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Based upon observations, interviews, and review of policies and procedures and Quality Assurance Performance Improvement Program data, the hospital failed to meet the Condition of Participation for Physical Environment as evidenced by:

1) Failure to maintain the physical environment of the offsite Intensive Outpatient Psychiatric Program to ensure dietary services, equipment, and furnishings were maintained in a safe manner.

On 10/14/11 at 11:40 AM, an immediate jeopardy situation was found to exist in this facility and reported to the hospital's administrator S1. The immediate jeopardy situation was the hospital's failure to ensure the physical environment of the Intensive Outpatient Psychiatric Program (IOP) was maintained in a safe and sanitary manner. This was evidenced by the hospital's failure to ensure the infection control program developed and implemented infection control measures related to the physical environment of the outpatient program.

Inspection of the refrigerator located next to the group therapy room revealed the freezer section had a dark frozen substance covering the bottom of the freezer with a plastic spoon frozen into the substance. Three used 1/2 gallon ice cream containers, no documentation of date opened, were being stored directly on top of "green onion sausages", the sides of the freezer and the freezer door had frozen food substances particles on the sides. The refrigerator contained a crockpot container of covered "dip" along with the soda. Interview with the program manager revealed an employee brought the dip from home the day before for patient consumption. Packages of ham and wieners were stored in the crisper area of the refrigerator with unopened soda cans. On the refrigerator door, there was a pint of opened milk (expired 10/14/11), containers of mustard, mayonnaise, jelly, butter, cheese, canned biscuits, and an unsealed package of "Little Smokey Sausages" all being stored together on the same shelf. On the bottom shelf of the refrigerator door there was an opened package of shredded cheese, an opened box of bacon, a bottle of used ketchup, a bottle of used pancake syrup, and a can of biscuits. There were no dates indicating when the food items were opened.

Inspection of the refrigerator located in the "kitchen" area revealed in the freezer there was a package of shrimp and a dark red substance frozen to the bottom of the freezer. Interview with the program manager (S22) during this observation revealed when asked what this frozen substance was, he replied "it's probably from the deer meat". When asked if this red frozen substance was blood from the deer meat, S22 responded "well, it could be". On the stove was a pot of water with wieners and a pot of chili. Interview with S22 revealed he was in the process of preparing the patients lunch which would be chili dogs. Further observations in the kitchen area revealed on one side of the two compartment sink there was standing water with dishes present. Interview with S22 on 10/14/11 at 9:50 AM, revealed he started washing dishes the day before (10/13/11) and had not had a chance to finish. When asked about the cleaning of the kitchen utensils and pots and pans, S22 replied he used lime dishwashing liquid. A large ceiling to floor shelf, located against the opposite wall, contained large cans (6 lb 10oz) of food items such as fruit cocktail, kernel corn, yams, pork and beans, green beans, and spaghetti sauce. Interview with S22 revealed the large cans of food items were used for the patients lunch. A restaurant was used to cater the patients lunches approximately six months ago; however, this restaurant had closed so he now prepared all snacks and lunches for the patients. When asked if temperatures were checked on the prepared foods and the water, S22 stated "no" and he was not aware this needed to be checked. S22 further stated the only thermometers he had were located in the refrigerators.

Inspection of the cabinet in the kitchen area revealed three containers of a patient's medications were being stored on the shelf along with Raid Insect killer and Gum Spirits of Turpentine. On the second shelf there was an ash tray that contained a cigarette butt.

A plan of removal was submitted by the hospital on 10/14/2011 at 3:15 PM. Review of this plan of correction for the immediate jeopardy revealed in part, the Refrigerator/Freezer will be cleaned or replaced, all items will be dated and labeled, and a temperature log was to be maintained daily. The stove located in the kitchen area was to be removed. No meals were to be prepared or delivered for patients on the premises; only pre-packaged snacks were to be provide. General cleanliness was to be maintained daily with periodic inspections by the hospital staff monthly and reported to the infection control committee. The exterior grounds were to be inspected daily by the nurse.

On 10/17/11 at 9:30 AM, the immediate jeopardy situation was removed due to the hospital implementing corrective actions which included; removal of the stove and refrigerator in the kitchen area; cleaning all kitchen counter tops and sinks; removal of all food items except for pre-packaged snacks; removal of all food products and free standing storage cabinets; refrigerator/freezer located next to the group therapy area cleaned with monitoring logs in place to ensure appropriate temperatures and cleanliness. (See findings at A0724).

Based upon observations of the Outpatient Department (IOP), reviews of the hospital's Infection Control Program/Surveillance Log Book/meeting minutes, QAPI Plan/meeting minutes, Governing Body/Medical Staff meeting minutes, and Administrative interviews the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) there failed to be an Infection Control (IC) Officer designated and approved by the Governing Body/Medical Staff (A0748);
2) there lacked indicators developed to monitor for infection control issues identified in the Intensive Outpatient Program [IOP] to ensure dietary services and food/equipment were maintained in a safe and sanitary manner (A0749);
3) a lack of an active Infection Control program implemented that included all departments/services provided by the hospital by a failure to identify and maintain a log of potential infection control issues in the IOP (A0750); and
4) the Administrator, Medical Staff and Director of Nursing had ensured all departments of the hospital had infection control issues reported through the Quality Assessment/Performance Improvement committee as evidenced by a lack of documentation hospital-wide departments had developed, implemented, and reported to Infection Control their identified issues(A0756).


