Printed: 01/09/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES 1x1) PROVIDERISUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 B. WING 12I21t2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 {x4} ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (Xe (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR LSC IDENTIFYING TAG CROSSAREFERENCED To THE APPROPRIATE DATE DEFICIENCY) A 000 INITIAL COMMENTS A 000 '[Submission of this plan of correction is not an 2/10/17 iadmission that the citations are true or that the HOSPITAL COMPLAINT SURVEY ?059?3' Vio'ate?i the ?1'95- This Medicare hospital compiaint survey was Conducted on the following dates: 12l12?16l2016 000: Response to Medicare Hospital and 12/19-21/2016 by Washington State Complaint Survey Department of Health surveyors: Paul Kondrat, RN. MN. MHA: Elizabeth Gordon, RN. {35 noted, an action pian was submitted and Valerie RN, MS. Alex Glei, REHS, FHA accepted in response to the immediate and JOY Williams. RN: BSN- jeopardy finding. Corrective actions included: ?Analysis and reduction of overrides in the medication dispensing devices; -Pharmacy staffing increases; -Physician order requirements for overrides; -Two nurse verification for overrides; ?After?hour pharmacist verification process The Fire Life Safety (FIIJS) inspection was conducted on 12l14/2016 by Washington State Patrol Deputy Fire Marshai Donald West (See Inspection report). Surveyors assessed issues related to the following MEDICARE complaints: #69120; revision; #69393; #70129; #70130; #70131; #70133; and ?Pharmacy policy revision relative to overrides #70136. and home medications. During the course of this survey, the DOE-I surveyors determined that there was a high risk of serious harm. injury, and death due to the extent of de?ciencies. This resulted in one ?nding of IMMEDEATE JEOPARDY in the foiiowing area: Faiiure to provide suf?cient pharmaceutical services to meet the scope. complexity, and needs of the patients served. The hospital initiated corrective actions on 12/20/2016 but surveyors were unable to verify the plan's implementation deveioped by the hospitai for the IMMEDIATE JEOPARDY and the state of IMMEDEATE JEOPARDY remained in place at the time of survey team exit. Removal of the state of JEOPARDY 1i l1 I OR PROVIDERISUPPLIER REPRESENTATIVES SIGNATURE TITLE 1X6) DATE Any de?ciency statement ending with an asterisk denotes a de?ciency which the institution may be excused from correcting providing it is determined that other safeguards provide suf?cient protection to the patients . (See instructions.) Except for nursing homes, the ?ndings stated above are disclosable 90 days foilowing the date of survey whether or not a plan of correction is provided. For nursing homes. the above ?ndings and plans of correction are disciosable 14 days following the date these documents are made avaiiable to the If deficiencies are cited, an approved pian of correction is requisite to continued program participation. FORM Previous Versions Obsolete 27mm if continuation sheet Page 70f53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8L MEDICAID SERVICES Printed: 01/092017 FORM APPROVED OMB NO. 0938-0391 There must be an effective governing body that is legatiy responsibie 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 This Condition is not met as evidenced by: Based on observation, interviews, and document reviews, the hospital failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body. Failure to meet patient rights, quaiity assessment and performance improvement, pharmaceuticat services and physical environment requirements STATEMENT OF (x1) PROVIDERISUPPLIERICLIA (X2) CONSTRUCEON DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 504011 13. WHO 121219016 NAME OF OR STREET CITY, STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 {x4} ID SUMMARY OF ID PLAN OF CORRECTION (x5) (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE 0053530? TAG OR TAG TO THE APPROPRIATE A 000 Continued From page 1 A 000 was verified on a revisit on 12l29l2018 at 12:30 PM by Paul Kondrat, RN, MN, MHA and Joy Williams, RN, BSN. Cascade Behavioral Hospital is NOT lN COMPLIANCE with Medicare Hospital Conditions - of Participation: 42 CFR 482.12 Governing Body 42 CFR 482.13 Patient Rights 42 CFR 482.21 Quality Assessment and Performance Improvement 42 CFR 482.25 Pharmaceutioai Services 42 CFR 482.41 Physical Environment Sheii 270V11 482.12 GOVERNING BODY A 043 A 043 Upon completion of the survey, the CEO, 2/10/17 Medical Director, Governing Board members, and Director reviewed the findings and began formulation of the Pian of Correction. The Governing Board deiegated responsibility of ensuring compietion of all corrective actions to the CEO. The CEO is responsible for reporting the results of the corrective actions and use of monitoring Systems to the Governing Board. See A0115, A0263, A0490, A0700 FORM Previous Versions Obsolete If continuation sheet Page 2 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF (X1) AND PLAN OF IDENTIFICATION NUMBER: 504011 MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED B. WING 12f21f2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH WA 98168 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY TAG OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (Xe CORRECTIVE ACTION SHOULD BE To THE APPROPRIATE A 043 Continued From page 2 risks an unsafe healthcare environment for patients. visitors, and staff. Findings: 1. The Governing Body failed to effectively manage the functioning of the hospital to protect patients from harm as evidenced by the JEOPARDY condition identi?ed on 12(20/2016 for failure to provide suf?cient pharmaceutical services to meet the scope. complexity, and needs of the patients served. 2. Failure to provide oversight of the Performance Improvement Program deiegated to the Medical Staff. 3. Failure to protect and promote each patient? 5 rights. 4. Failure to maintain the condition of the physical plant and the overali hospital environment of care. Due to the scope and severity of deficiencies detaiied under 42 CFR 482.13 Condition of Participation for Patient Rights; 42 CFR 482.21 Condition of Participation for Quality Assessment and Performance Improvement; 42 CFR 482.25 Pharmaceutical Services; and 42 CFR 482.41 Condition of Participation for Physical Environment. the Condition of Participation for Governing Body was NOT MET. Cross~Reference: Tags A0115, A0263. A0490, A0700 A 084 CONTRACTED The governing body must ensure that the A 043 A 084 Amendment 2/1/2017: The CEO will issue weekly reports to the Governing Board related to the hospital's ongoing efforts toward compliance for alt citations. Conference calls will be held as needed for dialogue. The target compliance is 90% for standards cited. Any score below 90% require remediation with the affected employee andlor further anaiysis of possible system issues. FORM Previous Versions Obsolete If continuation sheet Page 3 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE SERVICES Printed: 01/092017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA W) CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 3- WING 12l2112016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) iD SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (x5) pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR LSC INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE A 084 Continued From page 3 A 084 A084 Corrective 2/10/ 17 services performed under a contract are provided 1- The department heads resPommIe for in a safe and effective manner, contracts evaluated ail contracted patient care services and submitted those This Standard is not met as evidenced by: evatuations to the Medical Execume Committee for revaew and approval. Based on interview and review of hospital 2' The PURM DIrector rewsed the QAPI documents, the hospital failed to ensure that its process fo?ogf?ii areluitipn :15. i quality assurance and performance improvement a. refiew datesIthCe:er:e ca en ar (QAPI) processes included a systematic review of timeliness. contracted patient care services. b. The Department Head Failure to develop a process to oversee the performance of all Contracted patient care review the contract and services places patients at risk for provision of complete the evaluation. improper or inadequate care and adverse patient C. If there are service concerns, the Department Head will discuss those concerns with the clinical Findings: contracted service and develop a plan of improvement in order to On 12/20/2016 at 9:00 AM, during a discussion of ensure patient ca re needs are the hospital's quality pregram with Director of met. Risk and Quality (Staff Member #12),Surveyor d. Annually, all evaluations for #2 reviewed the hospital's process for evaluating contracted clinical services will the performance of contracted health services. in be forwarded to the Medical reviewing the contracted services documents, Executive Committee for Fevtew. Surveyor #2 found there was no evidence that the following contracted services had ever been Person: formally reviewed as part of the QAPI program for Director quality of services provided: Monitor -Universal Hospital Equip, Biomed On an annual basis, the Director present -Advanced Pharmaceutical Pharmacy Services the list of contracted patient ca re servrces with -Dietician Services completed evaluations by the assigned department ~Highline Physical Therapy - Physical Therapy head the MEC. meatmg' The .evaiuatlons Northwest Healthcare Linen Services Include any servrce related plan of Improvement. minutes will reflect the review and any actions taken on patient care A 115 482.13 PATIENT RIGHTS A115 contracts. A hospital must protect and promote each patient's rights. FORM Previous Versions Obsolete 27QV11 if continuation sheet Page 4 of 53 Printed: 01/091201 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) 0?2} {x3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 3- WING 12i2'li2016 NAME OF PROVIDER OR STREET ADDRESS. CITY. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (XS) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE SHOULD BE TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCE) TO THE APPROPRIATE A 115 Continued From page 4 A 115 See A 0123, A 0129, A 0164, A 0174 This Condition is not met as evidenced by: Based on Observation, interview, document review, and review of hospital policies and procedures, the hospital failed tO protect and promote patient rights. Failure to protect and promote each patient's rights risk the patient's loss of personal freedom, privacy, dignity, and harm. Findings: 1, Failure tO allow patients the right to exercise their rights to privacy and refusetreatment. 2. Failure to utilize the least reStrictive alternative to the use of seclusion and restraints. 3. Failure to release the patient from seclusion at the earliest possible time when documentation reflected no imminent risk Ofdanger. 4. Faiiure to investigate patient complaints prior to closure of the complaint. The cumulative effect of these systemic problems resulted in the hospital's inability to provide for patient safety and protect patient rights. Due tO the scope and severity Of de?ciencies under 42 CFR 482.13, the Condition Of Participation for Patient Rights was NOT MET. Cross Reference: Tags A0123, A0129, A0164, A0174 A 123 PATIENT RIGHTS: OF A 123 GRIEVANCE DECISION FORM Previous Versions Obsoiete 27QV11 "continuation sheet Page 5 0f 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE SERVICES Printed: 01/091201? FORM APPROVED OMB NO. 0938-0391 At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that patients were provided with a written response to their grievances for _1 Of 4 grievances reviewed (Patients Failure to provide patients with a written response to their grievance violates their right to be informed of how the hospital investigated and resolved the grievance. Findings: 1. The hospital's policy and procedure titled "Patient Grievance Policy" (Revised 10/2015; Policy (3.1001) read in'part: "The Patient Advocate will: Review results of the preliminary investigation. . . Complete a written report on the Grievance Resolution Form . . . Give written report to patient for review, comments and signature." 