PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ _ __ c B. WING 504012 NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 000 Initial Comments PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (XS) COMPLETION DATE E 000 MEDICARE COMPLAINT SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 482, conducted this health and safety suiVey. Onsite dates: 03/05/18 to 03/09/18 and 03/12/18 to 03/15/18 Intake number: 79682 The suiVey was conducted by: Lisa Mahoney, MPH, PHA Kimberly Metz, MSN, BSN, RN Elizabeth Gordon, RN, MN Tyler Henning, ScM, MHS, PHA Joyce Williams, RN, BSN Paul Kondrat, RN, MN, MHA During the course of this SUIVey, the DOH suiVeyors determined that there was a high risk of serious harm, injury, and death due to the extent of deficiencies. This resulted in two findings of IMMEDIATE JEOPARDY in the following areas: 1. The hospital did not develop and implement a system to ensure the safety of patients identified as being a danger to self or others (03/05/18, 4:30PM) 2. The hospital failed to provide adequate monitoring of patients admitted for suicidal ideation or assessed at risk for suicide in order to lABORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE TITLE (X6)DATE 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 disclosab!e 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: WOSU11 Facility lD: 013134 If continuation sheet Page 1 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 000 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 E 000 prevent future attempts (03/06/18, 4:45 PM) Removal of the state of IMMEDIATE JEOPARDY for Suicide Risk Asessment was verified on 03/13/18 5:12PM by the DOH survey team. Removal of the state of IMMEDIATE JEOPARDY for Identification of Patients who pose a danger to self or others was verified on 03/14/18 at 12:30 PM by The DOH survey team. Plan of Correction for Each soecific deficiencv ~ DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: (E007) The Hospital failed to provide a policy for providing treatment of special populations during an emergency. 42 CFR 482.12 Governing Body 42 CFR 482.13 Patient Rights Quality Assessment and 42 CFR 482.21 Periormance Improvement 42 CFR 482.22 Medical Staff 42 CFR 482.23 Nursing Services !May 23,2018 Procedure/process for implementing the plan of correction: • E 007 EP Program Patient Population CFR(s): 482.15(a)(3) E 007 [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:] (3) Address patienUclient population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** Policy for providing treatment of special populations during an emergency has been written and will be available under the emergency management section for policies. Monitorin• and Tracking procedures to ensure ~he olan of correction is effective: • • Will be reviewed on an annual basis. Plant operations manager will review the emergency plan and attachments on an annual basis. Process imorovement: Address orocess improvement and demonstrate how the acilitv has incoroorated imorovement actions into its Quality Assessment and Performance '\" - '"'' rev10usvers1onsuosoete t:Vem IU: WUbU- aCII y IU: U"IVI.:!'t 1r con muauon sneer !-"ageL or-, -,u PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 -0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES lmorovement (QAPil oro~ram. Address improvement in systems to prevent the likelihood of re-occurrence of the deficient loractice: • The policy will be communicated to staff and educate on location to find. • Review and any possible revisions will be presented to the safety/EOC committee. After the emergency plan and attachments have been approved will go to the Performance Improvement committee (PI committee). Individual Resoonsible: Zach Keefe, Plant Operations Manager Date Comoleted: May 23,2018 ' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 . Facility ID: 013134 1f continuation sheet Page 3 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO 0938-0391 CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERfCUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c B. WING 504012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 007 Continued From page 2 PROVIDER'S PlAN OF CORRECTION 10 PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5J COMPLETION DATE E 007 *Note: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC, FQHC, or ESRD facilities.] This STANDARD ·is not met as evidenced by: Based on observation and interview, the hospital failed to ensure that the emergency preparedness program adequately addressed the patient population. Failure to have policies and procedures addressing the patient population places patients at risk of injury or death in an emergency. Findings included: 1. Record review of the hospital document titled, "Emergency Operation Plan," showed that the hospital has a clinical services policy for providing treatment of special populations during an emergency. The policy was not included in the emergency operation plan documents. 2. On 03/13/18 from 10:00 AM to 11 :20 AM, Surveyor #2 interviewed the Director of Plant Operations (Staff#201) and the Maintenance Technician (Staff#202) regarding the emergency preparedness program. The director stated that the special populations policy would be a clinical policy and was not in the master emergency plan document list. During the time of the survey, the hospital failed to provide the surveyor with the clinical policy addressing the patient population. E 018 Procedures for Tracking of Staff and Patients CFR(s): 482.15(b)(2) E 018 [(b) Policies and procedures. The [facilities] must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 Jf continuation sheet Page 4 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ _ __ c 504012 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG {X5) COMPLETION DATE Plan of Correction for Each soecific deficien!;Y_ May 23,2018 E 018 Continued From page 3 develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) ofthis section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:] (2) A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICFIIID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICFIIID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice FORM CMS-2567(02-99) Previous Versions Obsolete EventlD: WOSU11 E018~ (E018) The Hospital failed to use a tracking form used to track patients in various circumstances during an emergency. Procedure/process for implementing the plan of correction: • • • Tracking forms will be used in emergency management situations and will be available to staff in the emergency management book located centrally on each floor in the nursing area. HICS form 255 and 260 will be located in the EOP. Staff will be identified and trained to participate in the incident command system. • Plant operations manager is currently taking the incident command ICS 100 FEMA course. • HR director has already completed the ICS 100, 200, 700, and 800, and National Emergency response and rescue training in disaster preparedness. Monitoring and Tracking procedures to ensure he olan of correction is effective: • EOP will be reviewed annually for compliance by the plant operations manager any revisions or recommendations will be presented to the Safety/EOC committee and then to Facility ID: 013134 If continuation sheet Page 5 of 110 PRINTED: 0411012018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO 0938 -0391 CENTERS FOR MEDICARE & MEDICAID SERVICES the PI committee. Process imnrovement: Address nrocess imorovement and demonstrate how the facilitv has incornorated imnrovement actio~s into its Oualitv Assessment and Performance lmnrovement IOAPil nro•ram. Address imorovement in svstems to orevent the likelihood of re-occurrence of the deficient loractice • The forms will be reviewed post Emergency management drills. Review and any possible revisions will • be presented to the safety committee then reported to the PI committee. Individual Resoonsible: 17ach Keefe, Plant Operations Manager Date Comoleted: May 23, 2018 I FORM CMS-2567{02-99) Previous Versions Obsolete Event ID: WOSU11 Facility lD: 013134 If continuation sheet Page 6 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 018 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 E 018 employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at§ 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at§ 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure that the emergency preparedness plan accurately addressed the hospital policy for tracking patients during an emergency. Failure to ensure that the emergency preparedness plan adequately addresses the hospital policy for tracking patients risks the inability to adequately track patients in the event FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 7 of 11 0 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c B. WING 504012 NAME OF PROVIDER OR SUPPLIER 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE 3955156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4)1D PREFIX MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG E 018 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE E 018 of an emergency. Findings included: 1. Record review of the hospital document titled, "Emergency Operation Plan," showed that three tracking forms were to be used to track patients in various circumstances during an emergency. The forms were not found in the emergency preparedness program documents. 