had one Chief Executive Officer (CEO), who was responsible for both the Madonna Rehabilitation Hospital and the LTACH.

B. A review of the current organizational chart revealed the lines of authority for both the Madonna Rehabilitation Hospital and the LTACH were drawn directly under the responsibility of the same individual, further confirming that the CEO was responsible for both Madonna Rehabilitation Hospital and the LTACH. The term ' hospital ' on the chart referred to both entities.

Based on interview and a review of the 2014 budget, the Long Term Acute Care Hospital (LTACH) failed to prepare and establish an overall institutional budget that was independent of the Madonna Rehabilitation Hospital 'System' budget and exclusive to the LTACH. Lack of an individualized independent budget has the potential of failing to provide the resources and equipment necessary to ensure quality of care and services for all patients of the Long Term Acute Care Facility. The facility had 96 certified beds. The facility census was 47 on entrance 3/4/14. The sample size was 31.

Findings include:

A. An interview on 3/4/2014 at 3:30 PM to 5:00 PM, with the accounting manager revealed that all sources of income from both the Madonna Rehabilitation Hospital and the LTACH were merged together in the budget. The profits from all sources were invested back into the entity that demonstrated the greatest need.

B. A review of the annualized budget labeled, "Summary Financial's Five Year Overview", revealed following the last set of columns at the bottom of the page was labeled, "Hospital Totals ARU (Acute Rehabilitation Hospital), ARX (pediatric unit of the rehabilitation hospital), & LTACH (Long Term Acute Care Hospital)". These columns summarized from both the Acute Rehabilitation Hospital & the Long Term Acute Care Hospital, "total patient days, discharges, gross charges, direct costs, indirect costs, and operating income". This confirmed that funds from the overall institutional budget of LTACH were merged with the Madonna Rehabilitation Hospital rather than kept separate.

Based on a review of a selected sample of contracts and staff interviews, the governing body failed to establish or maintain contracts that were independent of the Madonna Rehabilitation Hospital 'System' and exclusive to the Long Term Care Hospital (LTACH). This had the potential to affect all patients of the Madonna Rehabilitation Hospital receiving contracted services. The facility had 96 certified beds. The facility census was 47 on entrance 3/4/14. The sample size was 31.

Findings include:

A. A review of contracts for the provision of services for dietary management, organ procurement, biomedical equipment maintenance, additional laboratory services and one physician, all referenced Madonna as the 'hospital', 'corporation' or 'client' and did not individually reference LTACH.

B. An interview with the Chairman of the governing body on 2/26/2014, at 10:30 AM confirmed that all contracts had been developed with the understanding that both the Madonna Rehabilitation Hospital and LTACH were included.

Based on record review of Patient Right information provided to patients on admission and staff interview, the facility failed to ensure the Long Term Acute Care Hospital (LTACH) had its own independent Patient Right information. The facility used a Madonna Rehabilitation Hospital 'System' Patient Right guide/handbook which included information for the all of the providers in the Madonna Rehabilitation 'System' [the Madonna Rehabilitation Hospital, LTACH, and the Skilled Nursing Facility]. This has the potential to affect all patients in the 96 certified beds of the facility. The facility census was 47 and the sample size was 31.

Findings Are:

A. A staff interview with the Director of Quality and Risk Management for Madonna Rehabilitation Hospital 'System' on 3/4/14 at 3:30 PM, revealed that all Patient Rights information provided to patients on admission are not hospital specific but are system wide and include both the Madonna Rehabilitation Hospital and the LTACH.

B. A review of the current "Patient Information & Visitor Guide Winter 2014, Madonna Rehabilitation Hospital" that was provided to patients on admission, included Patient Rights information. The guide/handbook is written as 1 book for all provider types. Under the section titled "Levels of Care" on page 9 the information is provided for "Acute Rehabilitation (AR), Transitional Care Unit (TCU), Long Term Acute Care (LTACH), Rehabilitation Day Program, and Therapy Plus Outpatient Services."

Based on record review and staff interview the Madonna Long Term Care Hospital [LTACH] failed to independently provide patient rights information to its patients on admission. This had the potential to affect all patients in the facility 96 certified beds. The facility census was 47 on entrance and sample size was 31.

Findings are:

A. A review of the current " Patient Information & Visitor Guide Winter 2014, Madonna Rehabilitation Hospital" provided to patients on admission included Patient Rights information. The guide/handbook is written as 1 book for all of the Madonna Rehabilitation Hospital 'System' provider types. Under the section titled "Levels of Care" on page 9 the information is provided for "Acute Rehabilitation (AR), Transitional Care Unit (TCU), Long Term Acute Care (LTACH), Rehabilitation Day Program, and Therapy plus Outpatient Services."

B. A staff interview with the Director of Quality and Risk Management for the Madonna Rehabilitation Hospital 'System' on 3/4/14 at 3:30 PM, revealed that all Patient Rights information provided to patients on admission were not specific to the LTACH, but were Madonna Rehabilitation Hospital 'System' wide and included both the Madonna Rehabilitation Hospital and the LTACH.

Based on record review of Patient Right information provided to patients regarding grievances on admission, review of the Operational Directives [OD's - facility policies and procedures] related to grievances, and staff interview, the Long Term Acute Care Hospital (LTACH) failed to independently inform patients of their grievance rights and failed to have an independent process for resolution of grievances. This has the potential to affect all patients who have potential grievances or concerns about their care. The facility census was 47 and the sample size was 31.

Findings are:

A. A staff interview with the Director of Quality and Risk Management for Madonna Rehabilitation Hospital 'System' on 3/4/14 at 3:30 PM, revealed that all Patient Rights information provided to patients on admission are not specific to the LTACH, but are system wide and include both the Madonna Rehabilitation Hospital and the LTACH.

