HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements of 42 CFR 482.1 as evidenced by failing to be primarily engaged in providing inpatient services. The regulation at 42 CFR 482.1 implements the statutory requirement at Section 1861(e) of the Social Security Act (Act). The regulation requires that: (i) Hospitals participating in Medicare must meet certain specified requirements and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals.

The Act defines hospital as: an institution that ". . . is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons..."

Findings:

Average Daily Census

The hospital's ADC, as provided by S3MR was 0.04 for 2017 and 0.13 for 2018.

On the start of the survey, 4/2/18 at 9:00 a.m., there were no current inpatients in the hospital to directly observe the actual provision of care and services to patients, and the effects of that care.

Review of a hospital list of admission, provided by S3MR, revealed the hospital admitted 15 patients from January 2016 through April 2, 2018. The census on April 2, 2018 was 0.

Month and Year Number of admissions

October 2016 0
November 2016 1
December 2016 3
January 2017 3
February 2017 1
March 2017 0
April 2017 1
May 2017 0
June 2017 0
July 2017 0
August 2017 0
September 2017 2
October 2017 0
November 2017 0
December 2017 0
January 2018 1
February 2018 3
March 2018 0


Type of patients admitted as inpatients and Criteria for Hospital Admission:

In an interview 4/2/18 at 2:25 p.m., S2ADON verified the ADC was 0.04 for 2017 and 0.13 for 2018 (January through March). The ADON indicated that the type of patients admitted to the inpatient hospital beds included patients with infections, those requiring IV fluids (for dehydration), IV antibiotics, patients with unstable blood glucose, with increased oxygen needs, wound care, altered mental status (caused by dehydration and UTIs).

S2ADON reported that the critera for admission was the need for a higher level of care for one of the long term residents in one of the SNF units licensed under the same state license as the hospital. S2ADON further indicated criteria included patients with diagnoses that included pneumonia, UTIs, change in mental status, abnormal blood (glucose that required stabiliation and regulation), and management of infections such as those requiring IV antibiotics. The ADON reported exclusions included patients that needed cardiac, neurology, orthopedic, surgical, and intensive care services, or required artificial ventilation.


Average Length of Stay:

In an interview 4/2/18 at 10:50 a.m. S3MR confirmed the ALOS for 2017 was 3 days, and 3 days for 2018.


Staffing Patterns:

Review of staffing schedules revealed an RN and CNA were assigned to the hospital each shift. In an interview on 4/2/18 at 2:25 p.m., S2ADON verified an RN and a nursing aid were assigned on each 12 hour shift every day, whether or not the hospital had current patients. S2ADON further reported all services were available 24 hours a day, 7 days a week whether or not the hospital had current patients admitted. These included, in part, Pharmacy, Dietary Services, Radiology, and Laboratory. Physicians were onsite during day hours of the week, and on-call nights, weekends, and holidays.


Surgical Services:

Review of services provided revealed no surgical services were provided.


Provider-based off campus departments:

In an interview 4/2/18 at 2:25 p.m. S2ADON reported no outpatient services or off-site departments were provided.


Number of inpatient beds in relation to the size of the facility.

In an interview 4/2/18 at 1:40 p.m., S1ADM verified the 10 bed certified hospital was under a state license from LDH/HSS that included 289 SNF beds, certified under a seperate provider number. S1ADM indicated the 10 STAC hospital beds were used for admission of the facililty's SNF residents only. He indicated the faciliy was known in the community as a Long Term Care facility, and did not admit patients to the STAC hospital from outside the facility. He further indicated that if services not provided by the hospital were needed, the pateints would be transferred to another STAC hospital for that higher level of care and services.


Scope of Services provided:

In an interview 4/2/18 at 2:25 p.m., S2ADON identified the most commonly provided services to hospital patients were IV Therapy, Wound Care, Respiratory, Radiology, Physical Therapy, Laboratory, Nursing, Dietary, Pharmacy, and Physician coverage.

How the facility advertises itself to the community:

The facility is licensed by LDH/HSS for 299 beds and under that license there are 289 long term care beds (SNF/NF), and 10 acute care hospital beds.

In an interview 4/2/18 at 1:40 p.m. S1ADM reported the Villa Feliciana Medical Complex was viewed by the community as a Long Term Facility. The community did not percieve the facility to provide inpatient hospital services to community members. The ADM indicated the hospital only admitted to the certified beds those LTC residents who needed acute care.