Western State Hospital Comparison Of CMS Survey 2015 And .

Western State Hospital Comparison of CMS Survey 2015 and CMS Survey 20171. Repeat Citations: 10 of the 57 citations from the October 2015 survey were repeat citations.2. CMS Survey 2015: 10 B-Tag Citations: Psychiatric Hospital Codes 26 A-Tag Citations: General Hospital Codes 0 K-Tag Citations: Life Safety Codes3. CMS Survey 2017: 0 B-Tag Citations: Psychiatric Hospital Codes 33 A-Tag Citations: General Hospital Codes 24 K-Tag Citations: Life Safety Codes4. General Themes of the 2015 Survey were psychiatric care, active treatment, treatment planning,Quality Improvement Program. Patient rights related to seclusion and restraint.5. General Themes of the 2017 Survey were adequate medical services to patients, patient’s rights as itrelated to safe guard of self-harm, abuse neglect, Quality Improvement Program, Physical plant andLife Safety Codes.A-Tags: Hospital operations Condition level deficiencies2017 CMSCitations(5/25/2017)A043 - 482.12Governing Body2015 CMSCitations(11/5/2015)A022 Licensureof HospitalA043 Gov BodyREPEATED DeficiencyCITATIONNurse staffing plans not postedREPEATEDA049 - 482.12(a)(5)Medical StaffAccountabilityA 115 - 482.13Patient RightsA-083ContractedServicesA 115 PatientrightsWSH CMS Survey Comparison: 2015 vs. 2017Effective systems to ensure patients receive highquality healthcare that meets their needs in a safeenvironment were not developed and maintained.Did not ensure that medical care providers wereconsidered an integral part of the patient's healthcare team; and did not include medical careoutcomes as part of the hospital's quality program.Indeterminate whether pt care contractors met allMedicare Conditions of ParticipationREPEATEDDid not ensure patients receive care in a safesetting which safeguards vulnerable individualsfrom self-harm and harm from others;Page 1 of 9

A118 482.13(a)(2) PatientRights:Grievancespt grievances not promptly addressedA123 482.13(a)(2)(iii)PATIENT RIGHTS:NOTICE OFGRIEVANCEDECISIONResults of the grievance investigation were notshared with the patientA 143 PatientRights: PersonalPrivacyA144- 482.13(c)(2)PATIENT RIGHTS:CARE IN SAFESETTING-A 144 PatientRights: care insafe settingPhysical privacy not providedREPEATEDA145 Patient Rights:Free from Abuse /HarassmentPatient not adequately protected from an incidentof possible exploitation and situation notimmediately assessed when brought to theattention of staffMedical records were not stored in a securelocation not subject to unauthorized access.A. 146 482.13(d)PATIENT RIGHTS:CONFIDENTIALITYOF RECORDSA174 482.13(e)(9)PATIENT RIGHTS:RESTRAINT ORSECLUSION2017. Policies and procedures for use of a handheld metal detector not developed. 2015: patientprivacy curtains not utilizedA 154 Use ofRestraint orseclusionPatients’ rights to be free from restraints were notprotectedA 164: Restraintor SeclusionHospital staff did not take time to consider anddetermine less restrictive interventions wereineffective before restraints were appliedA 169: PatientRights Seclusionand restraintHospital staff members did not write orders forrestraints which were specific to the type andnumber of restraints requited and not on an "asneeded" basisA 174 Patientrights Seclusionand RestraintWSH CMS Survey Comparison: 2015 vs. 2017REPEATEDPatients were not removed from seclusion orrestraint at the earliest possible time regardless ofthe length of time identified in the orderPage 2 of 9

A 175 482.13(e)(10)PATIENT RIGHTS:RESTRAINT ORSECLUSION-A 175 PatientRights Seclusionand RestraintREPEATEDHospital staff did not follow hospital policy tomonitor patients placed in seclusion or restraintsA 194: PatientRights Seclusionand RestraintA 263 482.21 QAPIA 263 QAPINot following policies and procedures forcaring for secluded or restrained patients, riskedphysical and psychological harm, loss of dignity,and violation of patient rights.REPEATEDA 286 PatientSafetyA273 482.21(a),(b)(1),(b)(2)(i), (b)(3)DATA COLLECTION& ANALYSIS-A385 482.23NURSING SERVICESDid not develop, implement or maintain a hospitalwide integrated QAPI program that includedselection of meaningful quality indicators for alldepartments and servicesA 297PerformanceImprovementProjectsDid not develop or implement effectiveperformance improvement plans or projectsrelated to data analysis and goals which thehospital's Governing Body approved in August2015.A 308 QAPIGoverning BodyDid not develop or implement a hospital-wide planto monitor, evaluate, and improve the quality ofpatient care services through data collection andanalysis.A 309 QAPIExecutiveResponsibilitiesDid not develop or implement a quality assessmentand performance improvement (QAPI) plan.A 385 NursingServicesREPEATEDA 392 Staffingand Delivery ofCareA396 482.23(b)(4)NURSING CAREPLAN-Did not develop a hospital-wide quality assessmentand performance improvement (QAPI) plan tomonitor, evaluate, and improve the quality ofpatient care services through systematic datacollection and analysis.Did not develop or implement effectiveperformance improvementplans and projects to address patient safety.A 396 NursingCare PlanWSH CMS Survey Comparison: 2015 vs. 2017Nursing care provided by nursing staff membersnot provided in accordance with the patient'shealth care needs.Facility was not staffed with sufficient number ofnursing personnel to provide safe effective care topatients.REPEATEDStaff did not develop and initiate care plans forpatientsPage 3 of 9