B. A review of the current "Patient Information & Visitor Guide Winter 2014, Madonna Rehabilitation Hospital" provided to patients on admission, included Patient Rights information. The guide/handbook is written as 1 book for all the Madonna Rehabilitation Hospital 'System' provider types. Under the section titled " Levels of Care" on page 9, the information is provided for "Acute Rehabilitation (AR), Transitional Care Unit (TCU), Long Term Acute Care (LTACH), Rehabilitation Day Program, and Therapy Plus Outpatient Services." The guide/handbook informs patients they have the right to express concerns or complaints or to submit a grievance. Patients are requested to contact their nurse or case manager if they have a concern or complaint. If they cannot resolve it you "can ask a member of your care team to contact the Unit Manager or Quality Management." Patients are informed they will get an initial response within 24 hours and a written resolution generally within seven days.

C. A record review of the document titled "Madonna Rehabilitation Hospital Operational Definition, Subject: Grievance Resolution (1155)" revealed under the section titled Scope that the Operational Definition applied to "Business(s) with "X" in the box in front of their name. This included Hospital, Long Term Care, Therapy Plus and ProActive. Under the section titled "Units", the Operational Directive had an "X" in front of "AR [Acute Rehabilitation - a term also used to identify the Madonna Rehabilitation Hospital], AVCRH [Alexis Verzal Children's Rehabilitation Hospital which is the pediatric unit of the Madonna Rehabilitation Hospital], LTACH [Long Term Acute Care Hospital], TCU [Transitional Care Unit, part of the Skilled Nursing Facility (SNF), ECN [Extended Care part of the SNF), and Vent/Special Needs [part of the SNF]." The grievance process per the OD has been that the responsibility for oversight of the grievance resolution process was "delegated to the Director of Quality and Risk Management". A review of the "Madonna Rehabilitation Corporate Structure Programs & Functions" provided by administration on 2/25/14, revealed that Quality/Risk management was listed under Madonna Rehabilitation Hospital Support Services.

D. An interview on 3/5/14 at 2:15 PM with the Director of Quality and Risk Management for Madonna Rehabilitation Hospital 'System' confirmed that grievances are reviewed and processed by the Madonna Rehabilitation Hospital 'System' and not done independently by the the LTACH. The Director stated "you won't find anything separate for individual hospital provider types."

Based on record review, staff interview and review of Operational Definitions [OD's facility policies and procedures], the facility failed to ensure that 2 of 2 patients (Patient 6 and 7) who were physically restrained, had the restraint use included in the plan of care. This had the potential to affect patients in the LTACH who may require use of restraints. The facility census was 47 on 3/4/14 the day of entrance. The total sample size was 31.

Findings are:

A. Closed medical record review on 3/5/14 revealed Patient 6 was admitted on 2/17/14 for Respiratory Failure, post heart surgery. Review of Physician orders identified an order for bilateral hand mitts as a medical restraint on 2/18/14 at 9:18 AM for Patient 6. The order was discontinued on 2/20/14 at 8:35 AM. A record review of nursing documentation on 2/18/14 at 9:18 AM, identified that the purpose of the restraint was to "minimize risk for injury to self due to interference with treatment devices." The type of restraint implemented was documented as right and left mitts. Nursing staff also documented that the mitt restraints were discontinued on 2/20/14 at 8:35 AM. A review of Patient 6's Plan of Care [POC], found that the POC was initiated on 2/17/14 with the last update on 2/24/14. The patient was transferred to an Acute Care Hospital on 2/24/14 due to worsening Congestive Heart Failure. The POC failed to identify use of the mitt restraints for this patient.

B. A staff interview with Registered Nurse (RN) F 3/5/14 at 12:35 PM, confirmed there was "no care plan for restraint" for Patient 6.

C. Closed medical record review for Patient 7 on 3/5/14, revealed that Patient 7 was admitted on 10/5/14 with a tracheostomy after a motor vehicle accident with traumatic brain injury. The patient discharged to the Madonna Acute Rehabilitation Hospital on 10/18/13. Review of physician orders revealed that a right mitt restraint was ordered on 10/12/13 at 10:21 PM to minimize risk for injury to self due to "agitation, interference with treatment devices, impaired judgement, impulsive behaviors." Record review of Nursing Assessment documentation 10/12/13 at 10:30 PM, verified implementation of the Right hand mitt restraint to prevent "pulling at lines and tubes". The Nursing Assessment documentation on 10/13/13 at 8:10 AM noted continued use of the Right hand mitt restraint. The restraint was discontinued on 10/13/13 at 3:33 PM per physician order. Record review failed to identify the restraint use on Patient 7's POC.

D. Staff interview with RN F on 3/5/14 at 12:35 PM, confirmed the POC did not include the use of the restraint mitt device.

E. Record review of the facility OD titled " Madonna Rehabilitation Hospital Restraints and Seclusion (1819)" identified that the policy applied to both the Long Term Acute Care Hospital [LTACH] and the Madonna Rehabilitation Hospital as well as the Long Term Care [Skilled Nursing Facility]. The OD revealed that the policy "provides guidance for the appropriate use of restraint." Under section 5, titled "Modify Plan of Care," the policy stated "The use of restraint must be in accordance with a written modification of the patient's plan of care." The policy further stated that the plan of care was to be updated "as soon as possible but within 24 hours after initiation of restraint."

Based on staff interview and record review of restraint Operational Definitions [OD's - facility policies and procedures], the Long Term Acute Care Hospital (LTACH) failed to have its own independent policies and procedures to ensure safe and appropriate use of restraints for their patients. All of the OD's reviewed were Madonna Rehabilitation Hospital 'System' policies and were not exclusive to the LTACH. This had the potential to affect all patients of the LTACH who may require use of restraints. The facility has 96 certified beds. The census was 47 on entrance and the sample size was 31.