2. On 03/13/18 from 10:00 to 11 :20 AM, Surveyor #2 interviewed the Director of Plant Operations (Staff#201) and the Maintenance Technician (Staff #202) regarding the patient tracking forms. The director stated that the forms are not used and a patient roster would be utilized for tracking purposes. The director confirmed that the patient tracking section of the emergency operations plan did not accurately address the process the hospital would use during an emergency. • Arrangement with Other Facilities CFR(s): 482.15(b)(7) E 025 [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 8 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERfCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE ~ay E 025 Continued From page 6 E 025 §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 23,2018 Plan of Correction for Each specific deficiency ~ (E025) The Hospital failed to update the policy to accurately reflect the location of the facility. Procedure/process for implementing the plan of correction: •[for PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. •[For RNHCis at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCis and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure that it had developed arrangements with other facilities to receive patients in the event of the limitation or cessation of operations. Failure to develop arrangements with other facilities regarding the transfer of patients places patients at risk from inadequate care in the event of the limitation or cessation of operations during an emergency. • • The form was updated to local and state requirements. SPBH is currently enrolling in WATrac which will include agreements of transfer during emergency operations. Monitoring and Tracking procedures to ensure ~he olan of correction is effective: • Details ofWATrac and policy updates will be communicated through the safety/EOC committee. Process improvement: Address_process improvement and demonstrate how the lfacilitv has incorp.orated improvement actions !into its Qualitv Assessment and Performance lim_movement (OAPit prQ&I'am. Address improvement in svstems to prevent the likelihood of re-occurrence of the deficient practice • The MOUs will be reviewed post Emergency management drills. • Any revisions or recommendations will be presented to the Safety/EOC committee then to the PI committee. Individual Responsible: FORM CMS-2567(02-99) Previous Versions Obsolete Event lD: WOSU11 Facility ID: 013134 If continuation sheet Page 9 of 11 0 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Plant Operations Manager Date Completed: May 23,2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 10 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER: OMS NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A_ B U I L D I N G - - - - - - - - c B. WING 504012 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 025 Continued From page 7 ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE TAG E 025 Findings included: 1. Record review of the hospital document titled, "Emergency Operation Plan," showed that the facility did not develop prearranged transfer agreements with other facilities to receive patients in the event of an emergency that limits the ability of the hospital to adequately care for patients. 2. On 03/13/18from 10:00\o 11:20AM, Surveyor #2 interviewed the Director of Plant Operations (Staff #201) and the Maintenance Technician (Staff #202) regarding patient transfer agreements with other facilities. The director stated that no transfer agreements were in place, but the facility would rely on the regional hospital coalition to facilitate patient transfers. A defined memorandum of understanding with the regional health care coalition was not developed at the time of review. E 026 Roles Under a Waiver Declared by Secretary CFR(s): 482.15(b)(8) E 026 [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. AI a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 11 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPUER/CUA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING c 504012 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETION DATE ~ay E 026 Continued From page 8 E 026 [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment a( an alternate care site identified by emergency management officials. *[For RNHCis at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure that the emergency preparedness plan accurately addressed the hospital policy for use of alternate care sites. Failure to ensure that the emergency preparedness plan adequately addresses the hospital policy for alternate care sites risks the inability to adequately provide patient care in the event that an alternate location is needed. 23,2018 Plan of Correction for Each soecific deficiencv ~ (E026) The Hospital failed to have the alternate care sites located in the appendix. Procedure/orocess for imolementin~ the olan of co·rrection: • The facility in enrolled region 1 healthcare coalition and WATrac. This will include alternative care sites per the MOU which will be printed and placed in the EOP. Monitorine and Trackin~ orocedures to ensure the olan of correction is effective: • • EOP will be reviewed on annual basis . Any revisions or recommendations will be presented to the Safety/EOC committee then to the PI committee. Findings included: 1. Record review of the hospital document titled, "Emergency Operation Plan," showed that information regarding alternate care sites was to be located in an appendix of the emergency operations plan. No appendix existed at the time of review. 2. On 03/13/18 from 10:00 to 11 :20 AM, Surveyor #2 interviewed the Director of Plant Operations (Staff#201) and the Maintenance Technician (Staff #202) regarding the use of alternate care sites, specifically regarding the appendix that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Process imorovement: Address oro cess imorovement and demonstrate how the acilitv has incoroorated imorovement actions into its Qualitv Assessment and Performance lmorovement IOAPil oro~ram. Address imorovement in svstems to prevent the likelihood of re-occurrence of the deficient !practice: • Forms and procedures will be reviewed for post critique after emergency management drills. Individual Responsible: Facility ID: 013134 If continuation sheet Page 12 of 110 PRINTED: 04/1012018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMS NO 0938 -0391 Plant Operations Manager Date Comoleted: May 23, 2018 FORM CMS-2567{02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 lf continuation sheet Page 13 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERfCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) 10 PREFIX TAG 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE 10 PREFIX TAG (XS) COMPLETION DATE DEFICIENCY) E 026 Continued From page 9 ' E 026 supposed to list information on alternate care sites. The director stated that no appendix exists and this portion of the plan should be amended to accurately reflect hospital operations. E033 Methods for Sharing Information CFR(s): 482.15(c)(4)-(6) E 033 [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.22(c), CORFs under §485.68(c), and RHCs/FQHCs under §491.12(c).] (6) [(4) or (5)]A means of providing information about the general condHion and location of patients under the [facility's] care as permitted under45 CFR 164.510(b)(4). *[For RNHCis at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility ID: 013134 If continuation sheet Page 14 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY COMPLETED A BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE ID PREFIX TAG (X5} COMPLETION DATE DEFICIENCY) Plan of Correction for Each soecific deficiencv May 23,2018 E 033 ~ (E 033) The Hospital failed to update the policy to accurately reflect the location of the facility. E 033 Continued From page 10 made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Procedure/orocess for imolementine the olan of correction: The policies were updated to local and state requirements this included updating location. • • Based on record review and interview, the hospital failed to ensure that its policy re.garding disclosing