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Based on a review of available documentation and staff interviews, it was determined that the facility failed to have an effective Governing Body legally responsible for the conduct of the facility as an institution.

Findings were:

The facility was informed during the entrance conference on 1/8/13 at approximately 2:30 PM that the surveyors would need to review the Governing Body meeting minutes, bylaws, and programs. During an interview with the Chief Executive Officer the morning of 1/9/13, she stated that she was unable to retrieve any Governing Body documentation because the hard-drive that contained the information crashed. During an interview with the Chief Operations Officer the afternoon of 1/9/13, he stated that the governing body did hold meetings and provided documentation of several Governing Body agendas (not minutes) from previous years (2007 - 2010). As of the exit conference on 1/9/13, at approximately 5:00 PM, there was no documented evidence provided to the surveyors demonstrating an active governing body that assumed responsibility, control, management and oversight of the hospital.

Review of the " Article XII Committees of the Medical Staff " of the facility Medical Staff Bylaws stated, in part, " Pharmacy and Therapeutic (P&T) ...The P & T Committee meets quarterly. "

In an interview with the pharmacist on 1/9/13 in the conference room, she stated that the P&T committee had not met quarterly in 2012. The pharmacist provided a document entitled " El Paso LTAC Hospital Pharmacy & Therapeutics Committee Meeting Minutes - June 06, 2012 " and stated this was the only meeting held by the P&T committee in 2012. The pharmacist confirmed that the P&T meeting was not held quarterly in 2012 and there was no documented evidence provided that the P&T Committee met quarterly as required.

Review of the " Article XII Committees of the Medical Staff " of the facility Medical Staff Bylaws stated, in part, " The Infection Control Committee ...Meets at least ten (10) times yearly. "

The facility was informed during the entrance conference on 1/8/13 at approximately 2:30 PM that the surveyors would need to review the facility ' s minutes for the Infection Control Committee. In an interview with the Infection Control Director on 1/9/13 in the conference room, she stated that the Infection Control Committee met during the Medical Staff Committee Meeting and she had no documented evidence of committee meeting minutes or reports from the meetings. As of the exit conference on 1/8/13, at approximately 5:00 PM, there was no documented evidence of Infection Control Committee meetings provided to the surveyors for review.

Review of the " Article XII Committees of the Medical Staff " of the facility Medical Staff Bylaws stated, in part, " Improvement of Organizational Performance (IOP) ...Approves and reviews Performance Improvement Teams (PIT). Meets at least ten (10) times yearly. "

The facility was informed during the entrance conference on 1/8/13 at approximately 2:30 PM that the surveyors would need to review the facility ' s QAPI program. As of the exit conference on 1/9/13, at approximately 5:00 PM, the following documents are all that were provided to the surveyors for review:
? QAPI Meeting Minutes dated January 1, 2012
? QAPI Meeting Minutes dated November 14, 2012. These minutes were hand written, and in an interview with the Chief Executive Officer she stated that she wrote them from her memory on 1/9/13.
Cross refer CFR 482.21
Review of facility policy entitled, " Performance Evaluations Competency Assessment, " effective date 10/1/2006, stated, in part, " Documentation of competency will be completed within the first thirty (30) days of employment, but no later than sixty (60) days, at one year and annually thereafter. Annual competency assessments will coincide with performance evaluations. Documentation of performance will be completed within the first ninety (90) days of employment, but no later than 120 days, and annually thereafter. "

Review of facility document entitled, " El Paso LTAC Hospital Staff Development Standards of Practice Registered Nurse Skills Checklist " stated, in part " Skills must be performed under the supervision of the preceptor, charge nurse, supervisor or designee ...Competency testing based on identified needs are initiated and completed within the first 90 days of employment. "

Review of the personnel folders for the following RNs revealed that the RN skills checklist was not completed within the first 90 days of employment:
? Staff # 17 RN date of hire 1/5/09. Checklist completed 3/12 (March 2012).
? Staff #18 RN date of hire 9/21/07. Checklist completed 3/12.
? Staff #8 RN date of hire 7/19/11. Checklist completed 3/12.
? Staff #14 RN date of hire 1/28/10. Checklist completed 3/12.
? Staff #13 RN date of hire 10/15/11. Checklist completed 3/12.
? Staff #15 RN date of hire 8/18/08. Checklist completed 3/12.
? Staff #12 RN date of hire 1/17/10 - no documented evidence provided of completed competency skills checklist.