Findings are:

A. A review of the facility OD document titled "Madonna Rehabilitation Hospital, Subject: Restraints and Seclusion (1819), Program Scope: Hospital, Long Term Care Programs' revealed that "This policy provides guidance for appropriate use of restraint. The term patient will be used to refer to all individuals who receive care at Madonna." The Madonna Rehabilitation Hospital 'System' included The Madonna Rehabilitation Hospital, the LTACH, and the Skilled Nursing Facility. The Madonna LTACH did not have an OD regarding restraints exclusively for their patients.

B. A staff interview on 3/4/14 at 3:30 PM, with the Quality Assurance/Risk Manager for the Madonna Rehabilitation Hospital 'System' confirmed that the Operational Definitions, also known as Policies and Procedures" were not hospital specific, are system wide."

Based on record review and staff interview, the Long Term Acute Care Hospital (LTACH) failed to have its own hospital Operational Definitions [OD's - facility policies and procedures], and records to ensure that physicians and other licensed independent practitioners (LIP) met the requirements for training regarding the use of restraints. This had the potential to affect all LTACH patients whose physician or LIP may order a restraint. The facility had 96 certified beds. The census was 47 on entrance and the sample size was 31.

Findings are:

A. A review of facility OD titled "Madonna Rehabilitation Hospital, Subject: Restraints and Seclusion (1819), Program Scope: Hospital, Long Term Care Programs" revealed that "this policy provides guidance for appropriate use of restraint. The term patient will be used to refer to all individuals who receive care at Madonna." The Madonna Rehabilitation Hospital 'System' included the Madonna Rehabilitation Hospital, the LTACH and the Skilled Nursing Facility. The LTACH did not have OD's for restraints that were independent from Madonna Rehabilitation Hospital 'System' providers. The policy stated under the title "Employee Education and Training" and stated that "Physician Training (Hospital Units Only) - Only physician and licensed independent practitioners employed by Madonna and physicians contracted by Madonna to provide in-house attending physician services at Madonna, shall be authorized to order restraints for inpatients in the hospital licensed units of Madonna." The policy further states that "Education on Madonna's restraint policies will be provided" and that "status reports on attending physicians that have completed restraint education/training will be provided to the corporate compliance committee (A Madonna Rehabilitation Hospital 'System' committee) on an annual basis. Training and compliance will be coordinated by the Credentialing/Contract Review Specialist (A Madonna Rehabilitation Hospital System employee)." The facility medical staff is fully integrated into the Madonna Rehabilitation Hospital 'System' and there is no separate medical staff for the LTACH.

B. An interview with the Chief Medical Officer on 2/26/14 at 9:00 AM confirmed that there is one medical staff who served both the Madonna Rehabilitation Hospital and the LTACH.

Based on record review and staff interview, the Long Term Acute Care Hospital (LTACH) failed to have its own hospital policy and records to ensure physicians and other licensed independent practitioners (LIP) met the requirements for training regarding the use of restraints. This had the potential to affect all LTACH patients whose physician or LIP may order a restraint. The facility had 96 certified beds. The census was 47 on entrance and the total sample size was 31.

Findings are:

A. A review of facility the Operational Definition [OD's - facility policies and procedures] titled "Madonna Rehabilitation Hospital, Subject: Restraints and Seclusion (1819), Program Scope: Hospital, Long Term Care Programs" revealed that "this policy provides guidance for appropriate use of restraint. The term patient will be used to refer to all individuals who receive care at Madonna." The Madonna Rehabilitation Hospital 'System' included the Madonna Rehabilitation Hospital, the LTACH and the Skilled Nursing Facility. The LTACH did not have OD's for restraints that were independent from Madonna Rehabilitation Hospital 'System' providers. The policy stated under the title "Employee Education and Training" and stated that "Physician Training (Hospital Units Only) - Only physician and licensed independent practitioners employed by Madonna and physicians contracted by Madonna to provide in-house attending physician services at Madonna, shall be authorized to order restraints for inpatients in the hospital licensed units of Madonna." The policy further states that "Education on Madonna's restraint policies will be provided" and that "status reports on attending physicians that have completed restraint education/training will be provided to the corporate compliance committee (A Madonna Rehabilitation Hospital 'System' committee) on an annual basis. Training and compliance will be coordinated by the Credentialing/Contract Review Specialist (A Madonna Rehabilitation Hospital 'System' employee)." The facility medical staff is fully integrated into the Madonna Rehabilitation Hospital 'System' and there is no separate medical staff for the LTACH.

B. An interview with the Chief Medical Officer on 2/26/14 at 9:00 AM confirmed that there is one medical staff who served both the Madonna Rehabilitation Hospital and the LTACH.

Based on staff interview, review of random nursing Operational Definitions [OD's - facility policies and procedures] and review of the Nursing Organizational Structure Chart, the Long Term Acute Care Hospital (LTACH) failed to have an independent nursing service staff to provide care for the LTACH patients. This had the potential to place all patients at risk of receiving inadequate nursing services. The facility has 96 certified beds. The facility census was 47 on entrance 3/4/14. The sample size was 31.

Findings are:
A. Review of the Nursing Organizational Structure Chart received 2/26/14 from the Chief Nursing Officer(CNO), demonstrated the lack of separateness of the LTACH. The Chart revealed that the Director of the Madonna Rehabilitation Hospital Nursing and The Director of the Long Term Acute Care Hospital Nursing both report to the Vice President (VP)/ CNO, who reports to the Executive VP/Chief Operations Officer (COO) who reports to the President/Chief Executive Officer (CEO).

B. A interview with the CNO on 3/5/14 at 1:30 PM revealed, " I am the CNO for both the Madonna Rehabilitation Hospital and the LTACH."

C. An interview with the Director of Long Term Acute Care Hospital Nursing on 3/6/14 at 8:25 AM revealed, "I report to the CNO."