patient information in an emergency was specifically developed for the hospital's location. SPBH is currently enrolling in WATrac which will include agreements of transfer during emergency operations. Monitoring and Tracking procedures to ensure ~he olan of correction is effective: Failure to ensure that hospital policies accurately identify the hospital's location risks staff inability to effectively implement the policy. • Details of WATrac and policy updates will be communicated through the safety committee. Process improvement: Address orocess imorovement and demonstrate how the ~acili!Y has incoroorated imorovement actions into its Qualitv Assessment and Performance lm_Movement fOAPil proeram. Address improvement in svstems to prevent the likelihood of re-occurrence of the deficient loractice The MOUs and policies will be reviewed post Emergency management drills. Findings included: Record review of the hospital • policy titled, "Authorization to Disclose Patient Information," effective 05/17, showed that the hospital was to follow specific requirements for the state of Georgia regarding the release of patient information. The hospital policy did not address specifics of the location of the hospital. • • • On 03/13/18 at 4:15PM, ,The Director of Health lr'lformation Management (Staff #203) provided the E 034 policy to Surveyor #2 and confirmed via interview that the policy governed disclosure of patient information. Information on Occupancy/Needs FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Any revisions or recommendations will be presented to the Safety/EOC committee then to the PI committee. E 034 Individual Resoonsible: Plant Operations Manager Facility ID: 013134 lf contmuation sheet Page 15 of 110 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES CFR(s): 482.15(c)(7) PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 Date Comoleted: May 23,2018 ( I . FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility 10:013134 If continuation sheet Page 16 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) JD PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE PREFIX TAG (X5) COMPLETION DATE DEFICIENCY) E034 Continued From page 11 E 034 [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: .(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure that the emergency preparedness communication plan contained information on notifying the authority having jurisdiction (AHJ) regarding the hospital's occupancy and ability to provide assistance. Failure to ensure that the emergency preparedness communication plan contained information on notifying the AHJ regarding the hospital's occupancy and ability to provide assistance risks injury or death during an FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Plan of Correction for Each soecific deficiencv May 23,2018 ~ (E034) The Hospital failed to update policies for current facility. Procedure/orocess for imolementin• the olan of correction: • Policy will be updated to current location. This up to date on local and state codes. Monitoring and Tracking orocedures to ensure he olan of correction is effective: • Policies will be reviewed annually . Process improvement: Address process imorovement and demonstrate how the acilitv has incorporated improvement actions into its Oualitv Assessment and Performance Improvement (QAPI) program. Address imorovement in svstems to orevent the likelihood of re-occurrence of the deficient oractice: • • • Policies will be reviewed for accuracy during post emergency management drills. Any revisions or recommendations will be presented to the Safety/EOC committee then to the PI committee. The policy will also address that as not being a Med-surge hospital we do not qualify as the ability to provide assistance for patients with acute medical needs. We will as part of Facility ID: 013134 If continuation sheet Page 17 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO 0938 -0391 WATrac update our occupancy bed availability for behavioral health patients including ability to provide assistance and needs of facility to continue to provide care and services. Individual Resoonsible: Plant Operations Manager Date Comoleted: May 23,2018 FORM CMS-2567 (02-99) Previous Versions Obsolete Event JD: WOSU11 Facility ID: 013134 If continuation sheet Page 18 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ _ _ c 504012 B. WING 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4)10 TAG 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER PREFIX . MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E 034 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE E 034 emergency. Findings included: 1. Record review of the hospital document titled, "Emergency Operation Plan," showed that the hospital did not include information in its communication plan regarding disclosing occupancy or ability to provide assistance to the AHJ. The plan does contain a section regrading communication with the AHJ, but it only mentions notifying the AHJ to help facilitate a response and ensure operations continue. Plan of Correction for Each ~pecific deficien~y_ ,,, 't d· ay 23,2018 C pJ..&= (A 043) The Governing Board failed to provide effective oversight of the hospital and substandard practices. • Under 42 CFR 482.12 Conditions of Participation for Governing Body, 42 CFR 482.13 Condition of Participation for Patient's Rights, 42 CFR 482.21 Condition of Participation for Quality Assessment and Performance Improvement, 42 CFR 482.22 Condition of Participation for Medical Staff, and 42 CFR 482.23 Condition of Participation for Nursing Services 2. On 03/13/18 from 10:00 to 11 :20 AM, Surveyor #2 interviewed the Director of Plant Operations (Staff#201) and the Maintenance Technician (Staff #202) on notification of the AHJ regarding occupancy needs and the ability to provide assistance. The director confirmed that this information was not in the plan and stated the county emergency management program would be theAHJ. A043 A 043 GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... Procedure/orocess for imolementin~ the otan of correction: • • This CONDITION is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete ... 1 Event ID: WOSU11 Beginning April19, 2018 US Healthvest are requesting that the PI Directors be in attendance at the GB meeting and give a short summary of PI issues bein€ worked on. PI Committee including the PI dashboard will be presented to Medical Executive Committee then Fac!hly 10:013134 lf continuation sheet Page 19 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES reported to the Governing Board on a quarterly basis. Monitoring and Tracking procedures to ensure he. plan of correction is effective: • PI committee will present to the Medical Executive Committee a report which will then be communicated and sent to the Governing Board on a quarterly basis. Process improvement: Address process improvement and demonstrate how the acilitv has incoroorated improvement actions into its Qualitv Assessment and Performance Improvement (OAPil oro~ram. Address improvement in svstems to prevent the likelihood of re-occurrence of the deficient practice: • PI data and reports will be presented to the Governing Board after review in the Medical Executive Committee. This will include minutes and recommendations to the board. Individual Responsible: Ryan Robertson, Director of PI and Risk Date Completed: May 23,2018 FORM CMS-2567 (02-99) Previous Versions Obsolete Event 10: WOSU11 Facility ID: 013134 If continuation sheet Page 20 of 110 PRINTED: 04/10/2018 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 (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 15STH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PR.ECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 043 Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5} COMPLETION DATE A 043 Based on observation, document review and interview, the hospital's governing body failed to provide effective oversight of the hospital . Failure to provide effective oversight to prevent substandard practices for quality improvement, patient safety, management of the medical staff and nursing services resulted in an unsafe environment for patients. Findings included: Due to the scope and severity of deficiencies detailed under 42 CFR 482.12 Conditions of Participation for Governing Body, 42 CFR 482.13 Condition of Participation for Patient's Rights, 42 CFR 482.21 Condition of Participation for Quality Assessment and Performance Improvement, 42 CFR 482.22 Condition of Participation for Medical Staff, and 42 CFR 482.23 Condition of Participation for Nursing Servic;es, the Condition of Participation for Governing Body was NOT MET. Cross Reference: Tags A0046, A0048, A0049, A0067, A0068, A0115, A0263, A0338, and A0385 A 046 MEDICAL STAFF- APPOINTMENTS