2. Four patient complaints were selected for review of process and resolution. Sources included the patient complaint log. Each was reviewed for evidence of receipt, hospital review, investigation, ?ndings, and resolution of the grievance issue with the ?ndings reviewed with The Patient Advocate reviewed the Patient Grievance Policy on the requirement of providing a written response to a grievance. The Clinical Educator reeducated the clinical staftc on the grievance process with written responses provided to the patient. Education was provided in staff meetings through written and verbal communication. mendment 2/1l20?l7: The hospital?s grievance policy, log for grievances, and letters that are to be mailed to patients have all been revised and will be presented at the I/veekly Pl Committee on Thursday, February 9, 2017 for approval. From there, {they will go the Medical Executive Committee on February 9, 2017 and Governing Board at its next meeting thereafter. Weekly data toward compliance in the new processes is 90%. Any score below 90% will require remediation with the affected employee and/or further analysis of possible system issues. Persons Responsible: Patient Advocate Director Monitoring: The Patient Advocate will present an analysis of the grievance log and grievance responses to the PI and quarterly MEC (next meeting is Feb 9, 2017) and Governing Board meetings. Any issues requiring immediate attention will be addressed by the appropriate department head. STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICUA 0?2) {x3} DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 504011 3- WING 12l21i2016 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTEVE ACTION SHOULD BE CPMSEQION TAG OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE A 123 Continued From page 5 A 123 A 0123 Corrective Actions 2/10/17 FORM Previous Versions Obsolete 27QV11 If continuation sheet Page 6 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: SERVICES Printed: 01/09l2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA NUMBER: 504011 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING DATE SURVEY COMPLETED 12I21l2016 NAME OF PROVEDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, STATE, ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (M) to PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDEO BY FULL REGULATORY OR LSC INFORMATION) IO PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A123 A129 Continued From page 6 the patient who ?led the grievance. 3. Patient #2 ?led a patient concern notification on 6/3l2016 making ailegations of inadequate cieaning of the patient rooms, patient kitchen area, shower and bathrooms. A review of the grievance log indicated the complaint was ciosed. 4. On 12/15/2016 at 2:30 PM, Surveyor #3 interviewed the Patient Advocate (Staff Member it?) about the hospital grievance process. While reviewing the complaint log for Patient no action was documented indicating the patients concern had been addressed or resoived. Staff Member #7 con?rmed this observation. 482.1303) PATIENT RIGHTS: EXERCISE OF RIGHTS Patient Rights: Exercise of Rights This Standard is not met as evidenced by: Based on observation, interviews, document review, and review of hospitai policy and procedures, the hospital failed to protect patient rights. Failure to allow patients the right to refuse skinlclothing checks risks patient?s 1085 of personal dignity, privacy, and respect. Findings: 1. The hospitat's policy titted "Patient Rights and Responsibilities" (Reviewed 10/2016; Policy ADM.P.300) under the section read: "To assure that a patient is informed of his or her rights and upon receiving care and service from Cascade Behavioral Hospital A123 A129 A 129 Corrective Actions The Clinical Educator reeducated the nursing staff on the policy titled Skin/Ciothing Check. Education included an emphasis?on the proper procedure for assessing patients and procedure for patient?s refusai. Education was provided during staff meetings through verbal and ritten communication with competency testing. Person Responsibie: Patient Advocate Monitoring: The Director/designee wili perform at ieast 30 random audits per month to ensure compliance of 90% or above for at least 3 iconsecutive months. Audit resuits wiil be reported in the Pi and quarteriy MEC I and Governing Board meetings. FORM Previous Versions Obsolete 27QV11 if continuation sheet Page 7 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/091201? FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NUMBER: 504011 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (XS) DATE SURVEY COMPLETED 12i2?lr?2016 NAME OF PROVIDER OR CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY, STATE, ZIP CODE 12844 MILITARY ROAD SOUTH WA 98168 and to assure that these rights are known by hospital staff, physicians and other health care providers." The list of patient rights shall include but are not limited to the following: . . . 4. The right to personal privacy, and to be protected from invasion of privacy, PROVIDED, that reasonable searches may be conducted or other means used to detect and prevent contraband from being possessed or used on the premises. . . 13. The right to care that is considerate and respectful of your personal culture, values, beliefs, and preferences and to be treated in a manner promoting dignity and self-respect." 2. The hospital's policy titled "Skin/Clothing Check" (Reviewed 10l2016) read in part: "Voluntary patients who are not voicing or exhibiting self-harm behaviors, who refuse the skin/clothing check, wiil be given referral information and administratively discharged from the hospital." 3. On 1214/2016 at 12:00 PM, Surveyor #3 observed Patient #1 being admitted to the hospital. During the skin/clothing check process, Patient #1 was asked to change into a hospital gown and hand his clothing over to a nursing supervisor (Staff Member to be checked for contraband (hospital prohibited items). Patient#1 agreed but stated, I am not taking my underwear off, i am here voluntarily and am not going to do that. The other registered nurse in attendance (Staff Member informed Patient #1 that was acceptable. After Patient #1'3 clothing had been searched for contraband, Staff Member #1 asked the patient to squat and cough so they could check further for contraband. Staff Member #2 informed Staff Member #1 that squatting and checklcontraband policy has been revised HO remove the administrative discharge for patients who refuse the skin check process. Staff education has been conducted reiated to this change. Daily audits are already in progress and the results of which will be shared at the weekly Pl Committee to be held Wednesday, February 1, 2017 and to the Medical Executive Committee on Thursday, February 9, 2017. The target compliance is 90%. Any score below 90% require remediation with the affected employee andlor further analysis of possible system issues. (X4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (XS) PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTNE SHOULD BE TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE A 129 Continued From page 7 A 129 Amendment 2/1/2017: The hospital?s skin FORM Previous Versions Obsolete 270V11 If continuaticn sheet Page 8 of 53 Printed: 01109/2017 DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERJCLEA (X2) (x3) DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: A. BUILDING COMPLETED 50401 1 3- 12r21I2016 NAME OF OR SUPPLIER STREET ADDRESS, CITY, STATE. CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES lD PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE SHOULD BE cof?n? TAG OR LSC INFORMATION) TAG CROSS-REPERENCED TO THE APPROPRIATE A 129 Continued From page 8 A 129 coughing is no longer part of the process. 4. On 12/14/2016 at 1:37 PM, Surveyor #2 interviewed a registered nurse (Staff Member about the Skin/ciothing check done at admission. Staff Member #3 con?rmed that part of the process included having the patient squat and cough and then checking for any visible contraband. Surveyor #2 found similar understanding of the process while interviewing two other registered nurses (Staff Member Staff Member on the chemicai dependency and units. 5. On 12/1212016 at 2:30 PM, Surveyor#2 interviewed the Ciinicai Director of Adult Services (Staff Member about the skin/clothing check procedure process. Staff Member #6 explained the hospital had received complaints about the skinlclothing check procedure and had recentiy changed their policy about a month ago. The new policy no ionger required the patient to squat and cough and now allowed the patient to refuse the Skin Check. The surveyor asked Staff Member #6 to explain why the current policy directed staff to administratively discharge voluntary patients who refused the skin/ctothing check process. the acknowledged being unaware of that aspect of the policy. Staff Member #6 stated that each Clinical director was responsibie for disseminating the new policy information to their respective clinical staff . 6. On 12/20/2016 at 1:50 PM, Surveyor #3 conducted a review Of the hospitai's human resource training files. Three of the four nursing staff members (Staff Members #1 4) reviewed had no record of completing the new SkinfCIothing Check Competency as required. FORM Previous Versions Obsolete if continuation sheet Page 9 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 SECLUSION Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: Based on record review, interview, and review of hospitai policies and procedures, the hospital staff failed to consider the effectiveness of less restrictive interventions before applying both restraints and seclusion for 2 of 6 patients (Patients Failure to less restrictive alternatives to using both restraints and seclusion simultaneousiy puts patients at risk for loss of personal freedom and dignity. Findings: 1. The hospital policy and procedure titled "Seclusion and Physical Mechanical Restraint" (Revised 212016; Poiicy PC.R.100) under the section "Policy" read in part: "Restraints may oniy be used for the management of violent or self-destructive behavior that jeopardizes the immediate physicai safety of the patient, a staff member or others after less-restrictive interventions are ineffective or ruied-out . . . The section titled "Patient Rights" read "Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The type of technique or seclusion used must be the least restrictive The Clinical Educator reeducated nursing staff on the requirement of using less restrictive interventions prior to restraint and seclusion in protecting patients, staff, and/or others from harm. The education included an emphasis on de?escaiation techniques as weil as other therapeutic interventions. The Clinical Educator provided the education during staff meetings through the use of verbal and written communication with return demonstration. Person Responsible: Director Monitoring: The Directorfdesignee will audit all restraints and seclusions to determine appropriateness of use with less restrictive interventions. Any clinical issues requiring corrective actions will be addressed by the The Director will report audit results in the Pi and quarterly MEC and Governing Board meetings. STATEMENT OF (x1) (X2) (x3) DATE AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED NAME OF OR SUPPLIER STREET ADDRESS, CITY, STATE, CODE CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH WA 98168 ID SUMMARY STATEMENT OF DEFICIENCIES iD PLAN OF CORRECT20N (x5) PREFIX- DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR LSC TAG CROSS-REFERENCED TO THE APPROPRIATE A 164 Continued From page 9 A 164 $0154 Corrective ACtionS A 164 PATIENT RIGHTS: RESTRAINT OR A 164 2/10f17 FORM Previous Versions Obsolete 1 if continuation sheet Page 10 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0933-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 504011 B. WING (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 12/21/2016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY, STATE. CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 Restraint or seclusion must be discontinued at the earliest possible time. regardless of the length (x4) to SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF (x5) PREHX DEFECIENCY MUST BE PRECEDED sY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR TAG CROSS-REFERENCEO To THE APPROPRIATE DEFICIENCY) A 164 Continued From page 10 A 164 Amendment 2/1/2017: Seclusion 8; intervention that will be effective to protect the restraint forms were changed to 00mph! patient? a staff memberl or others from harm.? With standards and Staff were educated on . those changes. Audits are aiready in 2, On 12/12/2013 at 230 pm, Surveyor #3 progress and the results of which will be reviewed the hospital's restraint and shared at the WBGKIV Pi Committee to be sectusion order sheet for Patient #5 observing hGId Wednesday, February 1:201? and to that under the section titled "Type", the box the Medical Executive Committee on labeled "Mechanical Restraints (wrist, ankle, Thursday, February 9, 2017. The target chest)" does not specify how many restraints are compliance is 90%. Any score below 90% to be applied by the hospital staff. ill/ill require remediation with the affected . employee and/or further analysis of 3. On 12/15/2016 at 2:00 PM, Surveyor #3 possibie system issues. 100% of all interviewed the hospital 3 primary restraint restraint charts are being audited. educator (Staff Member about how many restraints are to be used when physical restraints are ordered by a physician. Staff Member #7 indicated that the registered nurse determines how many restraints are initially used. The staff member acknowledged that hospital staff generally start with restraining both the arms and legs. The Chest restraint is only used in rare occasions. 