On 10/14/11 at 11:40 AM, an Immediate Jeopardy situation was found to exist during the environmental tour conducted on 10/14/11 from 9:30 AM to 11:00 AM. During the tour, the following Infection Control issues were found:

Inspection of the refrigerator located next to the group therapy room revealed the freezer section had a dark frozen substance covering the bottom of the freezer with a plastic spoon frozen into the substance. Three used 1/2 gallon ice cream containers, no documentation of date opened, were being stored directly on top of "green onion sausages", the sides of the freezer and the freezer door had frozen food substances particles on the sides. The refrigerator contained a crock of covered "dip" along with the soda. Interview with the program manager revealed an employee brought the dip from home the day before for patient consumption. Packages of ham and wieners were stored in the crisper area of the refrigerator along with unopened soda cans. On the refrigerator door, there was a pint of opened milk (expired 10/14/11), containers of mustard, mayonnaise, jelly, butter, cheese, canned biscuits, and an unsealed package of "Little Smokey Sausages" all being stored together on the same shelf. On the bottom shelf of the refrigerator door there was an opened package of shredded cheese, an opened box of bacon, a bottle of used ketchup, a bottle of used pancake syrup, and a can of biscuits. There were no dates that indicated when food items were opened.

Inspection of the refrigerator located in the "kitchen" area revealed in the freezer there was a package of shrimp and a dark red substance frozen to the bottom of the freezer. Interview with the program manager (S22) during this observation revealed when asked what this frozen substance was, he replied "it's probably from the deer meat". When asked if this red frozen substance was blood from the deer meat, S22 responded "well, it could be".

On the stove was a pot of water with wieners and a pot of chili. Interview with S22 revealed he was in the process of preparing the patients lunch which would be chili dogs.

Further observations in the kitchen area revealed on one side of the two compartment sink there was standing water with dishes present. Interview with S22 on 10/14/11 at 9:50 AM, revealed he started washing dishes the day before (10/13/11) and had not had a chance to finish. When asked about the cleaning of the kitchen utensils and pots and pans, S22 replied he used lime dishwashing liquid.

A large ceiling to floor shelf, located against the opposite wall, contained large cans (6 lb 10oz) of food items such as fruit cocktail, kernel corn, yams, pork and beans, green beans, and spaghetti sauce. Interview with S22 revealed the large cans of food items were used for the patients lunch. A restaurant was used to cater the patients lunches approximately six months ago; however, this restaurant had closed so he now prepared all snacks and lunches for the patients.

When asked if temperatures were checked on the prepared foods and the dishwashing water, S22 stated "no" and he was not aware this needed to be checked. S22 further stated the only thermometers he had were located in the refrigerators.

A plan of removal was submitted by the hospital on 10/14/2011 at 3:15 PM. Review of this plan of correction for the immediate jeopardy revealed in part, the Refrigerator/Freezer will be cleaned or replaced, all items will be dated and labeled, and a temperature log was to be maintained daily. The stove located in the kitchen area was to be removed. No meals were to be prepared or delivered for patients on the premises; only pre-packaged snacks were to be provide. General cleanliness was to be maintained daily with periodic inspections by the hospital staff monthly and reported to the infection control committee. The exterior grounds were to be inspected daily by the nurse.

On 10/17/11 at 9:30 AM, the immediate jeopardy situation was removed due to the hospital implementing corrective actions which included: removal of the stove and refrigerator in the kitchen area; cleaning all kitchen counter tops and sinks; removal of all food items except for pre-packaged snacks; removal of all food products and free standing storage cabinets; refrigerator/freezer located next to the group therapy area cleaned with monitoring logs in place to ensure appropriate temperatures and cleanliness. (See findings at A0749)

Based upon reviews of 6 of 6 physician credentialing files (S12, 13, 18, 19, 20, 21), Governing Body Bylaws/meeting minutes, Medical Staff Bylaws, and Administrative interview, the Governing Body failed to ensure all physicians providing services to patients were granted privileges by the Governing Body as evidenced by a lack of a documented credentialing file for a Radiologist. Findings:

The surveyors requested a list of all physicians who provided care to patients in the hospital either as inpatients or outpatients. Upon review of the requested list of physicians and their credentialing files (S12, 13, 18, 19, 20, and 21), the surveyor discovered the hospital failed to have a credentialing file for a Radiologist.

Interview, on 10/18/11, 11:00AM, with S1 Administrator revealed when questioned who the radiologist was, S1 replied Contract A supplied the radiologist. Further questioning revealed the hospital staff were not aware the hospital must maintain a credentialing file on all physicians who provide services to their patients.

S1 Administrator confirmed the hospital did not have a credential file for a radiologist, therefore the Governing Body had not appointed one.

Review of the Medical Staff Bylaws revealed: Article III - Membership, Section 1. "Composition of the Medical Staff: The Medical staff shall be composed of fully licensed physicians who shall be authorized to treat or admit patients, or provide specific professional consultation...".

The hospital's Governing Body failed to ensure all physicians who provided care/services to patients had been credentialed and approved to make certain they were competent and licensed to provide care.