CFR(s): 482.12(a)(2) A046 [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This STANDARD is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 21 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: OMB NO 0938-0391 {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c B. WING 504012 NAME OF PROVIDER OR SUPPLIER 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Plan of Correction for Each soecific deficiencv ~ay 23,2018 A 046 Continued From page 14 Based on interview and record review, the hospital failed to ensure that medical staff credentialing followed the Medical Staff Bylaws for appointment of practitioners. Failure to ensure that the hospital follows the Medical Staff Bylaws for the appointment process of providers puts patients at risk of substandard care and adverse outcomes. A046~ (A 046) The Hospital failed to: • Ensure that medical staff credentialing followed the Medical Staff Bylaws for appointment of practitioners. o Follow the Medical Staff Bylaws for the appointment process of providers puts patients at risk of substandard care and adverse outcomes. Procedure/orocess for imlilementinR the olan of correction: Findings included: 1. Document review of the hospital document titled, "Medical Staff Bylaws Smokey Point Behavioral Hospital," showed that in article 3.4, Terms of Appointment and Reappointment, initial and reappointments to the Medical Staff shall be made by the Board upon a recommendation from the MEG (Medical Exective Committee). Document review of the hospital document titled, "Governing Board Bylaws," approved on 04/17 showed that the Governing Board selects and appoints the CEO (Chief Executive Officer) who is accountable to the governing board for the . recruitment of medical staff and the compliance with the Medical Staff Bylaws. • Credentialing coordinator will review all of the credentialing immediately report to the CEO and Medical director any credentials and privileges for accuracy and approval. Including one Susan Clark, MD. o CEO and Medical Executive committee will immediately review and approve any credentials and privileges needing amending. Monitoring and Tracking procedures to ensure he olan of correction is effective: o Document review of the hospital's Governing Board Meeting Minutes dated 01/17/18, under the section titled, "Newly Credentialed Stair', showed the name of a physician, Susan Clark, MD. Document review of the hospital's "Application Verfifciation Worksheet 3.24.17" for the physician named above showed that there was no signature documenting review by the credentials committee, no checks indicating approval for appointment or requested privileges and there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 o o The credentialing coordinator created a tickler system spreadsheet to keep track of upcoming credential renewals. This will be reviewed and monitored monthly. The credentialing coordinator will notify the CEO. The CEO will submit a short summary report to the PI Committee. Process imorovement: Address orocess Facility JD: 013134 If continuation sheet Page 22 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES improvement and demonstrate how the facilitv has incoroorated imorovement actions into its Quality Assessment and Performance lmorovement IOAPI\ oro~ram. Address improvement in systems to prevent the ikelihood of re-occurrence of the deficient practice: Review of the tickler system monthly by the credentialing coordinator will ensure that all provider files are up to date. Individual Responsible: Matt Crockett, CEO Date Comoleted: May 23, 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility ID: 013134 If continuation sheet Page 23 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c B. WING 504012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL {X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 046 Continued From page 15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPlETION DATE A046 was no signature on the signature line for the Medical Executive Committee Chairperson. 2. On 03/15/18 between 1.0:00 and 11:30 AM, the survey team interviewed members of the governing board. Surveyor #4 asked the governing board about the credentialing process and the lack of evidence for a functional Medical Executive Committee. The corporate Senior Vice President of Clinical Services (Staff #408) stated that the process needed "tightening up". Plan of Correction for Each soecific deficiency ''" C't d· 1.• ,ay 23.2018 ~ (A 048) The Hospital failed to assign committee A 048 members to the Medical executive committee. Procedure/orocess for imolementin~ the clan of correction: A 048 MEDICAL STAFF- BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This STANDARD is not met as evidenced by: Based on interview and review of Medical Staff Bylaws, and Medical Staff Rules and Regulations, the hospital's governing body failed to ensure that the hospital's medical staff structure allowed it to carry out its functions consistent with the rules, regulations and bylaws approved by the governing body. Failure to adequately staff and structure the medical staff consistent with the policies and procedures approved by the governing body in the Medical Staff Bylaws, puts patients at risk of substandard care and adverse outcomes. • The Medical Executive committee voted on the assignments ofthe President, Vice-President, and Secretary on 3/29/2018 • The MEC will assign a provider to each committee as per Section 11.3 and 11.4 of the Medical Staff By-Jaws and have it reflected in the minutes. Information will be reported to the Governing board at a minimum of quarterly by the MEC. • Monitoring and Tracking procedures to ensure ~he olan of correction is effective: • Meeting minutes will be reported to the governing body at minimum of quarterly. Findings included: Process imorovement: Address orocess FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility ID: 013134 If continuatlon sheet Page 24 of 11 o PRINTED: 04/10/2018 FORM APPROVED OMS NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES improvement and demonstrate how the ~acilitv has incoroorated imorovement actions linto its Quality Assessment and Performance lmorovement IOAPil oroeram. Address !improvement in systems to prevent the likelihood of re-occurrence of the deficient practice: • The Medical Director will ensure that the MEC is scheduled on a regular basis as approved by the MEC. Individual Responsible: Medical Director Date Comoleted: May 23,2018 FORM CMS-2567{02-99) Previous Versions Obsolete Event lD: WOSU11 Facility ID: 013134 If continuation sheet Page 25 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 -0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER!SUPPUER/CUA IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE 10 PREFIX TAG (XS) COMPLETION DATE DEFICIENCY) A048 Continued From page 16 A048 1. Document review of the hospital's document titled," Medical Staff Bylaws Smokey Point Behavioral Hospital," (approved 05/30/17) showed that article 11.2 of the bylaws describes the composition of the Medical Executive Committee (MEG) as having a President, Vice-President, and Secretary-Treasurer, who are all active members of the medical staff, and will also include the Chief Executive Officer as an ex-officio member. The duties of the MEG will include recommending to the board all manner of appointments, reappointments and staff membership, and will also account to the board and to the staff for the overall quality of care rendered to patients. Section 11.3 and 11.4 of the Medical Staff Bylaws showed that the MEG shall assign staff functions to include: Quality Management, Credentials Review, Continuing Education, Bylaws, Rules and Regulations, Treatment Plan and Medical Record Review, Util.ization Review, Pharmacy and Therapeutics, Infection Control, Risk Management and Patient Safety, Therapeutic Environment and Safety Function, Grievance Committee, and Practitioner Health. Provisions for staffing of these committee functions shall be either through staff assignment or through the MEG itself. 