4. On 12/14/2016 and 12/15/2016, Surveyor #3 reviewed the seclusion/restraint records of Patients #4 and #6 noting that hospital staff placed Patients #4 and #6 in both physical restraints and seclusion simultaneousiy on 8/12/2016 and 9/29/2016 respectiveiy based upon a physician order. No documentation indicating that a less restrictive alternative had - been considered or attempted first prior to the simultaneous application of both physical restraints and seclusion could be found. A 174 PATIENT RESTRAINT OR A 174 FORM Previous Versions Obsolete 270W 1 If continuation sheet Page 11 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/091201? FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 504011 MULTIPLE CONSTRUCTION A. BUILDING B. WING DATE SURVEY COMPLETED 1212112016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY, STATE, ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 of time identified in the order. This Standard is not met as evidenced by: Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that patients were released from seclusion at the earliest possible time for 3 of 6 patients reviewed (Patients #4 and Failure to remove patients from seclusion at the earliest possible time puts patients at risk for harm, loss of dignity, and personal freedom. Findings: 1. The hospital's policy and procedure titled "Seclusion and Physical Mechanical Restraint" (Revised 2/2016; Policy PCR. 100) underthe section read in part: "Restraints or seclusion shall be ended at the earliest possible time." 2. On 131512016 at 1:15 PM, Surveyor #3 interviewed the hospital?s principal trainerleducator for staff on the use of seclusion and restraints (Staff Member The surveyor asked Staff Member #7 when a patient should be released from seclusion. Staff Member #7 acknowledged that the trained registered nurse or physician would review and assess the patient's behavior to determine if seclusion or restraints could be discontinued. When asked by the surveyor what should happen if the documented behavior was described as sleeping, s/he indicated the door should be unlocked and the patient released from seclusion. 3. On 12/132016 at 11:30 AM in the adult The Clinical Educator reeducated nursing staff on the requirement of releasing patients from seclusion and restraint at the earliest possible time. The education included an emphasis on de?escalation techniques as well as other therapeutic interventions. The Clinical Educator provided the education during Nursing staff meetings through the use of written communication and return demonstration. Person Responsible: Director COOICNO Monitoring: The Director/designee will audit all. restraints and seclusions for release at the earlies possible time. Any clinical issues related to length of use requiring corrective actions will be addressed by the COOICNO. Results of the audit will be reported by the Director in {the Pi and quarteriy MEC and ?Governing Board meetings. (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY PULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COM?f?im TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) A 174 Continued From page 11 A 174 A 0174 Corrective Actions 2/10/17 FORM Previous Versions Obsolete 27QV1 1 if continuation sheet Page 12 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 81. Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 504011 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WZNG (X3) DATE SURVEY COMPLETED 121211201 6 NAME OF OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY, STATE, ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 unit (2 West), Surveyor #3 reviewed the medical record of Patient #3 who was placed into seclusion on 12/1/2016 at 8:30 AM and released from seclusion at 11:30 AM. The patient was placed in seclusion after being observed grabbing a food cart and running down a hallway repeatedly striking the cart against the wall. Documentation on the seclusion flow sheet indicated the patient?s observable behavior as "resting" or "sleeping" from 9:00 AM to 10:30 AM, a period Of 90 minutes. A progress note written at 10:30 AM indicated the patient was resting on the bed with eyes closed and verbalized understanding for the need for seclusion. "Will discontinue seclusion when staffing allows for1 to 1 support.? 4. On 12/14/2016 and 12/15/2016, Surveyor #3 reviewed seclusion/restraint flowsheet records of Patients #4 and #5 and noted the following: a. Hospital staff placed Patient #4 in seclusion and restraint on 9/29/2016 and did not release him/her from seclusion untii 9/30/2016, 3 period of 28 hours. Surveyor #3 noted the patient's observed documented behavior of steeping or resting for the following periods: --Frorn 9/29/2016 at 6:45 PM until 9:30 PM. a period of 2 hours and 45 minutes. --From 9/29/2016 at 10:45 PM until 9/30/2016- at 7:45 AM, a period of 9 hours. --From 9/30/2016 at 8:45 AM until 10:45 AM, a period Of2 hours. --From 9/30/2016 at 12:30 PM until 3:30 PM, a period Of 3 hours; estraint forms were changed to comply ith standards and staff were educated on those changes. Audits are already in progress and the results Of which wilt be shared at the weekly Pl Committee to be held Wednesday, February 1, 2017 and to the Medical Executive Committee on Thursday, February 9, 2017. The target compliance is 90%. Any score below 90% require remediation with the affected employee and/or further analysis of possible system issues. 100% of all restraint charts are being audited. A 174 Cmendment 2/1/2017: Seclusion (x4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE cor/?53m TAG on Lee TAG TO THE APPROPRIATE A 174 Continued From page 12 FORM Previous Versions Obsolete 270V1 1 if continuation sheet Page 13 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF (XI) PROVEDERJSUPPLIERJCUA 0?2) (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED . 504011 B. WING 12I2112016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TU WA 98168 (x4) go SUMMARY STATEMENT OF Io PROVIDERS PLAN OF CORRECTION (X5) PREHX (EACH MUST BE PRECEDEO BY FULL REGULATORY PREFIX CORRECTIVE SHOULD BE 90min? TAG OR IDENTIFYING INFORMATION) TAG CROSSAREFERENCED TO THE APPROPRIATE A 174 Continued From page 13 1). Hospital staff placed Patient #5 in seciusion on 12/11/2016 at 10:30 PM and was released from seclusion on 12/132016 at 7:15 AM. Surveyor #3 noted the patient's observed documented behavior on the seclusion flow sheet as "sleeping" from 11:35 PM until 7:15 AM, a period of 7 hours and 40 minutes. The surveyor found no evidence in the seclusion documentation to indicate the hospital staff considered removing the patient from seclusion early. 5. The director of adult services (Staff Member confirmed the findings at the time Of review. A 263 482.21 QAPI The hospital must develop, implement and maintain an effective, ongoing, hospital~wide, data-driven quality assessment and performance improvement program. The hospital's governing body must ensure that the program re?ects the complexity of the hospital?s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its program for review by CMS. This Condition is not met as evidenced by: Based on observation, interview, record review, and review of the hospital's quality program and quality documentation, the hospital failed to A174 A 263 See A0273, A0286, A0309, A0490, A0700 FORM Previous Versions Obsolete 27QV11 lf continuation Sheet Page 14 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 develop and implement a hospital-wide, data~driven quality assessment and performance improvement (QAPI) program. Faiiure to systematically collect and analyze hospital-wide performance data and to develop action plans to improve performance based on that data limited the hospitals ability to identify problems and formulate action plans. Findings: Failure to identify pharmaceutical services lacking suf?cient personnel to meet the scope, complexity, and needs of the patients served. Failure to provide oversight of the Performance improvement Program; Failure to collect and analyze data for performance measures assigned by the Governing Body, Performance Improvement Committee and the Medical Staff for the year 2016; Failure to measure, analyze and track adverse patient events; Failure to develop a process for identifying and reviewing reportable adverse events; Failure to ensure completion of action plans developed during review of adverse events; Failure to ensure and monitor the overali hospital environment was maintained in such a manner that the safety and weil being of patients was protected. STATEMENT or DEFICIENCIES (x1) 9(2) {x3} DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. COMPLETED 504011 3- WING 12l21l2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE. CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (M) ID SUMMARY STATEMENT or DEFICIENCIES ID PLAN OF CORRECTION (XS) DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR LSC TAG To THE APPROPRIATE A 263 Continued From page 14 A 263 FORM Previous Versions Obsotete 27QV11 if continuation sheet Page 15 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICAID SERVICES Printed: 7 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION A. COMPLETED 504011 8- WING 1 20112016 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. th=I CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98188 (mi In SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION (x5) DEFICIENCY MUST BE PRECEOEO BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO APPROPRIATE DEFICIENCY) A 263 Continued From page 15 A 263 The cumulative effect of these systemic problems resulted in the hospitai?s inabiIity to identify opportunities to improve patient Care. safety and outcomes of care. Due to the scope and severity of de?ciencies cited under 42 CFR 482.21, the Condition of Participation for Quaiity Assurance and Performance Improvement Program was NOT MET. Cross Reference: A-OZTS, A-0286, A-0309, A0490, A0700 A 273 482.21 DATA A 273 A 0273 Corrective Actions 2/ 10f 17 COLLECTION ANALYSIS The Pi Director reviewed the list of performance indicators, assigned by the Program Scope Governing Body, Pi Committee, and Medical (1) The program must include, bUt not be Iimited Staff for 2016. Of note, the foilowing ciinicai to: an ongoing program that shows measurabie data was aggregated, analyzed, and presented improvement in indicators for which there is to the Pt and MEC committees for assessment evidence that it will improve health outcomes of patient care processes. (2) The hospitat must measure, analyze, and track quality indicators and other aspects of Grievances performance that assess processes of care, ~Anticoagulation therapy and medication hospital service and operations. . . . . . reconCIiIatron upon admissron and discharge (b)Program Data -Restraint/Seclusion (1) The program must incorporate quality ~Eiopement rates and medication variances indicator data including patient care data, and -Medical consuitations/treatment other relevant data, for example, information -Contracted Services submitted to, or received from, the hospital?s -Pharmacy and Therapeutics (drug utilization, Quality improvement Organization. medication variances, adverse drug reactions, (2) The must use the data coitected t0" antibiotic usage, and nursing unit/med room Monitor the effectiveness and safetyof checks) services and quality of care; (3) The frequency and detail of data coiiection must be speci?ed by the hospitai's governing body. FORM Previous Versions Obsolete 2rov11 ?continuation sheet Page 16 0f 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) NUMBER: 504011 MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 12I21I2016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY, STATE, ZIP CODE 12844 MILITARY ROAD SOUTH WA 98168 (X5) Based on interview and review of the hospitai's quality program and quaiity documents, the hospital failed to collect and anaiyze data for performance measures assigned by the Governing Body, Performance Improvement Committee and the Medicai Staff for the year 2016. Failure to measure, anaiyze and track data related to performance measures as assigned leaves the hospital unable to identify areas of concern that may require improvement. Findings: 1. Review of the Performance improvement Pian (Approved 12l2015) and a document titled Performance Database - 2016 revealed that the hospitai was to collect and analyze data for 16 different performance measures. Each performance measure was assigned to a specific person for data collection and analysis, and the reporting frequency was de?ned. The Governing Board was to review the performance measures on a quarterly basis. 