" El Paso LTAC Hospital Staff Development Standards of Practice Licensed Practical/Vocational Skills Checklist " stated, in part " Skills must be performed under the supervision of the preceptor, charge nurse, supervisor or designee ...Competency testing based on identified needs are initiated and completed within the first 90 days of employment. "
? Review of the personnel folder for Staff #16 LVN revealed a date of hire of 2/12/09. The LVN skills checklist was not completed until 3/12 (March 2012).

Review of the personnel folders revealed no documented evidence that annual performance evaluations were conducted for 11 of 12 licensed personnel (Staff # 3, 11, 12, 13, 15, 16, 17, 18, 19, 20, and 25).

Review of facility policy entitled, " Employment Reference Checks " stated, in part, " To ensure that individuals who join El Paso LTAC Hospital are well qualified and have a strong potential to be productive and successful, it is the policy of El Paso LTAC Hospital to check the employment references of all applicants. "

Review of the personnel folders revealed no documented evidence that employment reference checks were conducted for 11 of 12 licensed personnel (Staff #3, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 25).

The facility failed to conduct Medical Staff meetings as required by Medical Staff Bylaws.
Cross refer CFR 482.12(a)(5)

The facility failed to ensure that the infection control program was active in the prevention, control, and investigation of infections and communicable diseases in accordance with nationally recognized infection control practices and guidelines as the Infection Control Plan and the Infection Control Policies and Procedures had not been reviewed or revised, performance improvement projects were not conducted as planned, and training was not based on nationally recognized infection control practices.
Cross refer CFR 482.42

The facility failed to ensure that the Infection Control Director was qualified by on-going education, training or certification in Infection Control.
Cross refer CFR 482.42(a)

The above was confirmed in an interview with the facility administrator the afternoon of 1/9/13 in the conference room.

Based on record review and interview, it was determined that the facility failed to implement and maintain a quality assessment and performance improvement (QAPI) program.

Findings were:

The facility was informed during the entrance conference on 1/8/13 at approximately 2:30 PM that the surveyors would need to review the facility ' s QAPI program. As of the exit conference on 1/9/13, at approximately 5:00 PM, the following documents are all that were provided to the surveyors for review:
? QAPI Meeting Minutes dated January 1, 2012
? QAPI Meeting Minutes dated November 14, 2012. These minutes were hand written, and in an interview with the Chief Executive Officer she stated that she wrote them from her memory on 1/8/13.
Facility policy entitled " Performance Improvement Plan " stated the following in part: " The El Paso Long Term Acute Care Performance Improvements Plan will support the process to provide a comprehensive plan of measurement and assessment of healthcare processes in order to fulfill the organizations accountability to the Medical Executive Committee, the General Medical Staff and the Governing Board for the provision of quality healthcare and services rendered to all of its customers ...Process Standard A. The Organizational Performance Improvement Plan is designed to systematically monitor, analyze decreased variations and improve healthcare and customer service process outcomes. "

Review of the " Article XII Committees of the Medical Staff " of the facility Medical Staff Bylaws stated, in part, " Improvement of Organizational Performance (IOP) ...Approves and reviews Performance Improvement Teams (PIT). Meets at least ten (10) times yearly. "

During an interview with the Chief Executive Officer on 1/8/13, she stated that she was unable to retrieve any other QAPI documentation because the hard-drive that contained the information crashed.

Based on a review of facility policies, staff interview, and the infection control plan, the facility failed to ensure that the infection control program was active in the prevention, control, and investigation of infections and communicable diseases in accordance with nationally recognized infection control practices and guidelines as the Infection Control Plan and the Infection Control Policies and Procedures had not been reviewed or revised, performance improvement projects were not conducted as planned, and training was not based on nationally recognized infection control practices.

Findings were:

Review of the facility Infection Control Plan for the years 2009, 2010, 2011, 2012, and 2013 revealed that the " Standard " and " Performance " and " Effectiveness " were unchanged from the 2008 document, and were simply copied from year to year, only changing the date on the document. The document for 2009, 2010, 2011, 2012, and 2013 all included the statement, " Review and approve 2008 infection control plan for surveillance indicators " and had not been updated to reflect the current year ' s plan in any of the documents. This was confirmed in an interview with the Infection Control Director the morning of 1/9/13 in the conference room.