2. On 03/12/18 at3:55 PM, Surveyor#4 interviewed the Medical Director about the makeup of the Medical Executive Committee and how it functions at the hospital. She stated that there were not enough physicians to have a medical executive committee. Currently, there are 2 full time physicians including the Medical Director, 1 part-time physician and 1 locums FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility 10: 013134 If continuation sheet Page 26 of 110. PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING 03/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 048 Continued From page 17 PROVIDER'S'PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETION DATE A 048 physician. A 049 MEDICAL STAFF- ACCOUNTABILITY CFR(s): 482.12(a)(5) A 049 Plan of Correction for Each specific deficiency ~ [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. May23,2018 (A 049) The Hospital failed to ensure that a privileged physician is on call at all times to provide supervision of mid-level providers and overall patient care puts patients at risk of harm rom substandard care. This STANDARD is not met as evidenced by: Based on interview and review of hospital documents, the hospital's governing body failed to ensure that it received periodic evaluations of the medical staffs quality of patient care services. Failure by the governing body to monitor and oversee the quality of medical services provided to the hospital's patient population puts patients at risk of substandard care and adverse outcomes. Findings included: 1. Document review of the hospital's Medical Staff (Provider staff) meeting minutes for 05/30/17,11/08/17,11/17/17,12/14/17,01/17/18 and 01/31/18 showed that meeting minutes contained outlines of discussion topics, but failed to include committee decisions for each topic, action items for completion including assignments, and successive minutes contained no follow-up information from items put forward from the previous meeting. Document review of the Governing Board Meeting minutes for 01/17/18 (The only minutes provided to the surveyors by the hospital) showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Procedure/orocess for implementing the olan of correction: • Medical Staff Committee minutes will be taken by the credential coordinator. Minutes will include more than the agenda. Additional text, action plans, and discussion of patient care will be included. PI committee meeting minutes • including data will be reported to the Medical Executive committee. • All Medical Staff Committee minutes will be sent to the Governing Board for review and approval. The On-Call schedule will be • developed and maintained including 24-hour physician coverage in order to enSure the provision of supervision to all mid-level practitioners. • The Medical director/designee will be responsible for addressing any lastminute changes or revisions to the oncall schedule. Monitorine and Trackine orocedures to ensure Fac1hty 10: 013134 If continuation sheet Page 27 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938- 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES he olan of correction is effective: • Minutes will be reported to governing board, including but not limited to the 24-hour coverage schedule of physicians providing supervision to mid-level practitioners. Process imorovement: Address process imorovement and demonstrate how the ifacilitv has incoroorated imorovement actions into its Qualitv Assessment and Performance Improvement IOAPil oro•ram. Address improvement in svstems to orevent the likelihood of re-occurrence of the deficient practice: • Minutes and on call schedule for physicians will be reported to the Governing Board. Individual ResPonsible: Dr. Elina Durchman, MD Date Comoleted: May 23, 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Even!ID: WOSU11 Facility ID: 013134 If continuation sheet Page 28 of 110 PRINTED: 0411012018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: OMB NO 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4)1D PREFIX TAG MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 049 Continued From page 18 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 049 that the following committees submitted meeting minutes to the Board for approval: Infection Control, Environment of Care/Safety, Performance lmprovemenUExecutive Credentials, Medical Staff, Pharmacy and Therapeutics, and Grievance. Medical staff minutes approved by the Board consisted of 6 bulleted items without additional text, or action plans. 2. On 03/15/18 between 10:00 and 11 :30 AM, the survey team interviewed the hospital's governing body, including the hospital's Medical Director (Staff #401) about how the governing body receives information about patient safety and the overall operation of the hospital. Members of the governing body stated that their monitoring is multidimensional and includes review of all meeting minutes and that staff members make presentations at various times in the facility. Surveyor #4 asked if the governing body had evidence that the Medical Director directly interacted with the board regarding the medical care of patients. The board members indicated that there were discussions with the Medical Director, but there was no documentation in the minutes to reflect the topics or the scope of those discussions. Cross Reference: Tag A0068, A0338 A067 A 067 CARE OF PATIENTS- MD/DO ON CALL CFR(s): 482.12(c)(3) [ ... the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is on duty or FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility 10:013134 If continuation sheet Page 29 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CUA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: OMB NO 0938-0391 {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING 03/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) 10 PREFIX TAG A 067 Continued From page 19 TAG A on call at all times. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX 067 Based on document review and interview, the hospital's governing body failed to ensure that a doctor of medicine or osteopathy was on call at all times to provide on site supervision of patient DATE Plan of Correction for Each soecific deficiencv illillt. This STANDARD is not met as evidenced by: (X5) COM PLETt ON (A 067) The Hospital policy titled assessment of patients failed to address information about the patient's physical health status which might affect the appropriateness of their admission. Ma 23,2018 Y care. Procedure/orocess for imolementiM the olan Failure to ensure that a privileged physician is on call at all times to provide supervision of mid-level providers and overall patient care puts patients at risk of harm from substandard care. of correction: • • Findings included: 1. Document review of the hospital's "on-call log" received from the Director of Performance Improvement and Risk (Staff #405)on 03/14/18, showed that from 01/29/18 to 03/31/18, a physician was only listed on call for 12-hour periods (8:00AM to 8:00 PM) for the following dates: 01/29/18, 01/30/18, 02/05/18, 02/12/18, 02/19/18,02/24/18,02/26/18,03/05/18,03/12/18, 03/19/18, and 03/24/18. The remaining shifts show either no one listed for coverage, or mid-level providers (Advanced Registered Nurse Practitioner, Physician Assistant). • • • Document review the hospital's "Medical Staff Policies and Procedure," effective date (4/17), showed that each month, the Medical Director will assure that a schedule identifying the psychiatrists and on-call dates is completed and distributed to all appropriate personnel. 2. On 03/15!18, between 10:00 and 11'30AM, the surveyors interviewed the hospital's governing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 A new calendar will be created to include 24 hour coverage of the physician on call. Policy will be revised to state that a physician is available 24 hours'a day as demonstrated by the on call calendar. All admission requests for patients with medical issues will be reviewed with the admitting practitioner. Should the admitting practitioner be a mid-level practitioner and the admission staff have a concern that the case needs further review the physician on call will be provided the information to ensure that the facility has the capability of handling the medical acuity of the patient. Should there remain further concerns the medical director will be contacted for final approval. • There is always an internal medicine • practitioner that can also be contacted for consultation, if the need arises. Any decision that was made contrary to the initial provider's order will be addressed, to explain why the patient Facility 10:013134 If continuation sheet Page 30 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMS NO 0938 - 0391 was or was not accepted. • If questions about admitting procedures following the admission criteria of the hospital exists, the case will be referred for FPPE/OPPE review. Monitorin~ and Trackin~ Drocedures to ensure he olan of correction is effective: • The CEO is notified of all patient admissions requests that are declined, in order to ensure that all EMTALA procedures have been complied with. • The Medical Staff will conduct OPPE/FPPE accordingly .. • The on-call schedule is updated monthly for the medical director. • Monitoring will include that the monthly physician calendar has a physician assigned for every day on calL This will be audited .. The number of days a physician is marked on call in the monthly schedule over the number of days in the month. This will be reported at the Medical Executive meeting. 