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1. Based on review of documents and interview with staff no evidence could be provided to confirm that services performed under a contract are provided in a safe and effective manner. This requirement was not met as follows:

Findings:

a. In review of the list of contracted services at the facility, documentation on how these services were evaluated and services were being provided in a safe and effective manner could not be proven.

b. Interviewed staff #1, Director of Quality at 10:00am and staff #2, Interim Chief Executive Officer on November 18, 2010 in the administration conference. Staff's #1 and #2 could not provide evidence that there was a mechanism to evaluate contracted services in the facility to prove that they were being provided in a safe and effective manner.

Based upon review of credentialing files facility policy and medical staff minutes and interview with staff the medical staff does not examine credentials for medical staff membership on the appointment of candidates. This requirement was not met as follows:

Findings:

a. Reviewed the credentialing files of 18 (1-18) physicians on the medical staff. It was observed that 17 out of the 18 physician credential files reviewed (94%) (files # 1,2,3,4,5,6,7,8,9,11,12,13,14,15,16,17 and #18) had credentialing information contained within the files that was expired. This information included expired physician ' s license (11 out of 18 =61%), department of public safety controlled substances registrations (DPS) (14 out of 18 =78%), drug enforcement administration (DEA) licenses (8 out of 18 =44%) and liability insurance (16 out of 18=89%) that were expired. There were reappointments of physicians that were past due and over 2 years old (6 out of 18 =33%) the facility requirement was that appointments to the active medical staff was good for only 2 years.

b. The Bylaws of the Medical Staff on page 2 under article II Purpose and Responsibilities section 1. Purpose states" The purpose of the Association......will assist in screening applicants for Medical Staff membership". The "Association" is another name for the Medical Staff. On page 3 of this policy under the section "Qualification" it states The Medical Staff shall be composed of Practitioners who can provide evidence of a current valid license issued by the state of Texas and must have a forced" professional liability insurance in not less than the minimum amount of $100, 000 per occurrence, $300,000 aggregate coverage." On page 4 of this policy under "Term of Appointment" for initial appointments it states " All other initial appointments to the Medical Staff..... will not be more than two years." On the section for reappointments this policy states "Reappointment to any category of the Medical Staff shall be for a period of not more than two years.

c. Interviewed staff#2, Interim Chief Executive Officer and staff #2 Director of Quality at 9:20am on November 17, 2010 in the administration board room who explained that they were recently notified on the evening of November 16, 2010 by a staff member responsible for organizing and updating the physician credentialing files that these files had not been updated in about 1 year. The staff member resigned from this position and administration is currently seeking a person to fill this newly vacant position. The medical staff which was suppose to examine the credential of candidates basically took the recommendation from this staff member who was responsible for organizing and updating the medical staff credentialing files that the credential in these files were updated and the medical staff member was eligible for appointment or reappointments. There were no checks and balance system in place to ensure that the credentials of these physicians were actually reviewed by a credentialing committee before a recommendation was given to the governing body on the appointments of these candidates. The staff members interviewed could not provide evidence that the requirements for this regulation were met.

d. Research was conducted through the Texas Medical Licensing board and Texas Department of Public Safety to check these physician (permits) licenses and controlled substances registration during this survey to see if these items were current and all 18 out of the 18 physician licenses and DPS registrations were current in these system. This confirmed that the updated information was not accessed and updated by the staff member responsible for updating these credentialing files as well as the information in the files not being examined by a the medical staff. Surveyors were unable to obtain information on current status of the Drug Enforcement Administration licenses and the physician liability insurance on these physicians.

Based upon review of credentialing files facility policy and medical staff minutes and interview with staff the medical staff does not examine credentials for medical staff membership on the appointment of candidates. This requirement was not met as follows:

Findings:

a. Reviewed the credentialing files of 18 (1-18) physicians on the medical staff. It was observed that 17 out of the 18 physician credential files reviewed (94%) (files # 1,2,3,4,5,6,7,8,9,11,12,13,14,15,16,17 and #18) had credentialing information contained within the files that was expired. This information included expired physician ' s license (11 out of 18 =61%), department of public safety controlled substances registrations (DPS) (14 out of 18 =78%), drug enforcement administration (DEA) licenses (8 out of 18 =44%) and liability insurance (16 out of 18=89%) that were expired. There were reappointments of physicians that were past due and over 2 years old (6 out of 18 =33%) the facility requirement was that appointments to the active medical staff was good for only 2 years.

b. The Bylaws of the Medical Staff on page 2 under article II Purpose and Responsibilities section 1. Purpose states" The purpose of the Association......will assist in screening applicants for Medical Staff membership". The "Association" is another name for the Medical Staff. On page 3 of this policy under the section "Qualification" it states The Medical Staff shall be composed of Practitioners who can provide evidence of a current valid license issued by the state of Texas and must have a forced" professional liability insurance in not less than the minimum amount of $100, 000 per occurrence, $300,000 aggregate coverage." On page 4 of this policy under "Term of Appointment" for initial appointments it states " All other initial appointments to the Medical Staff..... will not be more than two years." On the section for reappointments this policy states "Reappointment to any category of the Medical Staff shall be for a period of not more than two years.