Review of the facility " Infection Control 2008 Annual Appraisal " document revealed that " Nosocomial pneumonia is zero on the 1st quarter, 1 case identified on 2nd quarter, zero on 3rd quarter and slightly increased on the 4th quarter but still below the benchmark. " The annual appraisal was merely photocopied from the 2008 document for the following years, 2009, 2010, 2011, 2012, and 2013, with the current year typed in, the same language was in the documents for all years, including the above data on the document for the year 2013, which had not occurred yet (as reviewed by the surveyor on 1/9/2013). That the annual appraisal document was photocopied from the previous year without updating or any change was acknowledged in an interview with the Infection Control Director the afternoon of 1/9/2013 in the conference room.

The requirements of the " 2013 Annual Appraisal " included " Targeted HAI surveillance includes: VAP, Central Line Related bacteremia, SSI and UTI ...IC will maintain records and logs of demographically important nosocomial infection discovered in surveillance process. It includes: a. review of medical records of patients identified with suspected infection and/or infectious process b. positive cultures and history of significant infections c. the chosen method of surveillance is priority directed, targeted surveillance ...Areas in which focused studies are done include: a. surgical site infection (SSI) b. nosocomial infection rates for all patient care units (nosocomial pneumonia, VAP) ...Surveillance is a combination of ...chart audit... " In an interview with the Infection Control Director the morning of 1/9/13 in the conference room, she stated that she did not have documentation to demonstrate that these activities had been conducted.

Review of facility policy entitled, " Departmental Performance Improvement " for the Infection Control Department, effective date January 2008, stated, in part, " All operational standards related to infection control will be reviewed and revised at least every two (2) years by each Department with alterations made based on changes in treatment modalities, changes in equipment, changes in patterns of patient infectious processes, and results of quality assurance monitoring and evaluation activities. " In an interview with the Infection Control Director the morning of 1/9/13 in the conference room, she was unable to provide documented evidence of a review of all operational standards related to infection control.

Review of the Infection Control Policy and Procedure manual revealed an effective date of January 2008, with no subsequent review or revision.

In an interview with the Infection Control Director on 1/9/13 in the conference room, she confirmed that the Infection Control Policy and Procedure manual had not been reviewed or revised since 2008.

Review of the facility document, " Nosocomial Infection Prevention Strategies " stated, in part, " Al El Paso LTAC nosocomial infections are prevented utilizing the following strategies: ...2. Monitor isolation precaution and PPE usage. 3. Monitor central line associated bacteremia. 4. Monitor antibiotic usage. 5. Monitor urinary catheter usage and care practice techniques. 6. Monitor terminal disinfection of rooms. 7. Monitor nosocomial surgical site infection. "
In an interview with the facility Infection Control Director on 1/9/13, she stated she was unable to provide any documented evidence of the above.

Review of facility policy entitled, " Philosophies & Objectives " for the Infection Control Department, effective date January 2008, stated, in part, " The Infection Control Practitioner will tabulate the nosocomial infections and report infection rates and statistics to the Infection Control Committee. In an interview with the Infection Control Director on 1/9/13, she stated that she did not have minutes for Infection Control meetings and was unable to provide documentation which was presented to the Infection Control Committee. No documented evidence of the reports to the Infection Control Committee or the Infection Control Committee minutes was provided to the surveyors for review.

Review of the staff training documents provided by the Infection Control Director the morning of 1/9/13 revealed two stapled documents with a URL from " Wikipedia " and dated 11/4/2011 on the bottom of the documents. The first training document was entitled, " Blood-borne disease From Wikipedia, the free encyclopedia " and the second document was a Wikipedia article on Tuberculosis. From the Wikipedia web site: "Wikipedia is not considered a credible source... This is especially true considering anyone can edit the information given at any time " (). In an interview with the Infection Control Director on 1/9/13 in the conference room, she confirmed that the above documents were the handouts used in staff training on tuberculosis and blood-borne disease.

The following is from the State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals: " The hospital's program for prevention, control and investigation of infections and communicable diseases should be conducted in accordance with nationally recognized infection control practices or guidelines ...Examples of organizations that promulgate nationally recognized infection and communicable disease control guidelines, and/or recommendations include: the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), and the Association of periOperative Registered Nurses (AORN). "

Review of facility policy entitled, " New Employee Orientation " for the Infection Control Department, effective date January 2008, stated, in part, " The Infection Control Program will be a regular part of each General Hospital Orientation Program. 1. The infection Control Practitioner will be responsible for coordinating the provision of orientation materials to new employees. " Review of the personnel folders for 12 of 12 licensed personnel (Staff #3, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 25) did not reveal any documented evidence of infection control training for new employees.