D. A random review of 4 Madonna Rehabilitation Hospital OD's showed the lack of separateness related to the LTACH nursing department:
(1) The OD for Clinical Orders (2279) revised 5/16/11, indicated that the scope included the Hospital (The Madonna Rehabilitation Hospital and the LTACH) and the Long Term Care (Skilled Nursing Facility) including the Ventilator Assist Unit.
(2) The OD for Medication Administration Policy (2090) revised 2/1/11, indicated that the scope included "All Programs" (The Madonna Rehabilitation Hospital and the LTACH) as well as the Long Term Care [Skilled Nursing Facility-SNF] including the VAU (Ventilator Assist Unit-part of the SNF). (3) The OD for Adverse Drug Reactions (1700) revised 12/14/12, indicated that the scope included the Hospital (The Madonna Rehabilitation Hospital and The Long Term Acute Care Hospital) and the Long Term Care (Skilled Nursing Facility) including the VAU (part of the SNF). (4) The OD for Incident Reporting - Patients, Volunteers, Visitors, Proactive member (695) revised 9/13/13, indicated that the scope included "All Employees, All Businesses (The Madonna Rehabilitation Hospital, LTACH) and the Long Term Care (Skilled Nursing Facility) and Support Areas."
E. An interview with the Therapy Director on 3/3/14 at 2:50 PM verified, "When the OD's or legal papers are headed with Madonna Rehabilitation Hospital, that means it is the Madonna Rehabilitation Hospital Corporate 'System' and includes the 3 facilities (The LTACH, the Madonna Rehabilitation Hospital and the Skilled Nursing Facility). The scope may differentiate the businesses, if it says Hospital that means both LTACH and the Madonna Rehabilitation Hospital, if it says Long Term Care that means the SNF (Skilled Nursing Facility) including the VAU (part of the SNF) at Madonna.

Based on staff interview and review of the nursing staff schedule, the Long Term Acute Care Hospital (LTACH) failed to have an independent staffing department to provide nursing care exclusively for the LTACH patients. This finding placed all patients of the Long Term Acute Care Hospital at risk of receiving inadequate nursing care. The facility has 96 certified beds. The facility census was 47 on entrance 3/4/14. The sample size was 31.

Findings are:

A. An interview with the Chief Nursing Officer (CNO) on 3/5/14 at 1:30 PM, revealed:
- The staffing office is on the lower level of one of the 'campus buildings' and is open until 5 or 6 PM. They provide staff for all three areas of the Madonna Rehabilitation Hospital 'System' (The Madonna Rehabilitation Hospital, LTACH and Long Term Care (Skilled Nursing Facility-SNF) including the VAU (Ventilator Assist Unit-part of the SNF). After they close for the day, the Madonna Rehabilitation Hospital supervisor takes the staff calls for all 3 areas (The Madonna Rehabilitation Hospital, LTACH and the Long Term Care (Skilled Nursing Facility) including the VAU (part of the SNF).
- The LTACH staff does float [When a staff member is taken from their assigned area and sent to another area to work.]. They can be pulled [Taken off their assigned area and reassigned.] to float anywhere in the building (The Madonna Rehabilitation Hospital and the Skilled Nursing Facility including the VAU-part of the SNF).
- The nurses may or may not know when they arrive to work that they will be floated. They do code their time to the appropriate area if they do float.
- The LTACH MEDICAL ASSIST/CODE TEAM [A team that responds to medical emergencies or a code [Code is a cardiac or respiratory arrest incident] consisted of Respiratory Therapist's, 2 or 3 of the LTACH Nurses and a physician is in the house at the time of the occurrence. The LTACH MEDICAL ASSIST/CODE Team Nurses were assigned to respond because they have the Advanced Cardiovascular Life Support [ACLS] training. If the MEDICAL ASSIST/CODE occurred on the pediatric rehabilitation hospital [PEDS] a Pediatric Advanced Life Support [PALS] trained nurse was also responsible to respond.

B. An interview with the Director of LTACH Nursing on 3/6/14 at 8:25 AM revealed:
- The staffing office is in the lower level of the main building by Human Resources (HR) and they staff all of the nursing areas for the providers of the Madonna Rehabilitation Hospital 'System' [LTACH, the Madonna Rehabilitation Hospital, Children's (PEDS-Pediatric Rehabilitation Unit), the Skilled Nursing Facility including the Ventilator Assist Unit].
- The nurses do float to all the areas if needed. They report to work and then if floated they would code their timesheet differently.
- If a Code occurred the LTACH MEDICAL ASSIST/CODE Team [Which are 2-3 nurses from LTACH, RT and maybe a doctor] responds. The LTACH MEDICAL ASSIST/CODE Team responds anywhere in the building including the Madonna Rehabilitation Hospital, the LTACH and the Skilled Nursing Facility including the VAU (part of the SNF). The assignment sheet identifies which nurses are on the MEDICAL ASSIST/CODE Team per day. There was always 1-2 Nurse Therapists and 1 other Nurse, always 3 nurses are assigned.
C. An interview with the Director of Nurse Staffing on 3/5/14 at 10:45 AM revealed:
- "I am the director of the centralized nurse staffing office. We recruit and hire for the facility for all 3 care segments (LTACH, the Madonna Rehabilitation Hospital and the Skilled Nursing Facility including the VAU-part of the SNF). We also help with staff development and education." The Director of LTACH Nursing sets up the staffing grid and pattern needed for the LTACH and provides that to our staffing department. The staffing department then provides the right type of staff based on the grid and staffing pattern. The Director of the LTACH Nursing assesses the patient acuity and lets scheduling know if extra staff are needed for a specific time period. There is a core group of staff hired for the Madonna Rehabilitation Hospital and a core group hired for LTACH and the Skilled Nursing Facility/Ventilator assist area. The nursing staff does float if there is the need to cover a call in and if there is an overage on another area. We (the staffing department) try to use the Madonna Rehabilitation Hospital / PEDS staff first for the Madonna Rehabilitation Hospital before pulling from LTACH or Skilled Nursing Facility including the VAU -part of the SNF. If the PEDS unit is short we first check with Madonna Rehabilitation Hospital to see if someone can float to PEDS before pulling staff from another area.
D. A review of the 4 week schedule for LTACH beginning 2/1/14 through 2/28/14, provided by the Director of Nurse Staffing on 3/5/14, revealed that:
- RN's floated to assist staff in the LTACH on 19 occasions from the Skilled Nursing Ventilator Assist Unit; 6 times from the Madonna Rehabilitation Hospital; 5 times from the Support Staff (a group of staff that are scheduled daily and assigned anywhere in the 3 areas needed]; 19 times from the PRN (As needed) staff (a group that are staffed as needed and oriented to all units in the Madonna system.); and, 1 time from the Transitional Care Unit.
- NA's (Nurses Aides) floated to assist staff in the LTACH on 2 occasions from Skilled Nursing Facility Ventilator Assist Unit; 12 times from the Madonna Rehabilitation Hospital; 2 times from Support Staff; and 4 times from the PRN staff.