100% compliance target If compliance goes below the threshold of70% for 2 months a new corrective action plan will be created to address the finding. After 100% compliance is reached for 1 continuous month than spot checks of 2 medical records will be reviewed for the items monthly. Identified issues will be reported to the Director responsible for the identified item. Process imnrovement: Address orocess imnrovement and demonstrate how the lfacilitv has incoroorated imorovement actions into its Dualitv Assessment and Performance ImorovementlOAPll oro•ram. Address imnrovement in svstems to or event the likelihood of re-occurrence of the deficient lnractice: • The Medical Staff conduct OPPE/FPPE review on cases that there are questionable admissions of not following admission FORM CMS-2567 (02-99) PreviOUS Versions Obsolete Event ID: WOSU11 Facthty I D. 013134 If cont1nuatton sheet Page 31 of 110 PRINTED: 04/10/2018 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO 0938 - 0391 criteria. • The UM Committee reviews cases of questionable medical necessity. Individual Resoonsible: Medical Director Date Comoleted: May 23, 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility ID: 013134 If continuation sheet Page 32 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICUA IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03115/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 067 Continued From page 20 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A067 body. During the interview, Surveyor #4 asked the Medical Director (Staff#401) about how the hospital ensured there was 24- hour coverage o( patients by a physician, when the call log did not reflect that staffing. She stated that she is always available, but there was no documentation or policy that described that process. A 068 CARE OF PATIENTS- RESPONSIBILITY FOR CARE CFR(s): 482.12(c)(4) [ ... the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is responsible for the care of each Medicare patient with respect to any medical or psychiatric problem that-(i) Is present on admission or develops during hospitalization; and (ii) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine, or optometry; a chiropractor; or clinical psychologist, as that scope is-(A) Defined by the medical staff; (B) Permitted by State law; and (C) Limited, under paragraph (c)(1)(v) of this section, with respect to chiropractors. A 068 Plan of Correction for Each soecific deficiencv '"· f"ay23,2018 C't d· ~ (A 068) The Hospital failed to receive quality healthcare that met the patient's needs. Procedure/process for implementin~ the plan of correction: 1. CNO will re-train all nurses to review all possible sources of information regarding patient allergies, including: • Pre-hospital records • Patient interview • Family/friend interview • Any known pharmacy records • History & physical (if available) • Treatment team members This STANDARD is not rnet as evidenced by: • CNO will re-train all nurses on medical Based on interview, record review, and review of hospital policies and procedures the Governing Body failed to develop and maintain effective systems that ensured that patients received quality health care that met their needs in a safe environment. issues identified during the survey by written documentation and post tests which includes but not limited to. • Paralyzed patient care • Catheterization Failure to ensure patients are provided with care FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility 10:013134 If continuation sheet Page 33 of 110 PRINTED: 04/10/2018 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO 0938-0391 • Urinary Tract Infections • Anaphylactic Allergies • Diabetic care • Wound Care • • • • • • • • FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 All admission requests for patients with medical issues will be reviewed with the admitting practitioner. The facility will comply with its own admitting criteria from the admission, discharge and continued stay criteria policy and procedure. Included in this is the statement "The above may be waived, where appropriate only by the admitting attending physician with approval by the Medical Director." The Medical Director is always the final say in patient care. Should the admitting practitioner be a mid-level practitioner and the admission staff have a concern that the case needs further review the physician on call will be provided the information to ensure that the facility has the capability of handling the medical acuity of the patient. Should there remain further concerns the medical director will be contacted for final approval. There is always an internal medicine practitioner that can also be contacted for consultation, if the need arises. Any decision that was made contrary to the initial provider's order will be addressed, to explain why the patient was or was not accepted. Review of denials or questionable admissions will be reviewed in the Medstaff meeting and then reported to Medical executive committee. If questions about admitting procedures following the admission criteria of the hospital exists, the case will be referred for FPPE/OPPE review. Facility ID: 013134 If continuation sheet Page 34 of 110 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 • RNs & MHTs were retrained on the inventory of Central Supply. (Catheters have always been available in Central Supply) • . CNO published in the nursing newsletter that it is common for paraplegic patients to self-catheterize and to use the same catheter repeatedly, as long as proper Infection Control procedures are followed. • Staff were reminded to order dietitian consults at the time of the nursing admission assessment, if warranted. Since then, daily chart audits have been conducted and this area is examined for accuracy. Any adverse findings have resulted in A) the dietitian being immediately consulted and B) the employee being counseled. • By April 23, the CNO will have established a business relationship with a wound care clinic or consultant. The hospital will either transport patients in need of wound assessments to that clinic/consultant or have the clinic/consultant come to the hospital for consult. Medical & Nursing Staff will be educated on the new process. Additionally, the CNO will remind Intake personnel of our exclusionary criteria related to known wounds at the time of screening potential admissions. Monitorin~ and Trackin~ orocedures to ensure he olan of correction is effective: • Monitoring of the Nursing Assessment is occurring by the CNO/designee. All issues identified are being addressed immediately. • 15% of the medical records will be audited five times a week. Auditing will continue until 100% compliance for one month. If compliance goes below the threshold of 70% for 2 months a new corrective action plan will be created to address the finding. After 100% compliance is reached for 1 continuous month than spot checks of 2 medical records at a minimum will be reviewed for the items monthly. Identified issues will be reported to FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility lD: 013134 If continuation sheet Page 35 of 110 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 the CNO. • Questionable admissions and denials will be reviewed in the medstaff meeting and then reported in the Medical Executive Committee as well as review in OPPE/FPPE. Process improvement: Address Drocess improvement and demonstrate how the acilitv has incorporated improvement actions into its Oualitv Assessment and Performance Improvement (QAPI} program. Address imorovement in svstems to Prevent the likelihood of re-occurrence of the deficient 'oractice: Monitoring is reported in audit meetings and will continue to be addressed in PI Committee meetings. Individual Responsible: ohn Beall, CNO Date Completed: May 23,2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event 10: WOSU11 Facility ID: 013134 If continuation sheet Page 36 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4)10 PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 068 Continued From page 21 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X5) COMPLETION DATE A068 that meets acceptable standards of practice and meets the patient's healthcare needs in a safe environment risks deterioration of the patient's condition and poor healthcare outcomes. Findings included: 1. Document review of the hospital's policy titled, "Assessment of Patients," (effective 05/17) showed that at intake, the hospital obtains information on the caller's current condition, the type of services they are seeking, who referred the patient, and appropriate disposition. The policy does not address information about the patient's physical health status, which might affect the appropriateness of their admission. Document review of the hospital's policy titled, "Medical Staff Rules and Regulations" (Effective 04/17) showed that in Chapter 3, Criteria for Admission, all admissions shall meet the inclusion criteria as established by the medical staff and that admissions shall be on the order of a physician on the Medical Staff. 