2. Surveyor #2 interviewed the Director of Ciinical Services (Staff Member #1 3) about Performance Measure data coilecticn, anaiysis and reporting on 12l16l20?l6 at 1:45 PM. The interview revealed the following: a. The Performance Measure titled "Patient Rights and Grievances" was to measure grievance process compliance and number of On a basis, the Director wiil facilitate the tracking and analysis of performance measures for presentation to the Pi committee. Committee members wili implement action plans as documented in meeting minutes. Negative or undesired trends will be discussed by the committee for initiation of performance improvement actions as needed. The Medical Staff and Governing Board will be informed of data anaiysis and Pi initiatives on a quarterly basis to ensure impiementation of the quality and performance improvement program. (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEOEO er FULL REGULATORY (EACH CORRECTIVE ACTION SHOULD BE TAG OR INFORMATION) TAG CROSS-REFERENCEO TO THE APPROPRIATE DEFICIENCY) A 273 Continued From page 16 A 273 Persons Responsibie: 2/10/17 PI Director COOICNO This Standard is not met as evidenced by: Monitoring FORM Previous Versions Obsolete If continuation sheet Page 17 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8! MEDICAID Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCEES AND PLAN OF (X1) PROVIDERISUPPLIERICLIA NUMBER: 504011 B. WING (X2) MULTIPLE CONSTRUCTION A. BUILDENG DATE SURVEY COMPLETED 12121.12016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY. STATEI ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98163 SUMMARY STATEMENT OF DEFICIENCIES grievances. The information was to be collected and analyzed by the Performance Improvement Director and the Patient Advocate, and reported to the Performance Improvement Committee There was no report containing this information presented for surveyor review. The Director stated that the grievance committee had not been meeting and that the data was not being coliected or analyzed. to. The Performance Measure titled "National Patient Safety Goals" listed 5 goals that the hospital was to collect and analyze data for, two were reviewed by Surveyor 1) Reduce iikelihood of patient harm associated with anticoagulant therapy (Warfarin), and 2) Medication upon admission and discharge. The Chief Nursing Officer and the Risk Manager were responsible for data collection and anaiysis. and for reporting to the Pi Committee and the Governing Board There was no repOrt containing this information presented for surveyor review. c. The Performance Measure titled "Restraint/Seclusion" was to measure proper documentation of restraint and seclusion. The Directors of Nursing and the Risk Manager were responsible for the data collection and analysis, and for reporting to the Pi Committee and Governing Board. While the number of patients placed in restraint and seciusion were reported by the Performance Improvement Committee to the Governing Board, there was no report available for review related to proper documentation of restraint and seclusion. d. The Performance Measure titled "Risk Management/Patient was to measure suicides/suicide attempts,falls, grievances, anticoaguiants. restraints 8; seciusions, elopements, medication consuitations, Pharmacy Therapeutics indicators, and contracted services have been abstracted and analyzed and will go the Pl Committee on or before Thursday, February 9. 2017 and then to the Medical Executive Committee on Thursday, .. February 9, 2017 and Governing Board thereafter. The target compliance is 90%. Any score below 90% will require remediation with the affected employee and/or further analysis of possible system issues. (x4; ID iD PROVIDERS PLAN OF CORRECTION (XS) DEFICIENCY MUST BE PRECEDED SY FULL REGULATORY (EACH ACTION SHOULD BE me OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A 273 Continued From page 17 A 273 Amendment 2/1/2017: The 2016 data for FORM Previous Versions Obsolete 27QV1 1 If continuation sheet Page 18 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: FORM APPROVED OMB NO. 0938?0391 medication variances, elopements, contraband and patient satisfaction. The Risk Manager and Chief Nursing Of?cer were responsible for data collection-and analysis, and for reporting to the Performance Improvement Committee and Governing Board. The surveyor requested to review the data coilection and analysis for medication variances and elopement. While there was data presented to the surveyor for elopement and medication variances, there was no report containing analysis of the data. e. The Performance Measure titted "Medical Consuitationsfi'reatment" was to measure medical consultation for timeliness and appropriateness to the patient's individual needs. The Risk Manager and Chief Nursing Of?cer were responsible for data collection and analysis, and for reporting the information quarterly to the Performance improvement Committee and the Medicai Executive Committee. There was no report containing this information presented for surveyor review. f. The Performance Measure titled ?Contracted Services" referred to the Contract log for scope of service and quality measures. The Risk Manager and Chief Executive Of?cer were responsible for data collection and anaiysis, and for reporting this information annually to the Performance improvement Committee and the Medical Executive Committee. There was no report containing this information presented for surveyor review. Cross-reference: Tag g. The Performance Measure titled "Pharmacy and Therapeutics" was to measure drug utilization, medication variances, adverse drug STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. COMPLETED 504011 B. WING 12:2112016 NAME OF PROVIDER OR STREET ADDRESS. CITY, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH TUKWILA, WA 98168 (x4) Io SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION (Ks) DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE TAG OR LSC To THE APPROPRIATE A 273 Continued From page 18 A 273 FORM Previous Versions Obsolete 27QV11 if continuation sheet Page 19 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES Printed: 0110912017 FORM APPROVED OMB NO. 0938-0391 Standard: Program Scope (1) The program must include, but not be limited to. an ongoing program that shows measurable improvement in indicators for which there is evidence that it identify and reduce medical errors. (2) The hospital must measure, analyze,and track patient (C) Program Activities (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Executive Responsibilities, The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative of?cials are responsible and accountable for ensuring the following: - (3) That clear expectations for safety are established. This Standard is not met as evidenced by: Events Pl Director Medical Director Monitoring All elements of the Pi plan and 2016 performance improvement activities were reviewed by senior leadership, the Performance Improvement Committee (1/11/17) and the Medical Staff committees (1/10/17 and 1/11/17). The processes for adverse event analysis and tracking inciuding the Root Cause Analysis process was highlighted. 2016 data analysis and recommendations for action were reviewed by PI and MEC committees. Persons Responsible: On a basis, the Director will facilitate the tracking and analysis of Pi measures for adverse events for presentation to the Pi and MEC committees. Negative or undesired trends will be discussed by the committee for initiation of performance improvement actions as needed. The Medical Stairc and Governing Board will be informed of adverse event data analysis and tracking on a quarterly basis to ensure implementation of the performance improvement program. STATEMENT or DEFICIENCIES (x1) PROVIDERJSUPPLIERICLIA (X2) DATE SURVEY AND PLAN OF CORRECTEON NUMBER: A. COMPLETED 504011 B. 12:21:2016 NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL. 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE sY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE TAG OR INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A 273 Continued From page 19 A 273 reactions, antibiotic usage and nursing unit/med room checks. The Pharmacist was responsible for data collection and analysis, and for reporting this information quarterly to the Performance Improvement Committee and the Medical Executive Committee. There was no report containing this information presented for surveyor - A 286 Corrective Actions evIew. A 286 482-21 (50- 03(2)! PATIENT SAFETY A 286 1) Analysis and Tracking of Adverse Patient 32/10/17 FORM Previous Versions Obsolete 270V?l1 lfcontinuation sheet Page 20 of 53 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) IDENTIFICATION NUMBER: 504011 Printed: 0110912017 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY A. BUILDING COMPLETED B. 1212112016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY. STATE. ZIP CODE 12844 MILITARY ROAD SOUTH WA 98168 #1 - Analysis and Tracking of Adverse Patient Events Based on interview, record review and review of quality documents, the hospital failed to measure, analyze and track adverse patient events. Failure to analyze aggregate data related to adverse patient events risks the hospital?s ability to identify root causes and develop action plans and may contribute to an unsafe patientcare environment. Findings: 1. Review of the hospital policy and procedure titled "incident Reporting" . (Policy Approved 12/2013) revealed that the hospital's Risk Manager was responsible for collecting incident report data for statistical analysis and trending. Review of the hospital's Performance Improvement Plan (Policy Approved 1212015) revealed that it was the responsibility of the Medical Executive Committee and the Performance improvement Committee to review risk management activities by analyzing the results of incident reports. patient surveys and patient complaints to determine patterns of patient care occurrences and ensure that corrective action is or has been taken to the extent possible. 2. An interview with the Manager of Risk and Quality (Staff Member #12) on 12/1 412016 at 1:04 PM and 121200016 at 1:20 PM, and the Director of Clinical Services (Staff Member #13) on 1211 6/2016 at 1:45 PM revealed the following: Pl Committee will receive action plans for each Root Cause Analysis conducted along (Irvith a time frame for the completion of lthose action items. The PI Committee will .add those items to minutes and receive follow-up at each of its meetings until all items are resolved. Action items will typically be resolved within 90 days, some sooner, depending on the urgency associated with that action item. The target Icompliance is 90% of all items completed Ivlth 90 days. Any score below 90% will require remediation with the affected employee and/or further analysis of possible system issues (x4) ID SUMMARY STATEMENT OF lo PLAN OF CORRECTION (XS) pREle (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE mfg?? TAG OR INFORMATION) TAG TO THE APPROPRIATE DEFICIENCY) A 288 Continued From page 20 A 286 Amendment 2l1l2017: Going forward, the FORM Previous Versions Obsolete if continuation sheet Page 21 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8t MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICUA NUMBER: 504011 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 132112016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY, STATEI ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98163 (X4) TAG SUMMARY STATEMENT OF DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE PLAN OF CORRECTION COMPLETION DATE DEFICIENCY) A 286 Continued From page 21 a. incident reports were reviewed individually by the Risk Manager and other managers as needed but the data was not reviewed in aggregate iooking for patterns, trends and opportunities for improvement. b. Patient grievances were logged and reviewed individuaily but the data was not analyzed in aggregate looking for patterns, trends and opportunities forimprovement. c. The number cf patients requiring a medical transfer were reported to the Governing Board quarterly but the data was not analyzed in aggregate looking for patterns, trends and opportunities forimprovement. d. Hospital code data was not being collected or analyzed for the purpose of looking for patterns, trends and opportunities for improvement. #2 - Reportable Adverse Events Based on interview, record review and review of hospitai policies and procedures, the hospital failed to deveiop a process for identifying and reviewing reportable adverse events. Failure to recognize reportable adverse events inhibits the hospitals ability to perform in-depth review of the events and deveiop action plans. This failure places patients at risk for care in an unsafe environment. Reference: WAC 246-302-010 De?nitions ?Adverse health event" or ?adverse event" means the list of twenty?nine serious reportable events updated and adopted by the National Quality A 286 ITEM #2 Reportable Adverse Events The has educated the Pi Director on the requirements of All reportable events outlined in the NQF list of reportable adverse events, the requirement for reporting adverse events and elements of submitting a root cause analysis were discussed. All reportable adverse events wili be reported in a timely manner in accordance with 2f 10/ 17 FORM Previous Versions Obsolete If continuation sheet Page 22 of 53 Printed: 01/09/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) on} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 B-WING 12l21l?2016 NAME OF PROVIDER OR STREET ADDRESS. CITY. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES tD PLAN OF CORRECTION 0(5) PREFIX DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE COMptf-g'ow TAG OR LSC TAG CROSSREFERENCED TO THE APPROPRIATE 9? A 286 Continued From page 22 A 286 #2 continued Forum in 2011. in its consensus report on serious . reportable events in health care including all Persons appendices. Pt Director WAC 246?302-020 How and When to Report (1) Notify the department that an adverse health Monitoring event has occurred within forty-eight hours of On a basis, the Director will con?rmation of the adverse health event report all adverse events reported per WAC 246802-020 to the Pl committee and (2) Submit a report to the department within MEC and Governing Board quarterly. forty-five days of the con?rmation of the adverse health event. The report must include a root cause analysis and corrective action plan Reference: The National Quality Forum (NQF) identi?es and de?nes twenty-nine serious reportable events. The twenty-nine adverse health events including but not limited to: (T) Potential criminal events: Death or serious injury of a patient or staff member resulting from a physical assault battery) that occurs within or on the grounds of a health care setting. Findings: 1. The Hospital policy titled "Incident Reporting" (Policy Approved 1212013) stated that "in States where the is required to report Tragic/Serious incidents to the State, it must be done within the State requirements and notification of completion to Corporate Risk Management and Clinical Services Departments." The same policy stated that "All Level and II incidents require a Risk Manager investigation and completion of the Investigation Chronoiogy and Incident Recap Analysis." FORM Previous Versions Obsolete 27QV11 If continuation Sheet Page 23 0f 53 DEPARTMENT OF HEALTH AND HUMAN SERVECES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 09380391 The policy did not include the NQF list of reportable adverse events nor did it include the requirement for reporting adverse events and submitting a root cause analysis. 