Review of facility policy entitled, " Infection Control Plan " for the Infection Control Department, effective date January 2008, stated, in part, " The infection control process includes at lease (sic) one activity aimed at preventing the transmission of epidemiologically significant infections between patients and staff. "

Review of facility policy entitled, " Departmental Performance Improvement " for the Infection Control Department, effective date January 2008, stated, in part, " The Infection Control Practitioner ... will be responsible for developing, implementing, and evaluating performance improvement activities annually. "

In an interview with the facility Infection Control Director on 1/9/13, she stated that the current infection control performance improvement project/activity was monitoring hand washing using a data collection tool. The most recent document provided to the surveyors for review of the hand washing data collection tool was dated 6/2010. The Infection Control Director confirmed that there had been no monitoring or activity of hand washing, the performance improvement project/activities since 6/2010.

Review of facility policy entitled, " Departmental Performance Improvement " for the Infection Control Department, effective date January 2008, stated, in part, " There will be ongoing, systematic data collection pertaining to ...nursing unit reports, infection rate determination, antibiotic utilization, isolation precautions ...Evaluation of data will be done on an ongoing basis with regularly reported statistics determined as appropriate. " In an interview with the Infection Control Director on 1/9/13, she stated that she did not have this data or any documented evidence of an evaluation of the data. No documented evidence was provided to the surveyors for review.

Review of facility policy entitled, " Criteria for Reports to Committee " for the Infection Control Department, effective date January 2008, stated, in part, " The Infection Control Practitioner/designee will compile statistics and other information to be reported to the Infection Control Committee ...The following criteria/information will be reported: 1. Nosocomial infection rate that defines the infection by type, patient, location, onset of infection, organism(s), and physician ...5. Performance Improvement monitoring and evaluation data for tracking of any problems regarding infections ...Policies and procedures for review/revision ... "

Review of facility policy entitled, " Infection Control Plan " for the Infection Control Department, effective date January 2008, stated, in part, " Surveillance data is reported to the Infection Control Committee, Medical Executive Committee and the board of Directors. "

In an interview with the Infection Control Director the afternoon of 1/9/13, she stated that she did not have any documentation of the reports or documentation of surveillance activities provided to the Infection Control Committee, and she did not have any minutes of the Infection Control Committee meetings. There was no documented evidence of Infection Control Committee reports or meetings provided to the surveyors for review.

During a tour of the facility on 1/8/13, it was determined that the facility failed to maintain a sanitary environment.
Cross refer CFR 482.41(a)

The facility failed to ensure that the Infection Control Director was qualified by on-going education, training or certification in Infection Control.
Cross refer CFR 482.42(a)

The above was confirmed in an interview the afternoon of 1/9/13 in the conference room with the facility administrator.

Based on record review and interview, it was determined that the facility failed to conduct Medical Staff Committee meetings or ensure that the Medical Staff Committee was accountable to the Governing Body as there was no documented evidence provided during the survey.

Findings were:

Review of the " Article XII Committees of the Medical Staff " of the facility Medical Staff Bylaws stated, in part, " The Executive Committee will meet at least ten (10) times yearly and maintain a permanent record of its proceedings and actions ...The Executive Committee shall ...Represent the Medical Staff before the governing body, and be directly accountable to the Governing Body for execution of the duties and responsibilities of the Medical Staff. Carry out all other duties assigned to the Executive Committee in these Bylaws or by the Governing Body. "

The facility was informed during the entrance conference on 1/8/13 at approximately 2:30 PM that the surveyors would need to review the facility ' s minutes for the Medical Staff Committee. As of the exit conference on 1/9/13, at approximately 5:00 PM, there was no documented evidence of Medical Staff Committee meetings provided to the surveyors for review.

The above was confirmed in an interview with the facility administrator the afternoon of 1/9/13 in the conference room.

Based on record review and interview, it was determined that the facility failed to document communication, or attempted communication, of the patient ' s bill of rights for 5 of 19 patients.