E. An interview with Registered Nurse (RN) D on 3/6/14 at 10:40 AM revealed, "I have worked here for 7 months. My home hospital is LTACH but I do float to the Madonna Rehabilitation Hospital occasionally."

F. An interview with RN E on 3/5/14 at 2:00 PM revealed, "I am a Hospital Support Staff Nurse. I am assigned when I come in to an area. I work in the Madonna Rehabilitation Hospital, PEDS, and the Skilled Nursing Facility including the Ventilator Assist Unit or here on LTACH. Where ever they need me. I work three 12 hour shifts per week."

Based on record review, interviews, and observation of the HIM [Health Information Management] Department, the Madonna Long Term Acute Care Hospital [LTACH] did not have a separate and independent medical record for each inpatient and outpatient receiving services from them, nor were the medical records for the LTACH retained independently of other provider types in the HIM Department. This had the potential to affect the medical records information needs of all patients of the Acute Long Term Care Hospital. The facility had 96 certified beds. The facility census was 47. The sample size was 31.

Findings are:

A. An interview with the Director of HIM was completed on 3/25/2014 at 1:50 PM. During the interview the Director confirmed that a patient is assigned a Medical Record Number [MRN] upon admission for the first time to either of the two hospital providers, the Madonna Rehabilitation Hospital or the LTACH. The patient will keep the same MRN no matter which provider they transfer to in the Madonna Rehabilitation Hospital 'System'. The records are distinguished only by different account numbers for each admission. All of the records with the same MRN are filed together in the storage area of the HIM department.

B. The HIM Department that manages all patient medical records is a single area in one building that shares space, computers and employees among all of the providers of the Madonna Rehabilitation Hospital system, which was confirmed by interview with the HIM Director. Transcription is completed jointly for both the Madonna Rehabilitation Hospital and the Long Term Acute Care Hospital through a contracted service. Observation of the record storage shelves found the records are filed by MRN that are not separated out by provider type. An interaction with an employee working in the department revealed that the staff work on the medical records no matter if they are for the Madonna Rehabilitation Hospital, the Long Term Acute Care Hospital or the Skilled Nursing Facility. Boxes stacked at the end of a large work counter were labeled for off-site storage. The Director stated the records of the Madonna Rehabilitation Hospital and the Madonna LTACH are mixed together in each box unless they are death records or pediatric records that must be kept longer.

C. Review of Operational Definitions [OD - facility policies and procedures] found that they applied to all of the providers that encompass the Madonna Rehabilitation Hospital 'System'.

D. An interview with the Director of Admissions and Admissions Assistant A on 3/27/2014, revealed that the department is responsible for completion of admissions to the Madonna Rehabilitation Hospital, the Long Term Acute Care Hospital, the Transitional Care Unit [the Skilled Nursing facility], the Ventilator Assist Unit [part of the Skilled Nursing Facility] and the Pediatric Unit [part of the Madonna Rehabilitation Hospital which serves patients under the age of 19]. They added that the Extended Care North facility [Nursing Home] did their own admissions, but that information was given to the admissions department for the entry into the electronic medical record system. The Director of Admissions revealed that an MRN is assigned by their medical record programing system (Affinity). The patient has the same MRN "forever" regardless of which provider type in the Madonna Rehabilitation Hospital 'System' they are moved to, admitted to, readmitted to, or transferred between. Admissions Assistant A revealed that as long as the patient moves within the Madonna Rehabilitation Hospital 'System', the MRN remains the same. The Director and Admissions Assistant A revealed that when a patient is first admitted to the Madonna Rehabilitation Hospital 'System', they sign one consent for treatment, and as long as the patient does not leave the facility system, the same consent is used, even though the patient moves from one provider type to the other within the system. However, if the patient goes home or is discharged to another outside provider, and is readmitted to the Madonna Rehabilitation Hospital or Madonna LTACH, a new consent will be obtained at that time.

Based on interviews, record reviews, and observation of the pharmacy department area, the Madonna Long Term Acute Care Hospital [LTACH] failed to have a separate and independent pharmacy service to meet the needs of its patients as evidenced by shared employees, shared space for medications, and shared Operational Definitions [ODs - facility policies and procedures]. The Madonna Rehabilitation Hospital Pharmacy Department is shared with the Long Term Acute Care Facility [LTACH] and the Skilled Nursing Facility [SNF] providers. The pharmacy was not able to demonstrate the ability to independently provide the services necessary to meet the needs of the patients of the LTACH, putting the Condition of Participation for Pharmacy Services out of compliance. This finding places all patients receiving Pharmacy Services at risk of inadequate services to meet their medication needs.