2. Surveyor #2 reviewed a report of a patient to patient assault resulting in a serious patient injury. The patient was transferred to the emergency room for care and required follow-up specialty health care appointments for his/her injuries. The incident was reviewed by the Manager of Risk and Quality (Staff Member and the investigation Chronology and incident Recap was completed with recommendations for improvement based on the investigation. 3. An interview with the Manager of Risk and Quality (Staff Member #12) by Surveyor #2 on 12/20/2016 at 2:12 PM about the patient to patient assault revealed that Staff Member #12 was unaware that this particular incident was considered an adverse event by NQF. Staff Member #12 stated that a root cause analysis had not been completed nor had the incident been reported to the State as required by hospital policy. ITEM #3 Completion of Action Plans Based on interview and document review, the hospitai failed to ensure completion of action plans developed during review of adverse events. Failure to ensure completion of action plans limits the hospitals ability to correct systemic problems placing patients at risk for harm. Findings: A 286 item Completion of Action Plans ffhe and Pi Director were trained on analysis of adverse events and credible root cause analysis elements by the Regional Clinical Director. Adverse reportable events will be reviewed with credible action plans formulated and implemented in a timely manner. Persons Responsible: Pl Director Monitoring On a basis, the Director will present action plans based on analysis of adverse events to the Pi committee. Action plans will include date/s actions taken and persons responsible for action. The Medical Staff and Governing Board will be informed of actions taken in response to adverse events on a quarterly basis to ensure implementation of the analysis and actions taken in response to adverse events. STATEMENT OF DEFICIENCIES (Xi) 9?2) MULTIPLE (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED NAME OF PROVIDER OR SUPPUER STREET ADDRESS. Cl'i'Y. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION rx5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) A 286 Continued From page 23 A 286 2/10/17 FORM Previous Versions Obsolete 27QV11 If continuation sheet Page 24 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8c SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES {x1} 0?2) MULTIPLE {x3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) Io SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION {st (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLEPON TAG OR LSC INFORMATION) TAG TO THE A 286 Continued From page 24 A 286 1. Surveyor #2 reviewed the root cause analysis for 3 adverse events with the Director of Ciinical Services (Staff Member #13) on 12/16/2016 at 1:25 PM and with the Manager of Risk and Quality (Staff Member #12) on 12/20/2016 at 9:20 AM. Review of the action plans developed to correct identi?ed issues revealed the foiiowing: a. For the elopement issue, the action item to change the poiicy "Code Amber? (used to aiert staff of a patient who has wandered away from the nursing unit) to "Code had not been completed aithough staff were trained and Code was being used by the hospitai. b. For the sexual assault issue, one of the action items was a change to an assessment form foliowed by audits to ensure that assessments were properly conducted, documented, and risk reduction precautions were implemented. Staff Member #12 stated that the audits had not been done. A 309 482.21 QAPI EXECUTIVE A 309 A 309 Corrective Actions RESPONSIBILITIES The PI Director and Medicai Director reviewed 2/10/17 The hospital?s governing body (or organized ali elements of the PI pian and 2016 group or individuai who assumes fUiI performance improvement activities with the authority and responsibility for Operations of the Medicai Staff and MEC committees (1/10/17 hospital), medical Sift?! and administrative and 1/ 11/17). The processes for clinical and of?cra-Is are responsible and accountabie for non-clinical anaiysis and tracking were ensuring the foliowrng: highlighted. 2016 data analysis and 1) That an ongoing program for quaiity recommendations for action were reviewed by improvement and patient safety, including the the MEC. The Medical Staff-assagned reduction of medical errors, is defined, representation to the infection Control, implemented, and maintained Pharmacy Therapeutics, EOC, Safety and (2) That the hospital-wide quaiity assessment Performance Improvement committees. These and performance improvement efforts address committee participants Wiil report committee priorities for improved quality of care and patient activities to the MEC at least quarterly. FORM Previous Versions Obsolete If continuation sheet Page 25 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: Based on interview and review of the hospital?s performance improvement pian, the hospital's Governing Body failed to provide oversight to ensure that the quality assessment and performance improvement plan was fuliy implemented. Failure to provide oversight of the Quality Assessment and Performance improvement program to ensure full implementation of the performance Improvement plan limited the hospital's to identify systemic problems and develop action plans to improve patient care and ensure safety. Findings: 1. The hospital's Performance improvement Plan (Policy 300; Approved 1212015) stated that "Medical staff and management staff provide leadership for and actively participate in performance improvement activities and estabiish criteria for measuring, assessing and improving organization performance of both clinical and non-clinical processes and patient outcomes. They assure implementation of appropriate quality assessment and improvement activities and report the results to the Board through the Medical Executive Committee and Performance Improvement Committee. recommended priorities for quality and performance improvement activities. Persons Responsible: Medical Director President of the Medical Staff Monitoring . On a basis, the Director wiil facilitate the tracking and analysis of Pi measures for presentation to the Pi and MEC committees. Negative or undesired trends will be discussed by the committee for initiation of performance improvement actions as needed. The Medical Staffand Governing Board will be informed of data analysis and PI initiatives on a quarterly basis to ensure implementation of the quality and performance improvement program STATEMENT OF DEFICIENCIES (x2) 0?2) CONSTRUCWON (xa) DATE SURVEY AND PLAN or CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 B. WING 12?211201 6 NAME OF PROVIDER DR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE CASCADE BEHAVEORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) 20 SUMMARY STATEMENT or DEFICIENCIES ID PLAN OF CORRECTION 0(5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE DEFICIENCY) A 309 Continued From page 25 A 309 The MEC reviewed the 2017 PI Plan and 2/10/17 FORM Previous Versions Obsolete 27QV1 1 ?continuation sheet Page 26 of 53 Printed: 01/09/2017 DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICARE 8: SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPUERICLIA (X2) (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 504011 3- WING 1212-1 [201 6 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CODE CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH TUKWILA, WA 98168 (M) In SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (X5) PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE SHOULD BE TAG OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE A 309 Continued From page 26 A 309 The Medical Executive Committee is delegated the Authority and Accountability necessary for the delivery and assessment of all processes that contribute to the prevention of problems and the continual improvement of the quality. appropriateness and efficiency of patient care outcomes. Medical Executive Committee responsibilities, duty and authority for performance improvement activities are defined in the Medical Staff Bylaws." The hospital's Medical Staff Bylaws (dated 12/1/2013) under the section titled "Medical Executive Committee" read in: part 11.4.1 Quality Management: The duties involved in overseeing quaiity assessment and performance improvement are to at least an annual evaluation of the quality management program to assure its comprehensiveness and effectiveness, and document improvement in patient care and patient outcome studies; and performance of this function in a report on at least a quarteriy basis. 2. An interview with the Manager of Risk and Quality (Staff Member #12) and the Director of Clinical Services (Staff Member #13) revealed that the Medical Director is a member of the Performance improvement Committee but does not participate in performance improvement activities other than those that have to do with credentialing and privileging of medical staff . The Manager of Risk and Quality stated that the Performance improvement Program has never been formaliy evaiuated as required by the Medical Staff Bylaws. Cross Reference: A-0286 FORM Previous Versions Obsolete 270V11 'f mn?nuam?? Sheet Page 27 0f 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR 8: Printed: 0120912017 FORM APPROVED . OMB NO. 0938-0391 OF DRUGS (1) Drugs and bioiogicals must be prepared and administered in accordance with Federai and State iaws, the orders of the practitioner or practitioners responsibie for the patient's care as specified under and accepted standards of practice. Drugs and biologicais may be prepared and administered on the orders of other practitioners not speci?ed under ?482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospitai policies, and medicai staff byiaws, rules, and reguiations. (2) Ail drugs and bioiogicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federai and State laws and reguiations. including applicabie licensing requirements. and in accordance with the approved medicai staff policies and procedures. This Standard is not met as evidenced by: Based on record review, interview, and review of policy and procedure. the hospital failed to ensure that nursing staff foilowed physician orders for treatment of alcohol withdrawal for 1 of 3 patients reviewed (Patient Failure to follow such orders risks patients receiving inadequate or improper treatment, which may result in patient harm. Findings: Person Responsibie: Monitoring The Director/designer: wiil perform a random audit of at least 30 records per month to ensure compliance of 90% or above for four consecutive months. Any deficiencies will be addressed. Audit results wilt be presented to the PI and quarterly MEC and Governing Board meetings. STATEMENT OF DEFICIENCIES (x1) (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 504011 B. WING 132112016 NAME or PROVIDER OR SUPPLIER STREET ADDRESS, crrv. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF In PLAN OF (XS) (EACH DEFICIENCY MUST BE PRECEDED av FULL REGULATORY PREFIX CORRECTIVE SHOULD BE COMPLETION TAG on Lee INFORMATION) TAs CROSS-REFERENCED TO THE DATE DEFICIENCY) A 405 Continued From page 27 A 405 A 0405 Corrective Actions A 405 ADMINISTRATION A 405 The Clinical Educator re'educated the nursing 2/10/17 staff on the requirement of administrating medications as ordered for the treatment of alcohoi withdrawal. The Clinical Educator provided education during Nursing staff meetings through verbal and written communication. FORM Previous Versions Obsolete 27QV1 1 if continuation sheet Page 28 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8r MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 504011 B. WING (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 12/21/2016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY. STATE. ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 The hospital's policy and procedure titled [Clinical Institute Withdrawal Assessment] (Policy Approved 12/2013) established how often a patient was to be assessed for of alcohol withdrawal; how the patient's were to be scored using a withdrawal assessment scale and how medications were to be administered according to the patient?s score. The policy included a pro-printed order set titled "Lorazepam Orders for Alcohol Withdrawal" (dated 5/15/2014) used by physicians to order speci?c dosages of medications to be administered based on the patient's withdrawal assessment score. 