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Based upon review of physician credential files, medical staff bylaws, and staff interviews, the governing body failed to ensure the medical staff followed their bylaws related to the granting of medical staff membership and privileges in accordance with the medical staff bylaws (physicians S12, S13, S19, S20, S21). Findings:

Review of the medical staff bylaws revealed Article IV Appointment and Reappointment, Section 1. Application Process "Applications are delivered to the Hospital Administrator to check for completeness. The Administrator and/or Medical Director shall check references." "...authorize the Hospital to consult with members of the medical staff of other hospitals with which the applicant had been associated and others who may have information on his/her character, competency and professional qualifications and health." Section 2: "The credential process of the new applicant includes a review by the Administrator and the Medical Staff of all documented education and training, licenses, states of State and Federal DEA number, recommendations, references, and information from the National Practitioners Data Bank...". Under Article V, Delineation of Clinical Privileges, Section 1: "The initial determination of the clinical privileges shall be based upon the applicant's education and training, demonstrated competence and competency in relation to the privileges sought...".

Review of the credential files of the initial appointment for physicians S13 and S19 revealed there failed to be documented evidence the medical staff consulted with members of the medical staff of other hospitals with which the physicians had been associated with related to: 1) their character, competency and professional qualifications and health, 2) reviewed the clinical privileges related to the applicant's education, training and demonstrated competence and 3) completed a query with the National Practitioner Data Bank.

Further review of the medical staff bylaws revealed for Section 5: "Reappointment to the Medical Staff. All appointments to the Medical Staff are subject to a renewal annually...".
Review of the re-appointments for physicians S12, S20 and S21 revealed there failed to be evidence these re-appointments were renewed annually.

Interview with the hospital administrator S1 on 10/12/11 at 10:30 AM, confirmed the credential files for physicians S12, S13, S19, S20, and S21 failed to completed in accordance with the medical staff bylaws.

Based upon reviews of the Quality Assessment/Performance Improvement (QA/PI) Plan, Indicators and meeting minutes, Governing Body Bylaws and meeting minutes, the contract agreements relative to the services the laboratory and radiology was to provide, and interviews with the hospital's Administrator, the governing body failed to ensure the contracted services for laboratory and radiology had indicators developed to evaluate the services they provided. Findings:

Reviews of the QA/PI Plan, Quality Indicators and the contract agreements for laboratory and radiology services revealed there lacked documented evidence the contracted services had indicators developed for monitoring the 1) services they provided, 2) indicate the method used for reporting critical values of laboratory results/radiology reports, and 3) determined specified time frame for STAT (now) laboratory or radiology examinations.

Review of the Governing Body Bylaws revealed the following: "

Review of the Governing Body meeting minutes from October 28, 2010 to July 18, 2011, revealed there failed to be documentation relative to an evaluation of the services provided by the contracted laboratory and radiology companies.

Interviews, on 10/18/11 at 10:50 AM , with S1 Administrator and S3 Performance Improvement confirmed none of the services provided by the contracted laboratory and radiology companies had indicators developed nor had any of the services provided by the contracted laboratory and radiology companies been evaluated through the hospital's QA/PI program nor by the Governing Body.

There failed to be evidence the Governing Body had evaluated services provided by the contracted laboratory and radiology companies.

Based upon review of physician credential files, medical staff meeting minutes, medical staff bylaws, and staff interviews, the medical staff failed to ensure the bylaws were followed related to the appointment/reappointment process. This was evidenced by failure of the medical staff to follow the bylaws related to: 1) documentation of education, training, recommendations, references, and information from the National Practitioner's Data Bank for new applicants (Physicians S13 and S19), 2) review of education, experience, and training based upon data available from Medical Records and the QA/Performance Improvement Committee and data accessed from the National Practitioner's Data Bank (Physicians S12, S18, S20, S21), and 3) reappoint members to the medical staff annually (Physicians S12, S20, S21). Findings:

Review of the Medical Staff Bylaws revealed the following:

Article IV-Appointment and Reappointment
Section 1. Application Process: "Applications are delivered to the Hospital Administrator to check for completeness. The Administrator and/or Medical Director shall check references. The applicant shall be available to interview in regard to his/her application, authorize the Hospital to consult with members of the medical staff of other hospitals with which the applicant had been associated and others who may have information on his/her character, competency and professional qualifications and health. The Credentials section of the Medical Staff shall review applications, clinical privileges and forward appropriate recommendations regarding appointments to the Secretary of the Board for presentation at the next scheduled Board Meeting."

Section 2. Credentialing: "The credential process of the new applicant includes a review by the Administrator and the Medical Staff of all documented education and training, licenses, states of State and Federal DEA number, recommendations, references, and information from the National Practitioner's Data Bank. Specific requests for privileges shall be reviewed in detail and compared to education and training. The Medical Staff shall conduct this credentialing. A criteria based physician profile shall be completed on each applicant for reappointment and include at least a confidential physician profile evaluation, patient complaints, DRG and quality issues denials, lengths of stay and admission/reimbursement ratios, patient death, incomplete charts, etc."

Section 3. National Practitioner's Data Bank: "In the credentialing process, the Hospital shall query the National Practitioner's Data Bank for information, which may lend itself to ascertaining the quality and character of any and all physicians. After the initial application, the NPDB shall be queried a minimum of every two years."

Section 5. Reappointment to the Medical Staff: "All appointments to the Medical Staff are subject to renewal annually, on the basis of continuing eligibility requirements as stipulated above and a specific delineation of privileges requested. Relevant continuing education activity shall be documented for the proceeding Medical Staff years, when considering reappointment...All reappointments are subject to review of clinical privileges requested and physician profile criteria as indicated in the credentialing process and contingent on the approval of the Board."