c. Interviewed staff#2 ,Interim Chief Executive Officer and staff #2 Director of Quality at 9:20am on November 17, 2010 in the administration board room who explained that they were recently notified on the evening of November 16, 2010 by a staff member responsible for organizing and updating the physician credentialing files that these files had not been updated in about 1 year. The staff member resigned from this position and administration is currently seeking a person to fill this newly vacant position. The medical staff which was suppose to examine the credential of candidates basically took the recommendation from this staff member who was responsible for organizing and updating the medical staff credentialing files that the credential in these files were updated and the medical staff member was eligible for appointment or reappointments. There were no checks and balance in place to ensure that the credentials of these physicians were actually reviewed by a credentialing committee before a recommendation was given to the governing body on the appointments of these candidates. The staff members interviewed could not provide evidence that the requirements for this regulation were met.

d. Research was conducted through the Texas Medical Licensing board and Texas Department of Public Safety to check these physician (permits) licenses and controlled substances registration during this survey to see if these items were current and all 18 out of the 18 physician licenses and DPS registrations were current in these system. This confirmed that the updated information was not accessed and updated by the staff member responsible for updating these credentialing files as well as the information in the files not being examined by a the medical staff. Surveyors were unable to obtain information on current status of the Drug Enforcement Administration licenses and the physician liability insurance on these physicians. The medical staff bylaws policy on credentialing files was not enforce.

1. Based on review of 22 medical records (MR) both open and closed and interview with staff it was observed that there was frequent use of verbal order in these medical records. This requirement was not met as follows:

Findings:

a. In reviewing 22 medical records (MR 1-22)) it was observed that in 22 of 22 (100%) medical records reviewed (MR# 1-22) contained evidence of frequent use (3 -5 per day) of verbal orders.

b. Interviewed staff #1, Director of Quality and staff #11,Chief Nursing Officer at 2:30pm on November 17, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff interviewed agreed could not provide evidence that this requirement was met.

1. Based upon review of 22 medical records (MR) both closed and open and interview with staff it was observed that medical records were not promptly completed, dated and timed. This requirement was not met as follows:

Findings:

a. After review of medical records (MR 1-22) it was observed that there were 22 out of 22 (100%) of medical records (MR# 1-22) that were incomplete after 30 days of discharge. These medical records had medical documentation entries that were either not timed, dated or signed by the practitioner this included physician progress notes, physician orders and discharge summaries. There were 22 out of 22 (100%) medical records (1-22) that had verbal orders that were not timed, dated and/or authenticated by the physician within 48 hours of being given verbally. There were 8 out of 22 (36%) medical records (MR# 7,8,9,10,11,12,18 and MR#19) that did not contain discharge summaries, There were 2 out of 22 (9%) (MR #9 and MR#17) that had progress notes that were not signed. .

b. Interviewed staff #1, Director of Quality and staff #11, Chief Nursing Officer at 2:30pm on November 17, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff agreed and could not provided evidence that this requirement was met.

1. Based upon review of 22 medical records (MR) both closed and open and interview with staff it was observed that verbal orders were not authenticated within 48 hours. This requirement was not met as follows:

Findings:

a. After review of medical records (MR 1-22) it was observed there were 22 out of 22 (100%) medical records (1-22) that had verbal orders that were not timed, dated and/or authenticated by the physician within 48 hours of being given verbally. .

b. Interviewed staff #1, Director of Quality and staff #11, Chief Nursing Officer at 2:30pm on November 17, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff agreed and could not provided evidence that this requirement was met.

1. Based upon review of 22 medical records (MR) and interview with staff it was observed that there were medical records that did not contain discharge summaries with outcome of hospitalization, the case disposition, and any provisions for follow-up care. This requirement was not met as follows:

Findings:

a. After review of medical records (MR 1-22) it was observed that there were 22 out of 22 (100%) of medical records (MR# 1-22) that there were 8 out of 22 (36%) medical records (MR# 7,8,9,10,11,12,18 and MR#19) that did not contain discharge summaries.

b. Interviewed staff #1, Director of Quality and staff #11, Chief Nursing Officer at 2:30pm on November 17, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff agreed and could not provided evidence that this requirement was met.

1. Based upon review of 22 medical records (MR) both closed and open and interview with staff it was observed that medical records were not promptly completed within 30 days of discharge. This requirement was not met as follows:

Findings:

a. After review of medical records (MR 1-24) it was observed that there were 22 out of 22 (100%) of medical records (MR# 1-22) that were incomplete after 30 days of discharge. These medical records had medical documentation entries that were either not timed, dated or signed by the practitioner this included physician progress notes, physician orders and discharge summaries. There were 22 out of 22 (100%) medical records (1-22) that had verbal orders that were not timed, dated and/or authenticated by the physician within 48 hours of being given verbally. There were 8 out of 22 (36%) medical records (MR# 7,8,9,10,11,12,18 and MR#19) that did not contain discharge summaries, There were 2 out of 22 (9%) (MR #9 and MR#17) that had progress notes that were not signed.

b. Interviewed staff #1, Director of Quality and staff #11, Chief Nursing Officer at 2:30pm on November 17, 2010 in the administration conference room and showed and explained the deficiencies in the medical record. Staff agreed and could not provided evidence that this requirement was met.

1. Based on observation and interview with staff there was no evidence of the facility having a current therapeutic diet manual approved by the dietician and medical staff readily available to all medical, nursing, and food service personnel. This requirement was not met as follows:

Finding:

a. Based upon tour of the facility's kitchen with staff # 4, Dietician/Food Service Manager it was observed that the facility did not have a current therapeutic diet manual there was a therapeutic manual from 2003.

b. In an interview with staff #4, Dietician/Food Service Manager at 10:00am on November 17, 2010 this staff member could not provide evidence of having a current therapeutic manual in the facility. This staff member could not provide evidence that this requirement was met.