A 397 PatientCareAssignmentsA 405 482.23(c)(1),(c)(1)(i) & (c)(2)ADMINISTRATIONOF DRUGSDid not follow hospital policy to ensure a registerednurse (RN) was responsible for assigning thenursing care of each patient to other nursingpersonnel.Hospital staff members did not follow itsprocedure to identify patients prior to medicationadministration.A 450 482.24(c)(1)MEDICAL RECORDSERVICESHealth care staff did not follow hospital chartingrequirements when charting in medical records(accurate, legible, dated and timed)A 528 482.26RADIOLOGICSERVICES-Radiologic services were not properly operated ormaintained.A 535 482.26(b)SAFETY POLICYANDPROCEDURESRadiological services policies and procedures werenot periodically reviewed and revised to reflectcurrent standards of practiceA 536 482.26(b)(1)SAFETY FORPATIENTSANDPERSONNELDid not follow hospital policy to ensure that leadshielding vests were tested to ensure efficacy andsafety.A546 482.26(c),(c)(1) RADIOLOGISTRESPONSIBILITIESIonizing radiology services were not supervised bya radiologist.A620 482.28(a)(1)DIRECTOR OFDIETARY SERVICESDid not comply with the food safety requirementsof the 2009 Federal Drug Administration Food Code- failed to implement food safety requirements(hand hygiene, food safety)Did not implement its utilization review plan forservices provided to hospital patients.A652 482.30Utilization ReviewA658 482.30(f)REVIEW OFPROFESSIONALSERVICES-Professional services not reviewed as part of theUtilization Review program.A 700 482.41PHYSICALENVIRONMENTDid not provide a safe and secure environment forpatients.WSH CMS Survey Comparison: 2015 vs. 2017Page 4 of 9

A710482.41(b)(1)(2)(3)LIFE SAFETY FROMFIREDid not meet the requirements of the 2012 editionof the National Fire Protection Association (NFPA)101 - Life Safety Code (LSC) and 2012 edition of theNFPA 99 - Health Care Facilities Code (HCFC).A 724 CEA726 tem #1 - Expired Supplies –Patient care suppliesexceeded their designated expiration dates.Did not maintain air pressure relationshipsconsistent with industry standards for ventilation inhealthcare facilities.A 747 InfectionControlA 749 482.42(a)(1)INFECTIONCONTROLPROGRAM - N95A806 482.43(b)(1),(3), (4) DischargePlanning NeedsAssessmentDid not develop and implement an effectiveinfection prevention and control program.A 749 InfectionControl ProgramREPEATEDDid not implement its N95 respirator fit testingprogram.A 806 DischargePlanning NeedsAssessmentREPEATEDLack of written discharge planning policy thatincluded key members of the discharge teamputting patients on the discharge list withoutadequate assessmentA 843Reassessment ofDischargePlanning ProcessDid not use readmission data collected by theUtilization Review staff to evaluate theeffectiveness of discharge plans.A1123 482.52REHABILITATIONSERVICESDid not organize or staff rehabilitation services toensure the health and safety of patients.A1124 482.56(a)ORGANIZATION OFREHABILITATIONSERVICESOrganization and staffing of physical therapyservices was not appropriate to the scope ofservices offered.A1125 482.56(a)(1)DIRECTOR OFREHABILITATIONSERVICESDid not ensure that an individual directed theoverall operations of occupational therapy services.WSH CMS Survey Comparison: 2015 vs. 2017Page 5 of 9

A1132 482.56(b)ORDERS FORREHABILITATIONSERVICESDid not ensure that orders are written by a MDprior to performing therapeutic servicesA1133 482.56(b)(1)DELIVERY OFSERVICESDid not ensure that rehab services weredocumented in the medical recordA1134 482.56(b)(2)DELIVERY OFSERVICESDid not follow physical therapy recommendationsand the pt treatment plan to ensure alterations todurable medical equipment were completedB-Tags: Psychiatric hospital Condition level deficiencies2017 CMS Citations2015 CMS CitationsDeficiencyB 103Spec Med RecordsB 118Treatment PlanDid not provide treatment plan revisions, activetreatment, or assure continuity of careMaster treatment plans not providedB 125Active TreatmentB 136 Special StaffRequests for psychhospitalActive treatment or alternative interventions notprovided* Assure patient care was under the guidance of aqualified clinical director.* Assure clinical director was qualified perregulations ** Assure that monitoring of patient care andpsychiatric staff concerns for patient care wereaddressed.* Provide adequate numbers of RN's, LPN's, andMHT's to supervise and monitor patients.* Assure adequate activity staff to provide dailyinterventions for patientsDid not provide supervisor if a clinical directorservice chief or equivalent who is qualified toprovide the leadership required for an intensivetreatment program.Clinical Director did not meet the training andexperience by the American Board of Psychiatryand Neurology.No Citations for 2017B 141Director InpatientB 143Medical StaffWSH CMS Survey Comparison: 2015 vs. 2017Page 6 of 9