Article V - Delineation of Clinical Privileges
Section 1. Criteria "Each initial application for Staff appointment must contain a request for the specific privilege desired by the applicant. The initial determination as the clinical privileges shall be based upon the applicant's education and training, demonstrated competence and competency in relation to the privileges sought."

Section 2. Privilege Renewal or Modifications "After the first application for and granting of privileges, all subsequent evaluations for clinical privileges-whether they are made at the time of appointment to the Medical Staff, during the periodic reevaluation for clinical privileges (which must occur at least every two (2) years), or at some other point at the practitioner's request for a modification of privileges-must take into account the finding of the Hospital QA/Performance."

Review of the physician credential files revealed the following:

Physician S13: Medical Staff application, dated 04/13/11 with delineation of privileges requested. The hospital's medical director (physician S12) signed the privilege form but left blank the areas to be check marked if the clinical privileges requested were approved or denied. The medical director also failed to date when he signed the delineation of privileges. The form titled "Request for Professional Reference" was also blank. There failed to be evidence a National Practitioner Data Bank query was conducted, the applicant's training and education in relation to the clinical privileges requested were reviewed, and reference checks were conducted related to the applicant's association with other hospitals who may have information on his/her character, competency and professional qualifications and health.

Physician S19: According to interview with the hospital administrator on 10/11/11, physician S19 was the physician over the Intensive Outpatient Psychiatric Program. Review of the credential file revealed this family practice physician requested initial medical staff appointment on 04/03/11. The delineation of privileges form, dated 04/06/11, revealed S19 was requesting privileges for "General Psychiatry: General Medical Management - Privileges to admit, evaluate, diagnose, provide consultation, and treat patients who suffer from mental, behavioral, or emotional disorders with problems related to alcoholism and other drug dependencies, such as psychoactive drug use and addition, utilizing all forms of psychological and social treatment as well as medications." and "Consultative Services". The delineation of privileges failed to be approved and signed by the hospital's medical director S12. There also failed to be evidence the credential process of this new applicant included a review by the Administrator and the medical staff of all documented education and training, recommendations, references, information from the National Practitioners Data Bank and a detailed review of the physician's education and training compared to the privileges requested. Interview with the IOP Program Manager S22 on 10/14/11 at 10:30 AM revealed when asked if the IOP Program treated disorders related to alcoholism and drug abuse, S22 replied the program was for psychiatric patients only.

Physician S12: The physician submitted a medical staff re-appointment application in January 2011. The last reappointment process was conducted in September 2007. The Delineation of Privileges was requested and approved; however, there failed to be evidence a medical staff member approved these privileges. Review of the continuing education revealed all the information was from the year 2009 with no current information, there was no National Practitioners Data Bank query, and a documented review of professional references for competence and character failed to be conducted. A member of the Governing Board signed physician S12 was recommended and approved for active medical staff membership; however, a member of the medical staff failed to sign the recommendation.

Physician S20: The physician submitted a medical staff re-appointment application in January 2011. The last reappointment approval was dated 08/31/07. There failed to be documented evidence the credential file contained documentation of continuing education and training, recommendations and references, and a query from the National Practitioner's Data Bank.

Physician S21: Review of the credential file for the physician revealed an appointment application, an evaluation by the hospital's medical director for reappointment, and the delineation of privileges were present; however, there were no dates on any of the reappointment information. The credential file failed to contain documentation of continuing education and training, review of recommendations and references and a query from the National Practitioner's Data Bank.

Review of the medical staff meeting minutes from July 22, 2010 through July 18, 2011 revealed there failed to be documented evidence physicians S12, S20 and S21 were re-appointed to the medical staff.

Based upon review of the Radiology Contract Agreement (Contract A) and Administrative interviews, the hospital failed to ensure radiological services were available should a patient require an immediate x-ray as evidenced by a lack of a specified time frame for performance of STAT (immediate) x-rays. Findings:

Review of the Contract Agreement for Radiology Services (Contract A) revealed if a STAT x-ray was needed the company would make every effort to obtain the x-ray and "will be given top priority and every attempt will be made to act upon these requests immediately. ASAP (as soon as possible) will be acted upon as soon as the schedule allows." Further review of the contract agreement revealed there was not a specified time frame for STAT x-rays.

Interviews, 10/18/11 at 10:45AM, with S1 Administrator and S3 Performance Improvement Nurse confirmed Contract A (Radiology Services) did not have a specified time frame for completion of STAT x-rays.

Based upon reviews of 6 of 6 physician credentialing files (S12, 13, 18, 19, 20, 21), Contracted Radiology Agreement (Contract A), Medical Staff Bylaws, and Administrative interview, the hospital failed to ensure all physicians providing services to patients were granted specified privileges by the Governing Body and that a credentialing file was maintained and available for review to ensure the radiologist had current licensure, education and experience in radiology to meet the needs of the patients. Findings:

The surveyors requested a list of all physicians who provided care to patients in the hospital either as inpatients or outpatients. Upon review of the requested list of physicians, the surveyor discovered the hospital failed to have a credentialing file for a Radiologist.

