HospitalInspections.org

Based on interview and record review the Hospital's Governing Body:

-Failed to ensure that the Quality Assurance Program was hospital-wide
(Cross reference QAPI - 482.21)

-Failed to ensure that 134 outpatients received appropriate Discharge Planning once the hospital's Partial Hospitalization Programs were suspended.
(Cross reference Discharge Planning - 482.43)

Findings:

Record review of the Governing Board Meeting minutes dated 10/7/12 stated "Quality Management: 2012 Quality Plan, Quality Dashboard, and Performance Improvement Policy Manual submitted for approval. The radiology contract was submitted for review and approval..." The meeting minutes did not have any supporting documentation of the Quality Dashboard that was submitted for approval.

Record review of a policy titled "Governing Board Orientation" dated August 1, 2012 stated "II. Quality Improvement: The hospital Governing Board has the overall responsibility for the quality of patient care..."

Based on interviews and records review, the hospital failed to have a hospital-wide, data driven quality assessment and performance improvement program. Since August 24, 2012, when the hospital opened, the hospital failed to establish quality indicators for the offsite outpatient Partial Hospitalization Programs, the contracted Radiology department, the Dietary department and the Emergency Treatment Room.

Findings include:

The Chief Clinical Officer (CCO) stated 4/3/13 at 8:30 a.m. the hospital provides inpatient services and offsite outpatient partial hospitalization programs. The CCO stated that the Radiology Department was a contracted service.

Record review of inpatient versus outpatient statistics from August 24, 2012 to April 4, 2013 revealed the following:

Inpatient Admissions = 63 patients
Outpatient Services (lab = 0, x-rays = 0, emergency treatment room visits = 8) = 8 patients
Partial Hospitalization Outpatient visits = 24,853 patient visits

(0.3 % of services provided were for inpatient services and 99.7 % of services provided were for outpatient services / primarily Partial Hospitalization Programs (PHP's)

The Outpatient Partial Hospitalization Programs were as follows:

1) Pristine PHP Liberty, 9009 Boone Road, Houston, Texas 77099
(August 24, 2012 to March 15, 2013)

2) Pristine PHP Southwest, 3550 Dairy Ashford, Houston, Texas 77082
(August 24, 2012 to November 12, 2012)

3) Pristine PHP Southwest relocated to 10960 Stancliff Road, Houston, Texas 77072 and was renamed Pristine PHP New Horizon.
(November 13, 2012 to March 15, 2013)

Record review of the "Quality Improvement Committee" meeting minutes dated 10/5/12 and 11/19/12 revealed no discussion regarding the Outpatient Partial Hospitalization Programs which accounted for 99.7% of the hospital's business. The CCO provided two documents dated 12/13/12 and 12/19/12 that listed 24 PHP patients on each document. The documents were a medical record review to ensure proper documents were in each medical record. No Quality Indicators were provided for the PHP's prior to the surveyor's exit on 4/4/13.

Record review of Quality Indicators provided by the Chief Clinical Officer revealed:
-The only quality indicators for the dietary department was for refrigerator temperature checks from September 2012 to January 2013.
-No quality indicators were established for the contracted Radiology service.
-The hospital's emergency treatment room treated 8 patients since opening August 24, 2012. No quality indicators were established for the emergency treatment room.

The COO acknowledged 4/4/13 at 2 p.m.:
-The only indicators for the dietary department are refrigerator temperature checks and patient satisfaction reviews
-The contracted Radiology company has their own quality assurance
-No formal quality indicators have been established for the Outpatient Partial Hospitalization Program or the Emergency Treatment Room.

Record review of a policy titled "Performance Improvement, Medical Error Reduction and Patient Safety Policy" dated August 1, 2012 stated "Policy: To build a safer care environment by designing processes of care to ensure that patients are safe from preventable injury...To implement a planned, systematic, organization wide approach to performance improvement and safety improvement that responds to organizational priorities and is inclusive of the scope of care and services provided.........Governance: The Governing Board shall require a planned, systematic, organization-wide approach to designing, measuring, assessing and improving processes and performance."

Based on interviews and records review, the Hospital failed to have an effective discharge planning process. The Hospital suspended outpatient services at two Partial Hospitalization Programs (PHP's) on 3/15/13 and failed to provide discharge planning/teaching for the 134 active outpatients that were enrolled in the program.

#1) Pristine Hospital PHP Liberty, 9009 Boone Road, Houston, Texas 77099
#2) Pristine Hospital PHP New Horizons, 10960 Stancliff Road, Houston, Texas 77099

Findings include:

Interview 4/3/13 at 8:30 a.m. with the Chief Clinical Officer (ID# 2) revealed the hospital had opened two outpatient offsite Partial Hospitalization Programs 8/24/12. The CCO stated the hospital suspended both PHP programs on 3/15/13. The CCO acknowledged that due to a current hold on their CMS funds the hospital elected to suspend all outpatient PHP services until funding becomes available.

Record review of two outpatient PHP medical records (ID#'s 1 and 2) revealed they were actively enrolled in the PHP program when the Hospital suspended services on 3/15/13.

Patient ID# 1's medical record revealed they were admitted 3/4/13 with a diagnosis of Depression and Psychosis. The last physician progress note was dated 3/11/13. The record failed to have a physician order to discharge the patient and there was no documented discharge planning or teaching.

Patient ID# 2's medical record revealed they were admitted 1/7/13 with a diagnosis of Major Depressive Disorder and Anxiety. The last physician progress note was dated 3/15/13. The record failed to have physician order to discharge the patient and there was no documented discharge planning or teaching.

Interview 4/4/13 at 9 a.m. with the Chief Clinical Officer (COO) revealed that patient
ID#'s 1 and 2 were still considered "Active" patients of the Partial Hospitalization Program. The CCO acknowledged that the Hospital failed to follow their formal discharge planning process for the 134 actively enrolled patients in the PHP once the program was suspended.

Record review of a list of active outpatients at the offsite PHP ' s on 3/15/13 revealed:

1) Pristine PHP Liberty: 47 outpatients were active when the program was suspended on 3/15/13.
2) Pristine PHP New Horizon: 87 outpatients were active when the program was suspended on 3/15/13.

Interview 4/3/13 at 11 a.m. with the Medical Director revealed the Hospital has temporarily stopped the operation of the outpatient Partial Hospitalization Programs due to funding issues. When questioned about what happened to the 134 actively enrolled patients in the outpatient program the Medical Director stated "We just gave the PHP patients an extended break."

Record review of a policy titled "Discharge of a Patient" dated August 1, 2012 stated "Purpose: To provide for continuity of care...Policy: A physician's written order is required...Patient Education: Document all teaching in the interdisciplinary discharge summary.."

Record review of a policy titled "Discharge Planning" dated August 1, 2012 stated
- "Purpose: To optimize compliance with post-hospital plan of care..."
- "Required documentation: The following information must be documented in the patient's discharge not or on appropriate approved forms in the medical record:"
1.) Provision of all discharge-related patient / responsible caregiver education.
2.) Availability of transportation
3.) Assessment of availability of family / other caregiver and their readiness to assist with the care of the patient at home.
4.) Availability of assistance from community resources, including referrals to other health care agencies, as appropriate.
5.) Availability of medical equipment, supplies, and medication as indicated.
6.) Follow-up plan

The Hospital failed to ensure that a total of 134 patients with psychiatric disorders were provided discharge planning / teaching upon the suspension of their outpatient Partial Hospitalization Programs.