Findings were:

Review of patient medical records on 1/9/13 revealed that the following patients did not have a signed patient bill of rights in their record, nor was there evidence that the document was presented and witnessed by two members of the hospital staff, and there was not a note in the medical record signed by the witnesses indicating the reasons for their signatures:
? Patient #4, admitted on 11/0/12
? Patient #5, admitted on 11/13/12
? Patient #9, admitted on 10/31/12
? Patient #14, admitted on 11/3/12
? Patient #15, admitted on 11/20/12
A facility policy entitled " Patient Rights and Responsibilities Policy and Procedure, " effective date 1/1/06, stated the following in part: " The hospital will ensure that within 24 hours after the patient is admitted to the hospital; the Patient Rights described in this policy are explained and a copy, provided to the patient ... "

The above findings were confirmed in an interview with the Chief Executive Officer on 1/9/13.

Based on record review and interview, it was determined that the facility failed to ensure that 3 out of 19 medical records were completed within 30 days following discharge.

Findings were:

Review of patient medical records on 1/9/13 revealed that the following patients did not have completed medical records within 30 days following discharge:
? Patient #15, discharged on 11/23/12, had 1 unsigned history and physical.
? Patient #16, discharged on 11/19/12, had 1 unsigned order, and 4 unsigned dictated physician progress notes.
? Patient #19, discharged on 12/6/12, had 1 unsigned discharge summary.

The above findings were confirmed in an interview with the Chief Executive Officer on 1/9/13.

Based on observation and interview, it was determined that the facility failed to ensure that outdated and mislabeled medications were available for patient use.

Findings were:

During a tour of the facility on the afternoon of 1/8/12, the following observations were made:
Pharmacy:
? 12 individually packaged oral medications in a pill form were expired on 12/16/12, and 8 were expired on 11/11/12. These medications were located with active stock.
Facility policy entitled " Expired and Destroyed Drugs, " reviewed by the facility on 12/28/12, stated the following in part: " Expired medications will include those medications whose expiration date has passed. An indication of month and year will pertain to the last day of that month. Expired medications will be removed from active stock and stored in a secured area. "

Medication room on the 3rd floor:
? A vial of Diltiazem was opened and not dated. This vial was located in the medication refrigerator.
Facility policy entitled " Infection Control: Multiple Dose Vial, " reviewed by the facility on 12/28/12, stated the following in part: " Opened vials will be utilized for 28 days, or the manufacturer ' s expiration date, whichever is first, unless there is evidence of contamination or use of non-aseptic technique ... "

The above findings were confirmed during the same tour with the facility ' s Chief Executive Officer.

Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment.

Findings were:

During a tour of the facility on the afternoon of 1/8/13, the following observations were made:
? In the central supply room, plaster was crumbling and falling off the wall near the window towards the back of the room.
? In the pharmacy, the windowsills were covered with a layer of dust, and high horizontal surfaces were dusty; and in the area where controlled drugs are stored, ceiling tiles were broken and crumbling, and plaster was crumbling and falling off the wall.
The above findings demonstrate insufficient cleaning of surfaces and demonstrate surfaces that would be impossible to clean, thereby creating the potential of cross-contamination of patient supplies and medications.

The above findings were confirmed during the same tour with the facility ' s Chief Executive Officer.

Based on a review of facility policies, personnel records, and staff interviews, the facility failed to ensure that the Infection Control Director was qualified by on-going education, training or certification in Infection Control.

Findings were:

Review of the facility Infection Control " 2013 Annual Appraisal " requirements included " Ensure qualified individual oversaw appropriate and safe administration of IC plan. Participate in on-going educational opportunities to strengthen knowledge and improve effectiveness of clinical practice. "

Review of facility policy entitled, " Infection Control Practitioner Responsibility " for the Infection Control Department, effective date January 2008, stated, in part, " A qualified individual as outlined in the job description will manage the Infection Control Program. Preferably, Certified Infection Control Practitioner or ability to become certified ... "

Review of the Position Description for " Infection Control Coordinator " stated, in part, " Other qualifications ...Must have working knowledge of principles of epidemiology and infectious diseases. "

Review of facility policy entitled, " Infection Control Plan " for the Infection Control Department, effective date January 2008, stated, in part, " Continuing education for the ICP is required to m (sic) maintain current knowledge and practice in Infection Control and Infectious diseases. "

Review of the personnel record for the Infection Control Director revealed no documented evidence of Infection Control training or qualification through ongoing education, training, or certification to oversee the infection control program.

The above findings were confirmed in an interview with the Infection Control Director on 1/9/13 in the conference room, who stated she had attended training in Infection Control, but was unable to provide any documented evidence or information related to Infection Control qualifications.