Findings are:

A. An interview was completed with the Director of the Pharmacy Department on 2/25/2014 at 11:00 AM. Also participating in the interview was the Clinical Coordinator of Pharmacy Services who worked with the pediatric services of Madonna Rehabilitation Hospital and with the LTACH. The Director revealed that there are 22 employees in the department, and confirmed that all of the pharmacy staff worked with all of the Madonna Rehabilitation Hospital 'System' providers including the Madonna Rehabilitation Hospital, the LTACH, and the Skilled Nursing Facility [Ventilator Assist Unit, Transitional Care Unit, and the Nursing Facility]. The pharmacy had 2 Clinical Coordinators, each with assigned areas, however, both Coordinators covered for each other and assisted each other when needed.

B. A review of the ODs for the Pharmacy, revealed they were for the Madonna Rehabilitation Hospital 'System' which included all of the co-located providers, was confirmed by interview with the Director of Pharmacy. The ODs did meet the pharmacy requirements and standards of practice for pharmacy services but were not exclusive to the LTACH.

C. The Madonna Rehabilitation Hospital 'System' did have a Pharmacy and Therapeutics [P & T] Committee that met on a quarterly basis. Review of the P & T Committee meeting minutes revealed that business topics were not separated by provider type. The Madonna Rehabilitation Hospital 'System' formulary is in an electronic system utilized for all of the system providers. The Director confirmed that the joint Medical Staff suggest and/or approve of the medications in the formulary system.

D. The Madonna Rehabilitation Hospital 'System' providers utilize the same electronic system for medication tracking called Sunrise, and an Omnicell [medication dispensing system] was interconnected and utilized for all of the system providers.

E. A tour of the pharmacy department on 2/25/2014 following the interview with the Director of Pharmacy found the department shelved the medications for the SNF separately in one area of the pharmacy; however, the medications for the Madonna Rehabilitation Hospital and the LTACH were all shelved together in a larger area of the pharmacy covering 3 walls. There was one Omnicell vault for scheduled drugs used for all of the Madonna Rehabilitation Hospital 'System'. The pharmacy department had one room containing the intravenous fluids [IV] and laminar hood for admixtures and compounding, which the Director confirmed was used by all of the Madonna Rehabilitation 'System' providers. There was a large center work table that was used to fill carts for each of the individual providers' Omnicells. Interview revealed that the department pharmacists review the orders and ensure they are correct and appropriate before being added to the Omnicell system for administration to the patient. The pharmacists reviewed the orders for all of the providers and were not separate for each of the system provider types.

Based on pharmacy staff interviews, and review of pharmacy staffing schedules, the Madonna Long Term Acute Care Hospital failed to demonstrate that they had an adequate number of pharmacy employees to meet the ongoing medication needs of patients that was independent from the Madonna Rehabilitation Hospital 'System'. This had the potential to place all patients of the Acute Long Term Care Hospital who needed medications at risk for inadequate Pharmacy services. The facility census on entrance was 47. The total sample size was 31 patients.

Findings are:

A. An interview was completed with the Director of the Pharmacy on 3/5/2014 at 10:00 AM. Also present at the interview was the Clinical Coordinator for the Pediatric Unit of the Madonna Rehabilitation Hospital and the Madonna Long Term Acute Care Hospital [LTACH]. In the interview the Director revealed they have a total of 22 employees in the department including 2 Clinical Coordinators. The Director also verified that all of the staff in the department performed tasks for all of the Madonna Rehabilitation 'System' providers, including the Skilled Nursing Facility [Transitional Care Unit and the Ventilator Assist Unit as well as the Extended Care Nursing Home].

B. Review of the staffing schedule confirmed that staff was not divided in any way to indicate they were assigned to complete tasks for the Madonna LTACH exclusively. The Clinical Coordinator for the Madonna LTACH also performed tasks for the Madonna Rehabilitation Hospital and covered for the other Clinical Coordinator on their days off. The Clinical Coordinator participating in the interview was responsible for the Madonna LTACH, but also covered the pediatric unit [part of the Madonna Rehabilitation Hospital] as well as other 'System' providers.

C. The Madonna LTACH was not able to demonstrate that it had adequate pharmacy staff to ensure it could independently provide pharmacy services to meet the needs of its patients.

Based on pharmacy staff interviews, and facility record review, the Madonna Long Term Acute Care Hospital [LTACH] failed to have a separate and independent formulary developed and approved by an independent medical staff as evidenced by the combined medical staff and the combined formulary that included both the Madonna Rehabilitation Hospital and the LTACH. This finding had the potential to place all patients requiring medications at risk. The census on entrance was 47. The patient sample size was 31.

Findings are:

A. A review of the meeting minutes for the Pharmacy and Therapeutics Committee [P & T] for the year 2013, found documentation regarding suggested changes to the formulary which were approved by the committee members, and forwarded to the medical staff. The documentation did not differentiate between the Madonna Rehabilitation Hospital 'System' providers [The Madonna Rehabilitation Hospital, the LTACH, and the Skilled Nursing Facility].

B. An interview with the Director of Pharmacy was completed on 2/25/2014 at 11:00 AM. During the interview, the Director stated that there was one formulary in place for both the Madonna Rehabilitation Hospital and the LTACH. Interview revealed that they review categories of medications at the P & T committee meetings, and make recommendations for adding or removing drugs from the formulary. This information is then provided to the medical staff [the Madonna Rehabilitation Hospital 'System' medical staff] for approval. The formulary was electronic and was able to be accessed by both the Madonna Rehabilitation Hospital and the LTACH. The LTACH was not able to demonstrate they had a separate and independent formulary to meet the needs of their patients.