Review of the Medical Staff Bylaws revealed: "...ARTICLE IV-APPOINTMENT AND REAPPOINTMENT...Section 2. Credentialing The credential process of the new applicant includes a review by the Administrator and the Medical Staff of all documented education and training, licenses, states of State and Federal DEA number, recommendations, references, and information from the National Practitioner's Data Bank. Specific requests for privileges shall be reviewed in detail and compared to education and training. The Medical Staff shall conduct this credentialing...ARTICLE V--DELINEATION OF CLINICAL PRIVILEGES Section 1. Criteria Each initial application for Staff appointment must contain a request for specific privilege desired by the applicant. The initial determination as the clinical privileges shall be based upon he applicant's education and training, demonstrated competence and competency in relation to the privileges sought. Each Medical Staff member shall exercise only those clinical privileges specifically granted to him/her by the Medical Staff and the Board..."

Interview, on 10/18/11, 11:00AM, with S1 Administrator revealed when questioned who the radiologist was, S1 replied Contract A supplied the radiologist. Further questioning revealed the hospital staff were not aware the hospital must maintain a credentialing file on all physicians who provide services to their patients.

S1 Administrator confirmed the hospital did not have a credential file for a radiologist, and therefore the Governing Body had not appointed one.

The hospital failed to ensure the radiological reports were completed by a competent and licensed radiologist.

Based upon review of the contract agreement for laboratory services and Administrative interviews, the hospital failed to ensure the contracted laboratory companies had identified a specified time for reporting the completion of STAT and routine laboratory results. Findings:

Review of the Contract Agreements for Laboratory Services (Contracts B and C) revealed there failed to be a specified time frame for reporting results of STAT (immediate) laboratory results.

Interview, 10/18/11 at 10:30AM, with S1 Administrator and S3 Performance Improvement confirmed the laboratory contracts lacked a specified time for STAT laboratory results.

Based upon reviews of personnel files and Administrative interviews, the hospital failed to ensure a full-time Dietary Manager had been appointed to manage the day to day operations of the dietary service as evidenced by the previous full-time Dietary Manager left over one year ago, thereby leaving the hospital without a full-time Dietary Manager. Findings:

Review of hospital personnel files revealed the hospital had not appointed a replacement for the full time Dietary Manager's (DM) position when the previous Dietary Manager left employment over a year ago.

Interview, 10/11/11 at 11:30AM, with S4 Director of Nursing (DON) revealed when questioned as to who was the hospital's full-time Dietary Manager, he replied the former DM became ill and required hospitalization and therefore had to quit work and no other person replaced her. S4 further stated the hospital had a contract with a part-time Registered Dietitian (RD). When asked if the hospital had hired a replacement for the full-time Dietary Manager, S4 replied "No." S4 DON was questioned how long the previous DM had been gone, S4 responded about "one year".

Interviews, 10/18/2011 at 11:40AM, with S1 Administrator, S3 Performance Improvement and S4 DON revealed when they were questioned who the hospital's DM was, S1 Administrator stated he thought by having "a contract with a part-time RD was the same thing" as a DM. The surveyors explained the hospital must have a full-time DM in lieu of a full-time RD.

Interviews, 10/18/2011 at 11:40AM, with S1 Administrator, S3 Performance Improvement and S4 DON confirmed the hospital did not have a full-time Dietary Manager to be responsible for and oversee the daily dietary needs of patients.

Based upon reviews of the contract agreement for the Registered Dietitian (RD) S25, medical records, Governing Body meeting minutes and interviews, the hospital failed to ensure patients received documented and timely nutritional assessments by the RD as evidenced by delinquent medical records that date back to May and June 2011 for which there was a lack of documented nutritional assessments. Findings:

Review of the contract agreement (dated 08/17/2011 and signed by S25 RD), for the consulting RD (S25) revealed: "...will provide general dietary consultation to the above facility in the capacity of Consultant in nutrition and dietetics...The Consultant will assist in the development of ongoing in-service training programs, implementing and updating policies and procedures, and consulting with the administrator when necessary. During the hours of consultation, the consultant will assess nutritional status of patients, make recommendations, and document care in the medical records as needed...Consultant will service hospital on site on an as needed basis each month..."

Review of a list of delinquent medical records, dated May and June 2011 (for review by S25 RD), revealed a lack of documentation by contract S25 RD.

Review of Governing Body meeting minutes, dated July 18, 2011, revealed: "...held their scheduled quarterly meeting for the quarter ending June 30, 2011...D. New Business: No new business was discussed except for the enclosed Committee Report findings...F. Old Business: No old business to discuss." There failed to be documented evidence the Medical Staff and Governing Body had addressed the issue of S25 RD's delinquent medical records.

Interviews, 10/18/11 at 9:50AM, with S17 Medical Records Technician and contract S24 RHIT (Registered Health Information Technician) revealed S25 RD had records that were delinquent going back to May and June 2011. S17 stated "one day (name S25 RD) here about 30-40 minutes and she had to leave but said she would come back, but never came back, had her charts pulled for her to sign."

Continued interviews, with S17 and S24, revealed S25 RD completed current Dietary Evaluations on 10/17/11, but did not complete her delinquent medical records from May and June 2011 for Dietary Evaluations.

There failed to be documented evidence the issue of delinquent medical records for the contracted RD (S25) were discussed and addressed by the Governing Body.