2. Review of the medical records of three patients who experienced of alcohol withdrawal during their hospital stay revealed the following: a. Patient #7 was a 59 year-old patient who was admitted on 12/10/2016 for treatment of alcohol withdrawal. On 12/10/2016 at 9:30 PM the patient?s physician ordered the Alcohol Withdrawal Protocol initiating treatment for alcohol withdrawal Review of the medication administration record for Patient #7 revealed that on 12/1 012016 the patient received 1 mg of Lorazepam at 9:40 AM and 1 mg of Lorazepam at 2:20 PM. An interview by Surveyor #2 with a Registered Nurse (Staff Member during review of the patients alcohol withdrawal scores and administered medications revealed that based on the score assigned at 9:00 AM and 2:00 PM the patient's dose of Lorazepam should have been 0.5 mg at 9:40 AM and 0.5 mg at 2:20 PM. Staff currently being audited daily by the Nursing Director of CD Services. Analysis of the audits will go to the Pl Committee at each weekly Pl Committee starting Wednesday, February 1, 2017. The target compliance is 90%. Any score below 90% will require remediation with the affected employee and/or further analysis of possible system issues. Once several weeks of compliance is achieved, monitoring will become with the same targets. pm) It} SUMMARY STATEMENT OF DEFICIENCIES iD PLAN OF (X51 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY (EACH CORRECTIVE SHOULD BE TAG OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A 405 Continued From page 28 A 405 mendment 2/1/2017: protocols are FORM Previous Versions Obsolete 27QV1 1 If continuation sheet Page 29 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01l09l2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF OEFICIENCIES AND PLAN OF CORRECTION NUMBER: 504011 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 121219016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWTLA, WA 98168 (X4) ID SUMMARY STATEMENT OF DEFECIENCIES PREFIX (EACH DEFICEENCY MUST BE PRECEDED BY FULL REGULATORY TAG OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 405 Continued From page 29 Member #4 did not know why nursing staff administered the higher doses. A 490 482.25 PHARMACEUTICAL SERVICES The hospital must have pharmaceuticai services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital's organized pharmaceuticai service. This Condition is not met as evidenced by: Based on Observation. interviews, and document review, the hospitai failed to provide suf?cient pharmaceutical services to meet the scope, compiexity. and needs of the patients served. Faiiure to provide adequate pharmacy services risks patient safety and safe medication administration practices. Findings: 1. Medications being administered to patients prior to pharmacy veri?cation of orders resulting in high number of automatic dispensing machine overrides. 2. Patient home medications not being veri?edby a pharmacist prior to being administered. 3. Medication errors resulting from medication overrides of the automatic dispensing machines. 4. Expansion of hospitai services, Ciinicai units, A 405 A 490 See Tags A0491, A0493, A0500 FORM Previous Versions Obsolete 27OV11 ?continuation sheet Page 30 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 The pharmacy or drug storage area must be administered in accordance with accepted professional principies. This Standard is not met as evidenced by: Based on observation, interview. and review of policy and procedure, the hospital failed to ensure that hospital staff followed hospital procedures for use of a patient's own medications. Faiiure of staff to follow procedures for use of a patient's own medications piaces patients at risk for harm due to medication errors. Findings: 1. The hospitai poticy and procedure titled "Medications Brought in with Patients" (Policy 18; Revised 4/2014) read as fotlows: those medications that wili be used by the patient during their admission at the the staff on policy titled "Medications Brought in with Patients.? Education was provided during Nursing staff meetings through verbal and written communication. Education inciuded: ?Use of home medications only after the verification process is complete. ?Proper Iabelihg and initialing of the verification process on home medication bottles. ?Physician orders needed for use of home medications. The medicai staff were educated on the requirement of documenting dosages for home medication administration and ordering allowance of patient home medications. Education was provided through written and verbal communication. Persons Responsibie Medical Director Pharmacy Director STATEMENT OF DEFICIENCIES {x1} (X3) DATE SURVEY AND PLAN OF NUMBER: A. COMPLETED 50401 1 3- WING 121219016 NAME OF PRovroER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (M) ID SUMMARY STATEMENT OF PLAN OF CORRECTION (XS) PREFIX DEFICIENCY MUST BE PRECEDED sv FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR TAG TO THE APPROPRIATE DEFICIENCY) A 490 Continued From page 30 A 490 and patient census without a comparable increase in pharmacy services coverage. The cumuiative effect of these systemic problems resulted in the hospital's inability to provide for safe dispensing, use and administration. and tracking and controi of medications. Due to the scope and severity of de?ciencies under 42 CFR 482.25. the Condition of Participation for Pharmaceuticai Services was NOT MET. Cross Reference: Tags A0491. A0493. A0500 A 0491 Corrective Actions A 491 482.25(a) PHARMACY ADMINISTRATION A 491 The Clinicai Educator reeducated the nursing 2(10/17 FORM Previous Versions Obsolete 27QV11 If continuation sheet Page 31 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 504011 Printed: FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE consraucnon (x3) DATE SURVEY A. COMPLETED B. WING 1212112016 NAME OF 0R SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY. STATE, ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (X5) medications be inspected for proper identification, iabeling, and visual evaluation as part of the pharmacist verification process. Once a medication is veri?ed, the pharmacist will place a sticker on the packaging with the pharmacist's initials and date the medication as evidence the medication has been veri?ed "The order for a patient to take hisiher own medication must be written by the attending physician on the Physician?s Order form." 2. A tour of the medication room of three patient care units Rehab and Detox) on 1211912016 between 2:00 PM and 3:00 PM revealed the foilowing: a. One bottle Of home medication, Latuda 120 mg tabiets, was found for Patient #8 in the patient's medication tray in the Rehab unit medication room. The pharmacist attached a white printer label to the medication bottle with "veri?ed" written on the [abet along with the date (1211712016) and initials of the pharmacist. Staff administered the medication at 9:00 PM on 12/152016 and 12/16l2016 prior to pharmacist veri?cation. b. Two bottles of home medications, Provastatin Sodium 40 mg tablets and Dilt [Diltiazem] XR SR 180 mg capsules, were found for Patient #9 in the patient's medication tray in the Rehab medication room. The pharmacist veri?ed and labeled the medications using a "date openedlexpiration date" label rather than the pharmacy medication verification iabel. Staff administered the medications on 1211812016 at 9:00 AM. There was no physician order for the patient to take hisfher own medications. The Director/designee will perform a random audit of at least 30 patient?s own medication orders to ensure compiiance with the verification process. Any deficiencies will be addressed Audit results wiil be reported in the PI and quarterly MEC and Governing Board meetings. {Amendment 2/1/2017: The pharmacy director is auditing 100% of home medications and will first report his findings to the weekly Pi Committee on Wednesday, February 1. 2017, to the Medical Executive Committee on February 9, 2017 and to the Governing Board thereafter. Audits continue until several weeks of compliance Iat or greater than 90% has been achieved and sustained. The target compliance is 90%. Any score below 90% wilt require remediation with the affected employee and/or further analysis of possible system issues. (x4) iD SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE SHOULD BE TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE A 491 Continued From page 31 A 491 Monitoring FORM Previous Versions Obsolete if continuation sheet Page 32 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID Printed: 01/091201? FORM APPROVED OMB NO. 0938-0391 STATEMENT OF AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 504011 A. BUILDING B. WING (X2) MULTIPLE DATE SURVEY COMPLETED 121211'2016 NAME OF PaovzoER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY, STATE. ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ?3 PREFIX TAG SUMMARY STATEMENT OF (EACH MUST BE PRECEDED BY FULL REGULATORY OR LSC INFORMATION) ID PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE PLAN OF CORRECTION (X5) COMPLETION DATE A 491 A 493 Continued From page 32 c. Three bottles of home medications. Rayataz 300 mg capsuies, Norvir 100 mg tabiets and Truvada 200 mg tablets, were found forPatient #10 in the patient?s medication tray in the Rehab medication room. There was an initiai and date written directly on the medication bottie iabel (for the Rayataz and Truvada) but the surveyor was unabie to tell if the initials and dates were evidence of pharmacist veri?cation. There were no pharmacist veri?cation labels on the two medication botties. The Norvir medication had no label with date and signature indicating pharmacist veri?cation. All of these medications were in a plastic bag piaced in the patient's medication tray. Two notes were found in the bag, one stated that the pharmacist veri?ed Truvada and the other note stated the pharmacist had veri?ed Norvir. The notes were not attached in any way to the bottles of medication. Staff administered all three medications on 12/19/2016 at 9:00 AM. There was a physician order for administration of the patient's own medications but the order did not inciude speci?c dosages. d. One bottle of home medication, Diiantin 30 mg capsules, was found for Patient #11 in the patient's medication tray in the unit medication room. The pharmacist veri?ed and labeled the medication. Staff administered the medication on 12l19/2016 at 9:00 AM. There was no physician order for the patient to take his/her own medication. PHARMACY PERSONNEL The pharmaceutical service must have an adequate number of personnei to ensure quality pharmaceutical services, including emergency services. A 491 A 493 FORM Previous Versions Obsolete If continuation sheet Page 33 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR 8r MEDICAID Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) NUMBER: 504011 MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 12/21/2016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CETY, STATE. ZIP CODE 12844 MILITARY ROAD SOUTH TUKWELA, WA 98168 PLAN OF CORRECTION (X5) This Standard is not met as evidenced by: Based on document review and interview. the hospital failed to ensure the pharmacy was staffed with suf?cient number Of personnel to provide quality pharmaceutical services in order to meet the needs Of the patients and the staff providing care. Failure to provide suf?cient pharmacy staff to provide accurate and timeiy order processing and medication delivery places patients at risk of harm due to medication errors. Findings: 1. The hospital expanded its overall bed capacity by 42 beds within the past 12 months. During that period, two additional nursing units were opened (2 North - 18 beds; 2 West - 24 beds). Prior to the expansion, the hospital?s average daily census (ADC) was 66.58 patients. This year?s current ADC is 104.41 which represents a 57% increase or an additional 37.58 patients per day. The hospital pharmacy staf?ng or coverage did not increase correspondingly despite the increasedworkioad. 2. On 12/20/2016. Surveyor #3 reviewed a pharmacy document which captures a variety of key quality workload elements. The surveyor noted that the average number of medication doses administered increased by over 12,000 doses since the beginning of the year. The total number of medication overrides performed by nurses averaged 2,593 per month or nearly 87 per day. Similarly, the "inventory count Off" in the automatic dispensing machines totals refiect non-controlled substances discrepancies have increased to a Upon completion Of the survey, the CEO, Pharmacy Director, and Regional Clinical Director reviewed pharmacy staffing in order to ensure a sufficient number Of personnel. Effective 12/20/16, the Pharmacy Director increased pharmacy staffing hours by two (2) additional evening hours, seven days per week. The increase in pharmacy hours are prioritized on verification of new orders and order entry. Persons Responsible: Pharmacy Director CEO Monitoring The Director of Pharmacy wiiI track use Of the additional staffing hours and report utilization in the monthiy Pi and quarterly MEC and Governing Board meetings for a period of3 months. Any related deficiencies wiil be addressed on) i0 SUMMARY STATEMENT OF DEFICIENCIES ID PREHX DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX SHOULD BE TAG OR LSC TAG CROSS-REFERENCES TO THE A 493 Continued From page 33 A 493 A 0493 Corrective Actions 2/10/17 FORM OMS-256710299) Previous Versions Obsolete if continuation sheet Page 34 of 53 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE 8r SERVICES Printed: 0110912017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. COMPLETED 504011 129112016 NAME OF PROVIDER OR STREET ADDRESS. CITY. STATE, CODE CASCADE BEHAVIORAL HOSPITAL 1 2844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDERS PLAN OF CORRECTION (X5) DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVEACTION SHOULD BE TAO OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE A 493 Continued From page 34 average of 685 items. 