Based on a staff interview and a review of the Laboratory Contract for Emergency Services, After Regular Laboratory Business Hours, the Long Term Acute Care Hospital (LTACH) failed to have a contract to provide laboratory services for its patients that was separate and distinct from the Madonna Rehabilitation Hospital. This had the potential to affect any of the Long Term Acute Care Hospital patients who might require emergency lab services. The facility had 96 certified beds. The facility census was 47 on entrance 3/4/14. The sample size was 31.

Findings include:

A. The contract for laboratory service with another hospital referred to the Madonna 'System' organization as 'laboratory department'.

B. On 3/4/2014 at 3:00 PM, an interview with the Laboratory Manager revealed that the contract applied to both the Madonna Rehabilitation Hospital and the LTACH.

Based on staff interview and facility record review the Madonna Long Term Acute Care Hospital [LTACH] failed to have a formal and independent Utilization Review [UR] Committee consisting of 2 or more physicians to carry out the UR functions of the hospital. This had the potential to impact the covered length of stay/decision making for all patients needing or requesting a Utilization Review of their hospital stay. The census on entrance was 47, and the sample size was 31.

Findings are:

A. The staff identified by the facility as responsible for the UR function was the Manager of Case Management [the Manager] for the Madonna Rehabilitation Hospital and the Madonna Long Term Acute Care Hospital [LTACH].

B. A Madonna Rehabilitation Hospital 'System' Operational Definition [OD's - facility policies and procedures] titled, UTILIZATION REVIEW OF MEDICARE PATIENTS ON HOSPITAL UNITS, SCOPE: Acute Rehabilitation Hospital and Long Term Acute Care Hospital revealed that Utilization Review (UR) is defined as activities designed to determine the appropriateness of a patient's admission, continued stay, and/or discharge, and/or efficient use of available resources. The OD identified 15 steps to complete the UR process. The OD did not identify a UR committee that required physicians and practitioners of any variety or number.

B. An interview with the Manager was completed on 2/26/2014 at 1:15 PM. The UR Committee consisted of the Interdisciplinary team for the patient which may include the attending physician(s) and other staff. The Manager further reported that when the Manager receives information that a patient is reaching high outlier cost status, the Medical Director [titled Vice President of Medical Affairs, a physician who is over the medical staff] will review the medical record and make a determination regarding the medical necessity of continued stay., however, the attending physician did have input into the decision.

C. The Manager stated the verification of UR function is contained in the plan of care for all patients. If the Manager felt that a case needed reviewed, the Manager would go to the Medical Director and request the Medical Executive Committee review the case. The facility would let the patient know that benefits would be ending and would work with the patient, patient's family, and the interdisciplinary team regarding discharge planning. The Manager would also see that the patient received a Letter of Non-Coverage. [Note the Medical Staff, Medical Director, and Medical Executive Committee are not exclusive employees of the Madonna Rehabilitation Hospital, they are employed by the Madonna Rehabilitation Hospital 'System'].

Based on record review of Maintenance Service Contract for the Madonna Rehabilitation Hospital 'System' and administrative staff interview the Madonna Long Term Acute Care Hospital (LTACH) was unable to independently maintain its facility and equipment. This finding placed the safety of all LTACH patients at risk. The facility has 96 certified beds. The census was 47 on entrance and the total sample size was 31.
Findings are:
A. A record Review of the document titled "Biomed 360 Agreement" also identified as "Agreement # [name of company] -2321 " was signed by the President and Chief Executive Officer for the Madonna Health 'System' on 8/3/11. The document stated the contract was in effect for 3 years. Services provided include electrical safety, preventative maintenance, repairs, and management services for to "assist Customer with the management of its equipment maintenance program."
B. An administrative interview with the Director of the LTACH on 3/5/14 at 1:30 PM confirmed the Biomed 360 contract agreement was for the Madonna Rehabilitation Hospital 'System' which included both the LTACH and Madonna Rehabilitation Hospital. The Director further confirmed that the onsite Maintenance Services at the Madonna Rehabilitation Hospital and the LTACH were provided by Madonna Rehabilitation Hospital 'System' employees.

Based on interview and review of the organ, tissue and eye procurement contracts the Long Term Acute Care Hospital (LTACH) and the Madonna Rehabiltiation Hospital failed to have separate, individual contracts with the Nebraska Organ Recovery System [NORS] and the Lions Eye Bank. This finding potentially could cause the facility to fail to identify/allow potential organ donations in response to patient or family/responsible parties wishes. The facility has 96 certified beds. The facility census was 47 on entrance 3/4/14. The sample size was 31.
Findings are:
A. An interview with Registered Nurse [RN] C on 2/27/14, at 8:25 AM revealed, "Yes this is the contract with Nebraska Organ Recovery System and the Lions Eye Bank for the Madonna Hospitals [Madonna System]. " An interview with the Chief Nursing Officer on 3/5/14 at 3:50 PM confirmed, that the contracts with the Nebraska Organ Recovery System and the Lions Eye Bank were for both Madonna Hospitals [The Madonna Rehabilitation Hospital and LTACH].
B. A review of the Lions Eye Bank of Nebraska, Inc. Donor Institution Agreement signed 9/25/13 identified the Donor Institution as Madonna Rehabilitation Hospital 'System'.
C. A review of the Nebraska Organ Recovery System Donor Institution Agreement signed 9/20/13 identified the agreement as including both the Madonna Rehabiliation Hospital and LTACH.
D. Interview with the Therapy Director on 3/3/14 at 2:50 PM verified, "...when legal papers are headed with Madonna Rehabilitation Hospital, that means it is the Madonna Corporate 'System' and included the 3 facilities [The LTACH, the Madonna Rehabilitation Hospital and the Long Term Care/Skilled Nursing Facility]..."