2. On 03/08/18 at 1:00 PM, Surveyor #5 interviewed a Physician Assistant (Staff#519) about patients admitted to the hospital. Staff#519 stated that medically unstable patients have been denied admission by the medical provider, based on the hospital's exclusion criteria, only to have the denial superceded. He stated that patients were denied admission and then showed up on the unit the next day. 3. On 03/15/18, between 10:00 and 11 :30 AM, the surveyors interviewed the hospital's governing body about admission of patients with complex medical needs. The Chief Nursing Officer (Staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 37 of 110 PRINTED: 04/10/2018 FORM APPROVED OMS NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE ID (X5) COMPLETION DATE DEFICIENCY) A068 Continued From page 22 A068 #407) stated that he receives calls "a couple of times a week" from intake staff regarding appropriateness (of admission). He stated that if he does not feel confident, then he speaks with the Chief Executive Officer (Staff #41 0). If he approves, they go forward with screening. Patient #525 4. On 03/09/18 at 8:30AM, Surveyor #5 reviewed the discharged medical record for Patient #525 who was admitted on 01124/18 for the treatment of suicidal ideation that included a plan to kill himself. The medical record review showed: The Emergency Department provider notes dated 01123/18 at 5:51 PM showed that the patient's medical history included: -Spina bifida (a spinal birth defect) -A neurogenic bladder (dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of urination) -An elevated white blood cell count -A urinary tract infection -Wheelchair bound -Has an anaphylactic allergy to peanuts . On 01/24/18 at 8:00 PM, a provider wrote admitting orders. Allergies were documented as "NKDA" (no known drug allergies). On 01125118 at 7:00AM, the Admission Medical History and Physical Examination showed that that the patient had an allergy to peanuts, spina bifida, neurogenic bladder, a urinary tract infection, and an activity restriction of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facirlty ID: 013134 Jf continuation sheet Page 38 of 11 0 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER 3955156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL {X4) JD PREFIX TAG 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A068 Continued From page 23 ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PREFIX TAG (X5) COMPLETION DATE A068 "wheelchair." Current genitourinary concerns showed that the patient catheterized himself with a Coude catheter and that he had weakness in his lower extremities. The physical assessment showed that the patient had swollen legs with atrophy related to the Spina Bifida and decreased strength in the lower extremities. Between 01/26/18 and 02/01/18, Surveyor #5 found no evidence that the provider wrote orders for the management of the patient's urinary concerns, including the need for a supply of catheterization equipment or for a bowel program related to the patient's Spina Bifid a and neurogenic bladder diagnosis. On 02/02/18, the provider wrote the following order: "Straight cath (catheterization) 4-6 times daily as needed for neurogenic bladder. May use own supply until pharmacy can provide appropriate cath." On 02/05/18 at 8:00PM, a nursing document showed that a supply of straight catheter equipment was obtained for the patient, 12 days after admission. On 03/08/18 at 1 :00 PM, Surveyor #5 interviewed a provider (Staff#519) about Patient #525. During the interview, Staff #519 stated that hospital staff had removed the patient's catheter from his room and thrown it away in the biohazard trash. Staff from another shift took it out of the trash, washed it, and returned it to the patient. On 02/01/18 at 10:15 AM, a Psychiatric progress note showed that the patient had ingested a nutrition bar containing nuts. Hospital staff administered two Epinephrine Pens and 50mg of FORM CMS-2567(02-99) Previous Versions Obsolete EventiD: WOSU11 Facility ID: 013134 If continuation sheet Page 39 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 -0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPUERICUA IDENTIFICATION NUMBER: (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A068 Continued From page 24 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS} COMPLETION DATE A068 Benadryl to the patient to control the anaphylactic response. The note also stated, "Emergency Department was called and patient was prepared for transport. Medical Director canceled transport and consulted medical." A change was entered on to the Admission provider orders where allergies had been previously documented as "NKDA" (no known drug allergies). A line was crossed through the word "NKDA" and "Peanuts Error 211118 11:30 am" was written next to the entry. On 02/01/18 at 11:00 AM, a progress note showed that the patient selected a snack at snack time and had taken a bite of it. A Physician Assistant assessed the patient and documented that the patient was having symptoms of anaphylaxis. The provider administered Epinephrine via an Epi-Pen injector. A second Physician Assistant assessed the patient and the patient received a second Epi-Pen injection. The documentation showed that the ambulance arrived, but that a Physician (Staff #515) called and "stated nona transport patient to the Emergency Room, monitor in the facility for complications." . On 03106118 at 9:00AM, Surveyor #11 and a provider (Staff#514) discussed the provider's concerns about the quality of care provided for Patient #525. The provider stated that she was concerned because the patient had received 2 doses of Epinephrine and the patient was not transported to an Emergency Room for further evaluation following.the incident. On 03/08/18 at 1 :00 PM, Surveyor #5 interviewed (Staff#519) about Patient #525. During the interview, Staff #519 stated that he ordered the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility 10: 013134 If continuation sheet Page 40 of 110 PRINTED: 04/1012018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c 504012 B. WING NAME OF PROVIDER OR SUPPLIER 0311512018 STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL MARYSVILLE, WA 98271 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG A 068 Continued From page 25 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TQ THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (XS) COMPLETION DATE A068 patient to be transferred to an Emergency Department because the patient had received two doses of epinephrine, the hospital had no airways and no way to start an intravenous line and he felt the patient needed to be monitored closely. He stated he had written twice for the patient to be transported to the Emergency Department for evaluation but that the Medical Director had overridden the order. Patient #504 5. On 03/12118, Surveyor#5 reviewed the medical record of Patient #504 who was admitted on 02/06/18 for treatment of Psychosis, Suicidal Ideation, Command Auditory Hallucinations to harm self, Audio, Visual and Tactile Hallucinations, poor sleep and poor appetite. The medical record review showed the patient was a diabetic and taking metformin (a medication used to treat patients with Type 2 Diabetes). The patient nutritional screen on admission showed the patient is a Diabetic, which required the patient to receive a referral for a Nutritional consult. Surveyor #5 found no evidence the patient was referred or received a Nutritional consult. On 0211 0/18 at 1 :30 PM, a provider wrote an order for a medical referral because the patient had been taking metformin as an outpatient. Surveyor #5 found no evidence the patient received a medical referral for her diabetes/diabetes medication. The patient medication administration record showed that the patient did not receive metformin during her hospitalization. Patient#1101 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility 10:013134 If continuation sheet Page 41 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 -0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE ID PREFIX TAG {X5) COMPLETION DATE DEFICIENCY) A068 Continued From page 26 A068 6. On 01/26/18 at 11:00 PM, Patient#1101 was readmitted to the psychiatric hospital for psychiatric care following discharge from a medical center where the patient received care for cellulitis and diabetic ulcers on the right great toe and 2nd toe. Review of the patient's discharged medical record showed the following: On 01/27/18 at 8:30AM, a medical consultant (Staff #11 05) completed the patient's history and physical. The history and physical examination showed that the patient had cellulitis and a diabetic foot ulcer. The medical consultant referred the patient for wound care and stated that the patient was medically stable for psychiatric treatment unless the wound worsens. The physician's order in the patient's medical record showed the medical consultant (Staff #1105) wrote an order on 01/27/18 at 8:40AM referring the patient to a wound care clinic as soon as possible, to evaluate and treat the wound. The medical consultant's documentation dated 01/30/18 at 8:30PM showed that the patient's diabetic foot ulcer was worsening. The medical consultant again recommended the hospital staff consult wound care. The medical consultant's documentation dated 02/02/18 at 8:45AM showed that the patient had an open wound on the second toe of the right foot. The consultant stated that the toe needed debridement (removal of damaged tissue) and the hospital staff should follow through with the wound care referral. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 42 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING c 504012 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL (X4) ID PREFIX TAG 03/15/2018 MARYSVILLE, WA 98271 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION DATE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A068 Continued From page 27 A068 There was no evidence in the medical record to show that the hospital had referred the patient to a wound care clinic for treatment of the diabetic ulcers. Document review of the form titled, "Memorandum ofTransfer," showed the hospital transferred Patient #11 01 to a medical center on 02/05/18 at 2:55 PM for treatment of the diabetic foot ulcers. On 03/07/18 at 5:00 PM, Surveyor #11 interviewed a registered nurse (Staff #11 01) about the referral to the wound care clinic for Patient #11 01. The registered nurse confirmed that the hospital did not send the patient to a wound care clinic. On 03/09/18 at 10:00 AM, Surveyor #11 reviewed the patient's medical record with the Chief Nursing Officer (Staff #11 02). The Chief Nursing Officer confirmed that there was no documentation in the patient's medical record indicating that the hospital referred the patient to a wound care clinic. When the surveyor asked Staff #11 02 about Patient #1101's missed medical referral, the Chief Nursing Officer stated that the registered nurse that transcribed the order was responsible for making the referral. On 03/13/18 at 3:15PM, the Discharge Summary completed by the provider (Staff #11 06) showed that the hospital transferred Patient #11 01 to the emergency department at the medical center for treatment of worsening toe infection and worsening levels of pain. On 03/14/18 at 11:15AM, Surveyor#11 interviewed a registered nurse (Staff #11 03) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WOSU11 Facility ID: 013134 If continuation sheet Page 43 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVJDERISUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X2) MULTJPLE CONSTRUCTION {X3) DATE SURVEY COMPLETED A. BUILDING _ _ _ _ _ _ __ c B. WING 504012 NAME OF PROVIDER OR SUPPLIER 03/15/2018 STREET ADDRESS, CITY, STATE, ZIP CODE 3955 156TH ST NE SMOKEY POINT BEHAVIORAL HOSPITAL MARYSVILLE, WA 98271 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 068 Continued From page 28 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A068 about the process for referring Patient #11 01 to the wound clinic. The registered nurse stated that at the time the order was noted by Staff #11 03, a medical consultant (Staff #11 05) and a nurse practitioner (Staff#1104) were there discussing the patient. The nurse stated that he thought the Nurse Practitioner would refer the patient to the wound clinic. The nurse found out later that referrals like this should be brought to the attention of the nurse manager. Staff #11 03 stated that he has not received training on the hospital's process for referring patients to outside facilities. Cross Reference: Tag 0396 A 115 PATIENT RIGHTS CFR(s): 482.13 A 115 Plan of Correction for Each soecific deficiencv ~ A hospital must protect and promote each patient's rights. )-larch 8,2018 (A 115-1) The facility did not develop and implement a system to ensure the safety of This CONDITION is not met as evidenced by: Based on observation, interview, and document review, the hospital failed to protect and promote patients' rights related to personal privacy, care in a safe setting, and restraint use, Failure to protect and promote each patient's rights risked the patient's loss of personal freedom, dignity, physical and psychological harm. The cumulative effects of these systemic problems resulted in the hospital's inability to provide for patient and staff safety, resulting in the surveyors' declaration of two immediate jeopardy situations. patient identified as being a danger to self or others. frhis posed a serious risk of harm due to: • No adequate system for communicating a patient's line of sight status to ward staff. • Staff unaware of Line of Sight status despite a provider order for Line of Sight in a patient's file. • Ward staff describing inadequate staffing to achieve line of sight monitoring. FORM CMS-2567(02-99) Prevtous VerSions Obsolete Event ID. WOSU11 Facthty JD. 013134 If conlmuatton sheet Page 44 of 110 PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 - 0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES • The facility-provided list of patients on the "Line of Sight" list did not contain 2 patients with orders, identified during the survey. Procedurelp_rocess for imp_lementing he plan of correction: All nursing staff were re-trained on Line of Sight policies and procedures, and danger to self and/or others treatment planning, by March 8, 2018. In order to demonstrate competency each nursing staff was tested, with competency documentation placed in the employees HR file. Nurses are ensure the process' was conducted appropriately respecting the patient's dignity and right to privacy, but also protecting the patient's safety. White boards are being audited by the Nurse Managers to ensure the accuracy of all special precautions are being listed accurately I compliance goes below the threshold of 70% for 2 months a new corrective action plan will be created to liance goes below the threshold of 70% for 2 months a new corrective action plan wilJ be created to address the finding. After 100% compliance is reached for 1 continuous month then spot checks of 2 medical records will be reviewed for the items monlhly. Identified issues after the I 00% monthly compliance will be reported to the CNO for follow up. • Suicide precautions will be communicated during shift report. The nursing report sheet will be used to maintain an accurate list of precautions for each client. • Nurses are ensure the process' was conducted appropriately respecting the patient's dignity and right to privacy, but also protecting the patient's safety. . • Re-education of staff on additional precautions including sexually acting out, assault, and elopement. • Documentation of alleged or observed incidents in the medical record. • Re-education of all clinical and nursing staff that treatment plans are updated per observations and incidents requiring an update per CMS and state requirements. • Auditing to ensure providers assigned correct levels of observation and appropriate orders. 15% of the medical records for each unit will be audited 5 days a week until 100% compliance is achieved for one continuous month. If compliance goes below the threshold of 70% for 2 months a new corrective action plan will be created to address the finding. After 100% compliance is reached for 1 continuous month than spot checks of 2 medical records will be reviewed for the items monthly. Identified issues will be reported in the daily chart audit meeting and data available and reported to the PI Committee. Monitorin!! and TracldnP nrocedures to ensure the nlan of correction is effective: Nurse Managers will audit the white boards daily and ensure hat all information including special precautions is accurate. FORM CMS-2567(02-99) Previous Versions Obsolete Even!ID: WOSU11 Facility 10: 013134 If continuation sheet Page 70 of 110 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/10/2018 FORM APPROVED OMB NO 0938 -0391 This will be audited with a I 00% compliance rating continuously for three months. Process imnrovemcnt: Address nrocess imnrovcment and demonsh"ate how the facility has incorporated imnrovcment actions into its Oualitv Assessment and IPcrformancc lmnrovemcnt fOAPn nroP"ram. Address improvement in svstems to nrevent the lil