3. On 12/14/2016 at 11:30 AM, Surveyor #3 interviewed a pharmacist (Staff Member about the adequacy of pharmacy staf?ng compared to the current workload. Staff Member #9 acknowledged the pharmacy workload had substantially increased within the past year. Slhe stated that since starting work at this facility almost a year ago. the hospital had added two more inpatient clinical units without a corresponding increase in pharmacy Operating hours or personnel. Staff Member #9 indicated that the average turnaround time for verifying new medication orders was 30 minutes but may be delayed up to an hour depending on volume of new admissions. 4. On 1211912016 at 2:30 PM, Surveyor #3 interviewed the Director of Pharmacy (Staff Member about the high number of medication overrides occurring within the hospital. Staff Member #8 stated that helshe had oniy been a member of the hospital staff for "less than a month" but acknowiedged the number of medication overrides was "high" indicating that pharmacy is oniy on?site during the day shift hours. Surveyor #3 asked Staff Member #8 if s/he had suf?cient pharmacy resources. Staff Member #8 stated that don't have enough pharmacy staff to do what we should." The director of pharmacy indicated that he/she had worked over the contracted hours every week except for the ?rst week when on orientation. 5. On 12/16/2016 at 11:00 AM, Surveyor #3 interviewed the Director of Adult Nursing Services (Staff Member about the high number of medication overrides occurring within the hospital. Staff Member #6 indicated A 493 Addendum 2/1/2017: Pharmacy has increased its hours of coverage in the evening hours. Overrides are being tracked daily and analyzed for time of day, type of drug, and reason for the override. The PI Director and Pharmacy Director will formally present their findings at the weekly PI Committee meeting beginning Wednesday, February 1, 2017. Pharmacy hours wiil continue to be adjusted as necessary to minimize the use of the override process. The facility wiit continue to evaluate hours needed by the pharmacy through recommendations by the contracted provider, number of over?rides due to tack Of pharmacist to conduct the first dose review, and medication errors related to overrides. FORM Previous Versions Obsolete 1 If continuation sheet Page 35 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR 8: MEDICAED SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 In order to provide patient safety, drugs and biotogicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: Based on document reviews, interviews, and review of hospital poliCles and procedures. the hospital failed to ensure drugs were controlled and distributed in accordance with applicable standards of practice. Failure to have adequate processes in place for medication orders to he received and dispensed in a safe and timely manner risks patient safety and medication errors. Findings: 1. The hospital policy and procedure titled "After-Hour Medication Stock with or without Pharmacy Review" (Revised 4/2014; Policy under the section titled "Statement of Policy? read "The facility recognizes the importance of pharmacist review prior to initiation of new drug therapy. This review has been shown STATEMENT OF (x1) 9?2) MULTIPLE (x3) DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 3- WING 12l21!2016 NAME OF PROVEDER OR SUPPLIER STREET ADDRESS, CITY. ZIP CODE CASCADE BEHAVIORAL 12344 MILITARY ROAD SOUTH TUKWILA, WA 98168 (X4) ID SUMMARY STATEMENT OF ID PLAN OF (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEOED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE DEFICIENCY) A 493 Continued From page 35 A 493 that medication overrides iS a "problem" stating "i think medication overrides are dangerous." The staff member acknowledged that nurses were overriding because of how long it takes for orders to be veri?ed in the system. Staff nurses have also complained they frequently run out of medications in the automatic dispensing machines on the weekends, "especialiy on Monday mornings" requiring nursing staff to search for medications on other ciinical units. A 500 482.25(b) DELIVERY OF DRUGS A 500 A 050? ?cums 2/10/17 The Pharmacy Director, and Director reviewed the process of medication overrides in the automated dispensing system. To ensure safe delivery of medications, the following system revisions were made: ?Reasons for overrides ?Two nurse witness system when overrides are needed ~Weekly review of overrides to assess for trends, rationale, and any needed system improvements The Ciinicai Educator educated the nursing and medicai staff on the revised system changes for oversight of the override system. Education was provided during Nursing and Medical Staff meetings through verbal and written communication. Persons Responsible: Medical Director Pharmacy Director Director FORM Previous Versions Obsoiete 270V11 If continuation sheet Page 36 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x1) NUMBER: 504011 B. WING (x2) MULTIPLE A. (X3) DATE SURVEY COMPLETED 12/21/2016 NAME OF OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY, STATE. ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 0(5) to decrease medication errors associated with the medication-use process. . .The hospital allows for an exception to pharmacist review of the medication order for certain situations when time does not permit pharmacist review. This often occurs in 'tirst doses' or 'emergency' situations. In such cases, an exception is allowed because signi?cant patient harm could result in the delay involved for a pharmacist review of the medication order, and the potential harm would outweigh the bene?ts of a pharmacist review." 2. On 12/20/2016, Surveyor #3 reviewed a pharmacy document which captured a variety of key quality workload indicators that included medication variances and medication overrides. The surveyor noted the hospital had a total of 23,348 medication overrides performed by nurses in the first nine months of 2016. Prior to the expansion Of the hospital bed capacity, the hospital average 2,221 medication overrides a month. With the opening of the two additional nursing units, the number of medication overrides had risen to a average of 2,700 representing a 22% increase or 479 additional overrides. Similarly, the surveyor noted that the number of medication variances (potential errors) by physicians had increased by four fold since the beginning of the year. 3. On 12/19/2016 at 3:00 PM, Surveyor #3 reviewed the hospital medication override list for the period 12/16/2016 at 4:00 PM until 12/19/2016 at 7:00 AM (the weekend) in which the pharmacy in?house coverage is only 6 hours a day. During this time period, the hospital admitted 14 patients and there was a total of 236 medication overrides initiated by the nursing staff. 0f the 236 medication overrides which occurred over the weekend, 85 of the overrides listed The Pharmacy Director/designee will report on the total number of overrides with aggregated trends, analysis, and system improvements to the Pi and quarterly Pharmacy and Therapeutics committees. Findings, recommendations and actions will be reviewed and reported at quarterly MEC and Governing Board meetings. Committee minutes wilt reflect data reporting, analysis, and system changes. A500 Amendment 2118/2017 Cascade Behavioral Health was cited for pharmaceutical services not meeting the needs of its patients. The cumulative effect of these systemic problems/findings results in the hospital's inability to provide for safe dispensing, use and administration, and tracking and control ofmedications. Immediate response included increased pharmacy hours by two (2) additional evening hours, seven (7) days per week. That staffing enhancement resulted in overrides being reduced to approximately 10 per day. Since then, the medical staff considered a night locker concept with a smaller inventory of medications but Ultimately decided not to endorse this idea. Coilectively, these systemic issues require additional time to implement process change, arrange additionai pharmacy Icoverage, establish 24/7 coverage solution to review all orders, and eliminate nursing access and overrides. (X4) :0 SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION PREFIX (EACH MUST BE PRECEDED av FULL REGULATORY PREFIX (EACH CORRECTIVEACTION SHOULD BE TAG OR INFORMATION) TAG - TO THE APPROPRIATE A 500 Continued From page 36 A 500 Monitoring FORM Previous Versions Obsolete 270V?i1 Ii continuation sheet Page 37 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR 8; MEDICAID SERVICES Printed: 01/092017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF {xn PROVIDERISUPPLIERICLIA (X2) {x3} DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. COMPLETED 504011 B. WING 12i21i2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 {x4} ID SUMMARY STATEMENT OF in PROVIDERS PLAN OF CORRECTION (XS) PREFEX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG 0R IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE 0? DEFICIENCY) A 500 Continued From page 37 A 500 Proposed Interim Plan "First Dose Needed" as the reason indicating the Temporary night and weekend pharmacists t0 pharmacy had not yet verified the medication provide additional COVeraQe be in place order in the automated dispensing system. Only by February 24: 2017- They physicaliy be 11 medication overrides listed "Emergency Use" present in the pharmacy to review and enter as the reason for the override. all new orders during their shift, just as the day?shift pharmacists currently do. The 4. On 1211 912016 at 2:30 pm, Surveyor as nurses? ability to override medications wilt be interviewed the Director of Pharmacy (Staff disabled permanently. Ali medication orders Member about the high number of medication be verified by a pharmaCiSt prior to overrides occurring within the hospitai. Staff administration. Member #8 indicated that nursing personnei can Responsible Person override and obtain any and alt medications in the Pharmacy Director (Pharmacist in Charge) hospitai's automated dispensing machines. Proposed Long Term Pian Helshe acknowledged that the hospitai's entire On or about April 11 201 71 the facility formulary was accessible to all nurses without transition pharmacist coverage to 24/7 any restriction through a combination of pharmacist on Site . and remote order entry. The Pharmacy 5- On 12/20/2016 at 2130 AM. Surveyor #3 Director, CEO and COO are evaiuating interviewed the Director Of options to obtain the necessary resources to Services (Sta?r Member about the Iestablish this service within this expedited high number of medication overrides occurring timefrarne. within the hospitai. Staff Member #6 indicated that medication overrides is a long standing problem. The staff member con?rmed that s/he was processing "too many medication error" incident reports. Staff Member #6 asked to be a member of the Pharmacy Therapeutics Committee to see if some improvement or progress could be made on this issue. Helshe acknowledged discussing medication overrides in meetings with the previous pharmacy director (Staff Member #10) former chief nursing Officer (Staff Member #11) and the quality risk manager (Staff Member #12) and the decision was made to continue to monitor the situation. A 700 482.41 PHYSICAL ENVIRONMENT A 700 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, FORM Previous Versions Obsolete 27QV11 If continuation sheet Page 38 of 53 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (x1) (X2) MULTIPLE (x3) DATE SURVEY AND PLAN OF NUMBER: A. BUILDING COMPLETED 504011 a. WING 12l21l2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF IO PLAN OF (X5) (EACH MUST BE PRECEDED BY FULL REGULATORY SHOULD BE TAG OR 1.30 IDENTIFYING FIX CROSS-REFERENCED TO THE TAG DEFICIENCY) A 700 Continued From page 38 A and to provide facilities for diagnosis and 700 treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: Based on observations. document review, and staff interviews, the hospital failed to ensure the condition of the physicai piant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients was protected. - Failure to maintain the structural integrity of the facility plumbing and ventilation system. Failure to follow manufacturer-recommended maintenance activities and scheduie. Failure to remove ligature risks in patient care areas. Failure to monitor and provide appropriate food temperature devices to ensure food temperatures are maintained at the required levels. Due to the scope and severity of de?ciencies cited under 42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET. Cross Reference: Tags A0701, A0710, A0724, A0726 A 701 482.41(a) MAENTENANCE OF PHYSICAL A 701 Corrective Actions 2/10/17 PLANT . A 1. and 2. The Director reeducated staff 701 on environmental factors contributing to ligature Iand self?harm risks particularly related to doors and handles. Training included mitigation strategies such as patient Observation and The condition of the physical plant and the overaii hospital environment must be developed and maintained in such a manner that the safety and FORM Previous Versions Obsolete 27QV11 ?continuation sheet Page 39 0f 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF NUMBER: 504011 Printed: 01/09l2017 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY A. BUILDING COMPLETED B. 12i2?ll201 6 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS. CITY. STATE, ZIP CODE 12344 MILITARY ROAD SOUTH TUKWILA, WA 98168 welt-being of patients are assured. This Standard is not met as evidenced by: Based on observation, interview and record review the hospital failed to maintain the condition of the physical plant and the overall hospital environment of care. Failure to maintain the physical plant increases the risk of infection to patients, staff and visitors. Findings: 1. On 12/13/2016 at 10:00 AM Surveyor #1 observed the door in the sunroom in the unit had a Closure mechanism that posed a ligature risk. in review of the "Proactive Risk Assessment dated August 2016, the facility had identi?ed door risks in geriatric unit and assessed it as "High" or "Severe Risk". The surveyor noted the columns labeled "What Action", "Time Frame", and "Intermediate Mediation Needed" for this item had limited or no information provided in these columns. 