Based upon review of outpatient policies and procedures, observations, and staff interviews, the hospital failed to ensure the physical environment of the Intensive Outpatient Program (IOP) was maintained at an acceptable level related to the storage and preparation of food items and the maintenance of furniture and carpets. Findings:

Inspection of the IOP which provides outpatient psychiatric treatment on 10/14/11 from 9:30 AM to 11:30 AM, revealed the following:

1. Inspection of the refrigerator located next to the group therapy room revealed the freezer section had a dark frozen substance covering the bottom of the freezer with a plastic spoon frozen into the substance. Three used 1/2 gallon ice cream containers, no documentation of date opened, were being stored directly on top of "green onion sausages", the sides of the freezer and the freezer door had frozen food substance particles on the sides. The refrigerator contained a crock pot container of covered "dip" along with the soda. Interview with the program manager revealed an employee brought the dip from home the day before for patient consumption. In the crisper area were packages of ham and wieners being stored with unopened soda cans. On the refrigerator door, there was a pint of opened milk (expired 10/14/11), containers of mustard, mayonnaise, jelly, butter, cheese, canned biscuits, and an unsealed package of "Little Smokey Sausages" all being stored together on the same shelf. On the bottom shelf of the refrigerator door there was an opened package of shredded cheese, an opened box of bacon, a bottle of used ketchup, a bottle of used pancake syrup, and a can of biscuits. There were no dates on any opened food items.

Inspection of the refrigerator located in the "kitchen" area revealed in the freezer there was a package of frozen shrimp and a dark red substance frozen to the bottom of the freezer. Interview with the program manager (S22) during this observation revealed when asked what this frozen substance was, he replied "it's probably from the deer meat". When asked if this red frozen substance was blood from the deer meat, S22 responded "well, it could be". On the stove was a pot of water with wieners and a pot of chili. Interview with S22 revealed he was in the process of preparing the patients lunch which would be chili dogs. Further observations in the kitchen area revealed on one side of the two compartment sink there was standing water with dishes present. Interview with S22 on 10/14/11 at 9:50 AM, revealed he started washing dishes the day before (10/13/11) and had not had a chance to finish. When asked about the cleaning of the kitchen utensils and pots and pans, S22 replied he used lime dishwashing liquid. A large ceiling to floor shelf, located against the opposite wall, contained large cans (6 lb 10oz) of food items such as fruit cocktail, kernel corn, yams, pork and beans, green beans, and spaghetti sauce. Interview with S22 revealed the large cans of food items were used for the patients lunch. A restaurant was used to cater the patients lunches approximately six months ago; however, this restaurant had closed so he now prepared all snacks and lunches for the patients. When asked if temperatures were checked on the prepared foods and the water, S22 stated "no" and he was not aware this needed to be checked. S22 further stated the only thermometers he had were located in the refrigerators.

Inspection of the free standing cabinet in the kitchen area revealed three containers of a patient's medications were being stored on the shelf along with Raid Insect killer and Gum Spirits of Turpentine. On the second shelf there was an ash tray that contained a cigarette butt along with containers of peanut butter, jelly, and a container of mustard.

The carpet throughout the facility was stained and dirty. There was also an odor of cigarette smoke throughout the facility.

On the outside in front of the building was an array of chairs, one being a recliner with the back broken and cigarette burns in the seat area.

Review of the hospital and outpatient policies and procedures revealed there failed to be policies related to dietary services and housekeeping for the outpatient department.

Based upon reviews of the Job Description Infection Control Nurse (S4), Medical Staff/Governing Body meeting minutes, and Administrative interviews the hospital failed to ensure there was an Infection Control Officer designated and approved as evidenced by the lack of a qualified individual appointed as the hospital's Infection Control Nurse. Findings:

Review of the Job Description for the Infection Control Nurse revealed: "...POSITION DESCRIPTION: Responsible for initiating and implementing practices, performance improvement, and reports for infection control throughout the facility. Monitors and administers employee health standards...JOB DUTIES/RESPONSIBILITIES: ...2. Keep abreast of current trends and developments; keep...informed of such developments...6. Participate in the formulation and revision of all hospital policies and/or procedures dealing with Infection Control. 7. Make rounds of patient care units and assist where needed in resolving problems and/or concerns..."

Review of the Medical Staff/Governing Body meeting minutes, (dated October 28,2010, Jan. 14, 2011, April 25, 2011, and July 18, 2011) revealed there failed to be documentation relative to the designation and appointment of an Infection Control (IC) Officer/Nurse.

Interviews, on 10/18/11 at 10:50AM, with S1 Administrator, S3 Performance Improvement, and S4 DON confirmed S4 had not been appointed by the Medical Staff nor approved by the Governing Body. S4 DON stated he had been performing the duties of the Infection Control Nurse/Officer since October 2008. S4 DON further stated he had not received any type of training in infection control practices (i.e. continuing education courses in infection control or certification). S1 Administrator stated S20 Physician (Internal Medicine) had been appointed by the Medical Staff to serve as a resource for Infection Control issues; however, he agreed there lacked an Infection Control Officer/Nurse who was responsible for the day to day infection control program.

There failed to be evidence the hospital had a designated and approved qualified Infection Control Officer.

Based on observations of the hospital's Intensive Outpatient Program (IOP), reviews of the Infection Control Plan/Surveillance Log Book, Infection Control meeting minutes and Administrative interviews, the hospital failed to ensure indicators were developed to monitor infections in the Intensive Outpatient Program [IOP] to ensure dietary services and food/equipment were maintained in a safe and sanitary manner. Findings:

Review of the Infection Control Plan and Surveillance Log Book revealed all departments of the hospital were to collect and report data relative to infection control issues and the Infection Control (IC) Officer was to report these findings quarterly to the Quality Assessment/Performance Improvement committee.

