PRINTED: 09/26/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 374024 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6262 SOUTH SHERIDAN ROAD SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM (X4) ID PREFIX TAG 08/24/2017 TULSA, OK 74133 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A 000} INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {A 000} On 08/23/17 and 08/24/17, Oklahoma State Department of Health surveyors conducted an unannounced revisit survey for the complaint survey conducted on 05/04/17. On 08/23/17 at 12:03 pm, during a tour of the facility, the surveyors observed: *Children's Unit (SW1) ages 4-12 years / 12 beds: No patients were admitted on the unit. Staff A stated the unit was not closed, but had no patients. *Adolescent Units (1 West) ages 12-17 years / 16 beds: One patients was admitted on the unit. *Adolescent Unit (3 West) ages 12-17 years / 8 beds: No patients were admitted on the unit, and Staff A stated the unit was closed. *Adult Unit: 24 beds had a census of 12 patients. On 08/24/147 at 11:43 am, the CEO stated, due to the loss of their Healthcare Authority (HCA) contract on 08/07/17, multiple patients had been transferred to other facilities. He stated the hospital had worked in conjuction with HCA to transfer patients to other facilities. Standard level deficiencies were cited as a result of the revisit survey. The following abbreviations may be found within this document: CEO= Chief Executive officer HCA= Health Care Authority {A 049} 482.12(a)(5) MEDICAL STAFF ACCOUNTABILITY {A 049} [The governing body must] ensure that the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 02UO12 Facility ID: HP2240 If continuation sheet Page 1 of 5 PRINTED: 09/26/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 374024 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6262 SOUTH SHERIDAN ROAD SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM (X4) ID PREFIX TAG 08/24/2017 TULSA, OK 74133 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A 049} Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {A 049} medical staff is accountable to the governing body for the quality of care provided to patients. This STANDARD is not met as evidenced by: Based on record review and interview, the hospital's governing body failed to establish a policy and processes that clearly defined and distinguished between child and adolescent. This failed practice had the potential to negatively affect the child population, by exposing them to inappropriate peers and creating a less therapeutic milieu in an older population. Findings: A review of the hospital document titled, "Shadow Mountain Continuum of Care" showed the patient treatment programs for both the acute units and PTRF (psychiatric treatment residual facility) units. The acute units were as follows: *SW1 Pediatric Acute age 4-11 [years,] *1 West age 12-17 [years], *3 West Transition age 12-14+ [years] A review of hospital policy titled, "Unit Assignment 06/17" documented its purpose as ensuring patients were treated in environments appropriate to their age and development. The policy documented a formal assessment and order set form would be completed by a Qualified Mental Health Professional or physician. On 08/23/17 at 2:00 pm, Staff A, provided a document titled, "Justification for admission or transfer of a child or adolescent to a treatment unit, not congruent with chronological age", and stated a patient's physician would complete an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 02UO12 Facility ID: HP2240 If continuation sheet Page 2 of 5 PRINTED: 09/26/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 374024 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6262 SOUTH SHERIDAN ROAD SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM (X4) ID PREFIX TAG 08/24/2017 TULSA, OK 74133 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A 049} Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {A 049} order set at time of admission . The document described patient descriptions that would provide the rationale for the qualified mental health professional designating a specific unit to which the patient would be admitted. Examples of some of the descriptions were: *"This patient is a low functioning child, immature 12 year old and will be admitted to the Child Unit that has patients with which this patient will be able to interact and function appropriately". *This patient is a small 12 year old and will be admitted to the Child Unit that has patients with which this patient will be able to interact and function appropriately". *This patient is a child exhibiting advanced maturity will be admitted to their advanced thinking/maturity/development to the Adolescent Unit..." A review of medical records showed 2 of 2 twelve year old patients (Patient #1 and # 2) contained no order designating which unit would meet their needs at time of admission. On 08/24/17 at 11:30 am, Staff A stated a copy of Patient#1's unit order was found in admitting. The order was completed by a Social Worker. On 08/24/17 at 12:40 pm, Staff A stated no unit order set was found for Patient# 2. A 273 482.21(a), (b)(1),(b)(2)(i), (b)(3) DATA COLLECTION & ANALYSIS A 273 (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 02UO12 Facility ID: HP2240 If continuation sheet Page 3 of 5 PRINTED: 09/26/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 374024 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6262 SOUTH SHERIDAN ROAD SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM (X4) ID PREFIX TAG 08/24/2017 TULSA, OK 74133 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 273 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 273 track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization. (2) The hospital must use the data collected to-(i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to create a quality improvement program which included the tracking, analysis, and identification of improvement opportunities for the patients requiring a higher level of care due to acute medical needs. This failed practice had the potential to increase the risk of all psychiatric patients with acute medical conditions that required transfer to a higher level of care. Findings: A review of hospital document titled, "Performance Improvement- June Analysis of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 02UO12 Facility ID: HP2240 If continuation sheet Page 4 of 5 PRINTED: 09/26/2017 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 374024 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6262 SOUTH SHERIDAN ROAD SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM (X4) ID PREFIX TAG 08/24/2017 TULSA, OK 74133 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 273 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 273 Medical Transfers: Acute" documented the occurrence of 4 patients transferred from the Adult Unit and 1 patient from the Pediatric Unit. A review of hospital document titled, "Performance Improvement- July Analysis of Medical Transfers: Acute" documented the occurrence of 1 patient transferred from the Adult Unit and 1 patient from the Pediatric Unit. Both documents provided no evidence that each transfer was reviewed in such a manner as to identify opportunities for improvement of nursing or medical management. The improvement actions within the document were not linked to specific issues identified in the case reviews, and the documentation did not illustrate how the actions would minimize the risk of future occurrences of the issues. On 08/24/17 at 11:30 am, Staff A stated the performance improvement project for the analysis of transfers was in its developmental stage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 02UO12 Facility ID: HP2240 If continuation sheet Page 5 of 5