Based on record review of the Organizational Chart for Therapy Services and administrative staff interview, the facility failed to ensure that Madonna Long Term Acute Care Hospital [LTACH] had its own independent director to supervise and administer the Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) services. The Director was part of the Madonna Hospital 'System' and functioned as Director for the Madonna Rehabilitation Hospital, the LTACH and the Skilled Nursing Facility. Failure to have a Director dedicated to the supervision and administration of therapies for Madonna LTACH patients places all therapy patients at potential risk for poor quality of care. The Madonna LTACH has 96 certified beds. The facility census was 47. The total sample size was 31.

Findings are:

A. An interview on 2/27/14 at 10:30 AM with the Vice President of Rehabilitation revealed the Inpatient side of the Organizational Chart for Rehabilitation Services applied to all of Madonna Rehabilitation Hospital 'System' levels of care which included the Madonna Rehabilitation Hospital, the LTACH, and the Skilled Nursing Facility.
B. Record review of the untitled Organizational Chart for Therapies provided by the Vice President of Rehabilitation for Madonna Rehabilitation Hospital 'System' on 2/27/14 revealed there is one Director for Inpatient Therapies and another for the Director of Speech positions.
B. An interview with the Director for Inpatient Therapies on 3/3/14 at 11:00 AM revealed the Director position was at the Madonna Rehabilitation Hospital 'System' level and supervised and administered the PT and OT staff which were shared among the Madonna Rehabilitation 'System' providers [the Madonna Rehabilitation Hospital, LTACH and Skilled Nursing Facility].
C. An interview with the Director of Speech Therapy on 3/3/14 at 11:45 AM confirmed the position was at the Madonna Rehabilitation 'System' level and supervised and administered the ST staff who shared between the Madonna Rehabilitation Hospital, LTACH, and Skilled Nursing Facility.

Based on staff interview and review of Operational Definitions (OD's- facility policies and procedures), the Long Term Care Hospital (LTACH) failed to ensure exclusive respiratory care department services offered to their patients that were independent from the Madonna Rehabilitation Hospital 'System' respiratory services offered to other providers in the system. This had the potential to affect all patients in the Long Term Acute Care Hospital who required Respiratory Care services. The facility census was 47 on entrance 3/4/14.
Findings are:
A. A review of the OD titled Madonna Rehabilitation Hospital (dated 2/14/2014) with the subject of Respiratory Care Providers and Scope of Service, revealed the "Madonna Rehabilitation Hospital only employs Respiratory Care Practitioners licensed in the State of Nebraska."
B. An interview with the Respiratory Care Manager on 3/4/14 at 3:35 PM, revealed that [gender] is the manager of the respiratory department and reports to the COO (Chief Operating Officer) of the Madonna Rehabilatation Hospital 'System'. The respiratory therapists are employed by the Madonna Rehabilitation Hospital 'System' and they are "deployed where it makes the most sense for that day." The respiratory therapists are scheduled to provide services in the Madonna Rehabilatation Hospital, LTACH, the pediatric unit and the Ventilator Assist Unit of the Skilled Nursing Facility. The Respiratory Care Manager also confirmed that respiratory OD's are Madonna Rehabiltiation Hospital 'System' policies and are not exclusive to the LTACH.

Based on staff interview and review of the Letter of Agreement, the Long Term Acute Care Hospital (LTACH) failed to provide a physician director of respiratory care services to provide services exclusively for that facility, independently of the other Madonna Rehabilitation Hospital 'System' providers [the Madonna Rehabilitation Hospital, the LTACH and the Skilled Nursing Facility]. This failure had the potential to affect the quality of respiratory care provided to all patients of the Long Term Acute Care Hospital who required or received respiratory care services. Census on the first day of survey was 47.
Findings are:
A. A review of the Letter of Agreement with an addendum signed (7/12/00) revealed the physician "agrees to serve as a Pulmonary Advisor to the Respiratory Department at MRH" (Madonna Rehabilitation Hospital).
B. An interview with the Respiratory Manager on 3/4/14 at 3:35 PM revealed that the Physician Director of Respiratory Services covered the entire respiratory department which included the Madonna Rehabiliatation Hospital, the LTACH and the Ventilator Assist Unit of the Skilled Nursing Facility.

Based on interview of radiology staff, and review of radiology department records, the Madonna Long Term Acute Care Hospital [LTACH] was unable to demonstrate that they had separate and independent qualified staff for provision of radiology services to meet the needs of their patients. This had the potential to impact all patients of the Madonna LTACH requiring radiology services. The facility census on entrance was 47, and the sample size was 31.
Findings are:
A. An interview with the Supervisor of Radiology [the Supervisor] was completed on 3/6/2014 at 10:00 AM. Interview revealed that the department had 2 full time employees, including the supervisor [a radiology tech], and another radiology tech [RT] along with 4 RT's working on an as needed basis.
B. A review of the Radiology personnel file licensure information verified the RT's were qualified to provide the services. A review of documentation provided by the Supervisor revealed that the Radiology Staff had been approved by the medical staff for the Madonna Rehabilition Hospital 'System'.
C. Interview with the Supervisor further revealed that the Madonna Rehabilitation Hospital 'System' had contracts with a local imaging company and a local acute care hospital to provide services that the 'System' did not have the equipment available to perform, such as ultrasound [test to view soft tissue using sound waves], venous Doppler's, echograms, EKG's [tests to look at cardiac function and blood flow], and other procedures that cannot be done with a portable x-ray machine. The Supervisor confirmed that all of the department staff were employed by the Madonna Rehabilitation Hospital 'System' [which includes the Madonna Rehabilitation Hospital, the LTACH, and all of the units of the Skilled Nursing Facility and Nursing Home]. The contracted services were contracted for the whole system and were not contracted specifically for the Madonna LTACH, therefore, the Madonna LTACH was not able to demonstrate the independent ability to meet the radiologic needs of its patients.