Review of Infection Control policy #IC 7.011, titled "Subject: Refrigerator/Freezer Temperatures" revealed: "I. POLICY It is the policy of this facility...regarding refrigerator/freezer temperatures. II. PURPOSE To prevent or control the spread of infectious diseases and maintain proper temperatures for food products, equipment,...III. PROCEDURE A. TEMPERATURES-Food Storage 1. REFRIGERATOR temperatures will be maintained between 34-40 degrees F. 2. FREEZER temperatures should be 0 degrees F. or below...4. TEMPERATURE RECORDING: Temperatures will be monitored twice daily and recorded on the refrigerator temp flow sheet by the C.N.A. per shift in all refrigerators/freezers where food is stored..."

Review of Infection Control policy #IC 5.001, titled "Subject: Dietary Department", revealed: "...III. PROCEDURE ...3. FOOD PROCUREMENT/STORAGE...e. ALL FOOD and supplies, whether refrigerated, frozen or in the storeroom, will be clearly labeled for easy identification. Non-food supplies will be stored in an area separate from food supplies..."
On 10/14/11 at 11:40 AM, an Immediate Jeopardy situation was was found to exist during the environmental tour conducted on 10/14/11 from 9:30 AM to 11:00 AM. During the tour, the following Infection Control issues were found:

Inspection of the refrigerator located next to the group therapy room revealed the freezer section had a dark frozen substance covering the bottom of the freezer with a plastic spoon frozen into the substance. Three used 1/2 gallon ice cream containers, no documentation of date opened, were being stored directly on top of "green onion sausages", the sides of the freezer and the freezer door had frozen food substances particles on the sides. The refrigerator contained a crock of covered "dip" along with the soda. Interview with the program manager revealed an employee brought the dip from home the day before for patient consumption. Packages of ham and weiners were stored in the crisper area of the refrigerator with unopened soda cans. On the refrigerator door, there was a pint of opened milk (expired 10/14/11), containers of mustard, mayonnaise, jelly, butter, cheese, canned biscuits, and an unsealed package of "Little Smokey Sausages" all being stored together on the same shelf. On the bottom shelf of the refrigerator door there was an opened package of shredded cheese, an opened box of bacon, a bottle of used ketchup, a bottle of used pancake syrup, and a can of biscuits. There were no dates indicating when the food items were opened.

Inspection of the refrigerator located in the "kitchen" area revealed in the freezer there was a package of shrimp and a dark red substance frozen to the bottom of the freezer. Interview, 10/14/11 at 9:50AM, with the program manager (S22) during this observation revealed when asked what this frozen substance was, he replied "it's probably from the deer meat". When asked if this red frozen substance was blood from the deer meat, S22 responded "well, it could be". There were 2 pots, one with wieners and the other was chili, cooking on the stove.

Interview, 10/14/11 at 9:55AM, with S22 revealed he was in the process of preparing the patients lunch which was hot dogs with chili. Further observations in the kitchen area revealed on one side of the two compartment sink there was standing water with dishes present. Interview with S22 on 10/14/11 at 9:50 AM, revealed he started washing dishes the day before (10/13/11) and had not had a chance to finish.

When asked about the cleaning of the kitchen utensils and pots and pans, S22 replied he used lime dishwashing liquid. S22 was questioned what the temperature of the dishwashing water was supposed to be and how he monitored it to ensure the needed temperature was maintained, S22 replied "I did not know the food and water temperatures had to be checked." S22 was questioned how he ensured the policies for food preparation were followed in the IOP, he replied, "I did not know I needed to check the temperatures." Explained to S22 that specific temperatures were needed to avoid food borne illnesses, such as hot foods leave the kitchen at or above 140 degrees F and for properly sanitized utensils the water temperature for manual washing must be 170 degrees F. S22 further stated the only thermometers in the IOP were in the refrigerators.

S22 confirmed the temperatures for the freezers were not monitored and documented, nor was the food temperatures and dishwashing water temperatures.

On 10/17/11 at 9:15 AM, the Immediate Jeopardy was lifted after an environmental tour was conducted at the IOP outpatient facility. During this inspection it was found the refrigerator located next to the group therapy room had been cleaned, the items inside dated, and an up-to-date temperature log was present on the front of the refrigerator. The refrigerator, stove, shelving units and free standing cabinets had been removed from the kitchen area.

Review of the Infection Control meeting minutes, dated September 2010 through September 30, 2011, revealed there failed to be documented evidence of infection control data had been reported relative to all departments of the hospital. Nursing Services was the only department that provided data to Infection Control.

Interview, 10/14/11 at 11:40AM, with S1 Administrator revealed when questioned if the IOP had submitted infection control data, he replied "I'm not sure, but after seeing what a mess this place is in, I'm sure they didn't, but they should."

Interview, 10/14/11 at 11:40AM, with S22 Program Director confirmed personnel in the IOP had not monitored and documented the freezers temperatures, nor had he (S22) 1)monitored the temperatures of the food he prepared for patients, and 2) monitored the dishwashing water temperature to make certain it was a 170 degrees so the cooking/dietary utensils were sanitized after use.

Interview, on 10/18/11 at 10:50AM, with S4 DON confirmed there has not been data collected nor indicators developed relative to all departments of the hospital. S4 further stated that Nursing Personnel collected and reported data in regard to inpatients who were either admitted with an infection or developed an infection while hospitalized.

The Infection Control Officer/Committee failed to take responsibility and ensure all patients who received services from the hospital's IOP received that care based on established hospital policies and procedures, and that they were provided in a clean, santiary environment as evidenced by: 1) when food was served, it was served at temperatures to ensure spoilage had not occurred; 2) when utensils were used they were sanitized according to approved sanitation guidelines; and 3) when food items were stored in the refrigerator/freezer the temperatures were monitored to ensure freezer temperatures remained at 0 degrees F or lower, and refrigerator temperatures were 34 degrees F or lower.

Based on observations of the hospital's Intensive Outpatient Program (IOP), reviews of the Infection Control Plan/Surveillance Log Book, Infection Control meeting minutes and Administrative interviews, the hospital failed to ensure data was collected from all departments of the hospital as evidenced by a lack of documented infection control data/indicators relative to the hospital's IOP, an outpatient department of the hospital, from September 2010 through October 14, 2011. Findings:

Review of the Infection Control Plan and Surveillance Log Book revealed all departments of the hospital were to collect and report data relative to infection control issues and the Infection Control (IC) Officer was to report these findings quarterly to the Quality Assessment/Performance Improvement committee.

Review of the Infection Control meeting minutes, dated September 2010 through September 30, 2011, failed to have evidence infection control data had been reported relative to all departments of the hospital. Nursing Services was the only department that provided data to Infection Control.

Interview, 10/14/11 at 11:40AM, with S1 Administrator revealed when questioned if the IOP had submitted infection control data, he replied "I'm not sure, but after seeing what a mess this place is in, I'm sure they didn't, but they should."

Interview, on 10/18/11 at 10:50AM, with S4 DON confirmed there has not been data collected nor indicators developed relative to all departments of the hospital. S4 further stated that Nursing Personnel collected and reported data in regard to inpatients who were either admitted with an infection or developed an infection while hospitalized.

Based upon reviews of the Infection Control Program/Surveillance Log Book, Governing Body/Medical Staff meeting minutes, Quality Assessment/Performance Improvement (QA/PI) Plan/meeting minutes, and Administrative interviews, the hospital failed to ensure the hospital had in effect an active hospital-wide infection control plan that included all departments of the hospital and reported findings to the QAPI Committee as evidenced by the Intensive Outpatient Program (psychiatric outpatient treatment/counseling--part of the hospital's outpatient department) that had dirty refrigerators/freezers; cooking utensils that were observed soaking in water from the day before; and chili and weiners cooking on a stove in the kitchen area without temperatures being monitored to ensure correct temperatures were achieved to avoid food spoilage. Findings:

Review of the Infection Control Program/Surveillance Log Book revealed there lacked hospital-wide indicators and the only indicators developed were for Nursing Services to report patients admitted with infections or if a patient developed and infection while hospitalized.

Review of Infection Control policy #IC 7.011, titled "Subject: Refrigerator/Freezer Temperatures" revealed: "I. POLICY It is the policy of this facility...regarding refrigerator/freezer temperatures. II. PURPOSE To prevent or control the spread of infectious diseases and maintain proper temperatures for food products, equipment,...III. PROCEDURE A. TEMPERATURES-Food Storage 1. REFRIGERATOR temperatures will be maintained between 34-40 degrees F. 2. FREEZER temperatures should be 0 degrees F. or below...4. TEMPERATURE RECORDING: Temperatures will be monitore twice daily and recorded on the refrigerator temp flow sheet by the C.N.A. per shift in all refrigerators/freezers where food is stored..."

Review of Infection Control policy #IC 5.001 titled "Subject: Dietary Department" revealed: "...II. PURPOSE To prevent or control spread of infectious diseases...III...3. FOOD PROCUREMENT/STORAGE...d. TEMPERATURE RANGES: ...Food in the refrigerator will be discarded after two (2) hours at temperatures above 45 degrees F...e. ALL FOOD and supplies, whether refrigerated, frozen or in the storeroom, will be clearly labeled for easy identification..."

Review of the Governing Body/Medical Staff meeting minutes (dated 07/18/11, 04/25/11, 01/24/11 and 10/28/10) revealed there failed to be evidence the hospital's S1 Administrator/Chief Executive Officer (CEO), Medical Staff nor the Director of Nursing (DON) ensured the hospital-wide QA/PI program addressed infection control concerns at the IOP and that there had not been data related to infection control reported from departments hospital-wide.

When S4 DON was questioned (10/18/11), relative to the IOP and the identification of infection control issues: 1) temperatures not documented for the freezers; 2) S22 Program Director cooking lunch for patients in the kitchen area without monitoring the food temperatures to ensure correct temperature was reached to avoid food borne illnessness; and 3) S22 washing dishes and not aware that a temperature of water must reach 120 degrees F for washing the various dishes/utensils, he replied he was not aware of those occurances. S4 was questioned who was responsible for identification and reporting of infection control issues in the IOP, he replied he was not certain.

S4 DON was questioned who reported Infection Control data to the QAPI Committee, he responded that he was the Infection Control Nurse and stated he should have been reporting.

Interview, on 10/18/11 at 10:50AM, with S4 DON confirmed there had not been data/indicators developed for all departments of the hospital; the only Infection Control data collected was from Nursing Services.

There failed to be evidence the Administrator/CEO, Medical Staff or the DON had monitored the effectiveness of the Infection Control Program to ensure all departments of the hospital had included data/indicators relative to infection control and reported those issues to the QAPI Committee to ensure that training programs were implemented and corrective actions were effected.