2. On at 10:00 AM Surveyor #1 observed that the handies on the small rectangular windows in the sunroom posed a ligature risk 3. On 12/1312016 at 10:10 AM Surveyor #1 observed that the flooring in the bathroom on the adult unit (3 West) was soft underneath the vinyi and that vinyl was rippled and not smooth. The bathroom was located next to 3 showers on 3 West. 4. On 12/13/2016 at 10:25 AM Surveyor #1 observed in the seclusion room on the adult increased monitoring of high risk patients. Staff required to successfully complete post training test. 3. Bathroom flooring was repaired by (contractor) on 1-12-17. 4. Ceiling links were repaired by (contractor) on 1?12?17. 5. Occluded pipes were repaired by contractor 1-12-17 6. Ceiling tiles were changed 1-16-17 by Maintenance staff 7. Burnt outlet was replaced by Maintenance staff by 12/23/16 8. Shower mold was remediated, old caulk was removed and the area cleaned and re-caulked by Maintenance staff (1/9/17) 9. Oscillating fans have been installed in all PHP patient care areas. Permanent ventilation systems are being evaluated. Persons Responsible: Plant Operations Director CEO Monitoring: The Plant Operations Director/designee will perform environmental rounds of the patient care areas to monitor ligature risks, integrity of flooring/walls/ceilings, furnishings, finishes, cleanliness and structures. Any deficiencies will be addressed during the environmental round. Results of the lenvironmental rounds will be reported in the Pl committee and quarterly MEC meetings. (x4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) pREFix DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY (EACH SHOULD BE TAG OR IDENTIFYING TAG To THE APPROPRIATE A 701 Continued From page 39 A 701 A 0701 Corrective Action FORM Previous Versions Obsolete If continuation sheet Page 40 of 53 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 504011 MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 1 2/21/2016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, STATE, ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 unit (2 West) a large crack in the ceiling, the crack appeared to be wet with exposed dry wail where work had previously been done. On 12/14/2016 between the hours of 2:00 PM and 3:00 PM Surveyor #1 observed towels soaked in water on the floor in the same seclusion room on 2 West where the ceiling was actively leaking. Surveyor #1 went to 3 West to see what was above the seclusion room and found that the three showers previously stated above were located above the seclusion room, the surveyor observed that one of the showers was in use during the incident. 5. On 12/15/2016 between 9:00 AM and 10:00 AM Surveyor #1 observed ?ooding over the rim of the shower onto the ?oor on 3 West next to room 303. During the incident. the surveyor observed facility staff (Staff Member #17) "snake" the drain and pull out small amounts of hair. Surveyor #1 did a visual inspection of the pipes using a ?ashlight and found the pipes were occluded. 6. On 12/13/2016 between the hours of 10:25 AM and 11:00 AM Surveyor #1 observed water damage on a ceiling tile iocated in the Rehab unit laundry room. 7. On 12/13/2016 between the hours of 10:25 and 11:00 AM Surveyor #1 observed a burnt outlet in the patient kitchen area in the Rehab unit, this is a potentiai ?re hazard. 8. On 12/13/2016 between the hours of 10:25 and 11:00 AM Surveyor #1 observed moid underneath the caulking in the shower room in the rehab unit. 9. On 12/15/2016 between the hours of 1 :30 PM and 3:00 PM Surveyor #1 entered into an outpatient building (PHP Building), the buildings occluded by temporary obstructions and have been assessed by an independent, professional plumber. The pipes have no on?going needs except routine cleaning and maintenance. To improve cleaning and maintenance, the hospital purchased distinct brushes to scour the drain pipes to remove hair and other debris. This cleaning will occur and as needed and has been added to facility and housekeeping rounds. The hospital has switched to paper towels that dissolve when wet to address drain clogging issues. A701 Amendment 2/18/2017 We propose to cool, circulate, and dehumidify our outpatient/PHP rooms with two portable air conditioners designed for that purpose, one in each room where patient care is delivered. The rooms measure: 1) 19 feet by 19 feet (361 square feet) 2) 17 feet by 29 feet (493 square feet) Before the summer heat arrives, we will instail two Honeywell model or similar, units which are designed to cool 500 square feet. These quiet units provide 14,000 BTU cooling. They can be used to cool or use the fan and dehumidify the air. The units? venting kits would be installed for the air conditioner to operate properly. (x4) in SUMMARY STATEMENT or DEFICIENCIES ID PLAN or CORRECTION (x5) PREHX (EACH DEFICIENCY MUST SE PRECEOED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCEO To THE APPROPRIATE A 701 Continued From page 40 A 701 Amendment 2/1/2017: The pipes were FORM Previous Versions Obsolete 270V1 If continuation sheet Page 41 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE SERVICES Printed: 01109/2017 FORM APPROVED OMB NO. 0938-0391 The hospital must meet the applicabie provisions of the Life Safety Code of the National Fire Protection Association. The Director of the Of?ce of the Federal Register has approved the NFPA 101 2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. A copy of the Code is available for inspection at the CMS information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. if any changes in this edition of the Code are incorporated by reference, CMS will pubiish notice in the Federal Registerto announce the changes. (it) Chapter 19.3.6.3.2, exception number 2 of the adopted edition of the LSC does not apply to hospitals. (2) After consideration of State survey agency findings, CMS may waive speci?c provisions of the Life Safety Code which, if rigidly applied, would result in unreasonable hardship upon the The hospital not require a waiver to compiy with STATEMENT OF (x1) (X2) (x3) DATE SURVEY AND PLAN OF NUMBER: A. BUILDING OOMPLETED 504011 WING 1212112016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. STATE. CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TU KWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES in PLAN OF CORRECTION (x5) PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE TAG OR LSC INFORMATION) TAG To THE APPROPRIATE WE DEFICIENCY) A 701 Continued From page 41 A 701 Between now and the installation of these ventilation system had not been replaced after a ventilation 0f ?19.39 patient care tire. Surveyor #1 observed 2 large rooms that are rooms Wt? be accomplished by the fan- used for group sessions for patients, one room iforc'ed heaters currently In 1-153 and did not have any windows and the other room had OSCIItatlng fans. N0 POIICY l3. needed to." . skyiights that did not open creating no means to staff to turn on the air condItroning. This vall ventilate in both rooms. be based on a consensus of the group of patients and staff at the time as it relates to comfort. A 710 LIFE SAFETY FROM FIRE (1) Except as othenivise provided in this section- A 710 A 0710 Corrective ActIons FORM Previous Versions Obsolete 27QV11 If continuation sheet Page 42 of 53 DEPARTMENT OF HEALTH AND HUMAN SERVECES CENTERS FOR MEDICARE 8r MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938?0391 EQUEPMENT Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: Item #1 Medical Supplies Based on Observation, interview, and record review, the hospital failed to ensure that patient care supplies did not exceed the manufacturer's designated expiration date. Failure to ensure patient care supplies do not exceed their expiration dates risks deteriorated and contaminated supplies being available for patient use. specified on the manufacturers labeling. Expired/nearing expiration products will be properly disposed of timely. All expired supplies and medications were removed and discarded on 12/21/16. I Person Responsible: Monitoring: The COO/designee will perform environmental rounds of the patient care areas to monitor integrity of products, supplies and medications. Any deficiencies will be addressed during the environmental round. Results of the environmental rounds will be reported in the Pl committee and quarterly MEC meetings. STATEMENT OF (X2) (x3) DATE SURVEY AND PLAN OF NUMBER: A. BUILDING COMPLETED 504011 WING 12(2112016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH TUKWILA, WA 98168 SUMMARY STATEMENT OF PLAN or (Xe (EACH MUST BE PRECEDED av FULL REGULATORY (EACH CORRECTIVE ACTION SHOULD BE TAG OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 710 Continued From page 42 A 710 facility, but only if the waiver does not adversely affect the health and safety of the patients . (3) The provisions of the Life Safety Code do not apply in a State where CMS ?nds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: Based on observation, interview, and document review, the hospital faiied to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition. Findings: . A 0724 Corrective Actions Refer to the de?crenCIes written on the Acute Medical Su lies The Care Hospital Life Safety inspection pp 2/10/17 reports directed/delegated Inspections by the Materials Department staff, Nursing staff and Pharmacy staff to ensure that all supplies and A 724 A 724 medications are not expired and within date FORM Previous Versions Obsolete 27QV11 If continuation sheet Page 43 of 53 Printed: 011091201 7 DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICARE 8i SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES {x1} (X2) CONSTRUCTION {x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 50401 ?i B. WING 12(2112016 NAME OF OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) so SUMMARY STATEMENT OF OEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY (EACH CORRECTWE ACTION SHOULD BE TAG OR LSC IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE WE A 724 Continued From page 43 A 724 Amendment Daily audits are being conducted on each of the units. Unit Findings: champions are responsible for Checking the ice machine logs to make sure the 1. On 12l1212016 at 11:00 AM during a tour of3 Cieanings are happening at least weekiy. West adult unit, Surveyor #3 found the The resuits of those audits first go to the foiiowing items in the wound supplies cabinet: weekly Pi Committee on Wednesday, February 1, 2017. The target compliance is a. One 500 ml bottle of 0.9% Sodium Chloride for 90% per unit. Any score below 90% Irrigation with an expiration date of 42016. require remediation with the affected employee and/or further analysis of it). One 500 mi bottle of 0.9% Sodium Chloride for possible system issues. irrigation with an expiration date of 9l2016. c. One box of sterile cotton-tippedapplicators with an expiration date of 212016. d. One box of steriie cotton-tipped applicators with an expiration date of 912016. e. One box of povidone-iodine swabsticks with an expiration date of10/2016. f. One 14 french Foley urethral catheter with an expiration date of7I2016. 2. On 1312/2016 at 1:00 PM. Surveyor #3 inspected the 3 West emergency cart and found the following: a. Two 1000 mi 0.9% Sodium Chioride intravenous ?uids with an expiration date of 5/2016. b. Five 10 ml 0.9 Sodium Chioride pre-?iled ?syringes with an expiration date 01512016. C. One 60 mi bottle Of povidone-iodine solution with an expiration date of 7l2016. 3. On 12l13/2016 at 1:35 PM Surveyor #4 FORM Previous Versions Obsolete 27QV11 'fcon??ua?on Sheet Page 44 0f 53 Printed: 0110922017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (X1) PROVIDERISUPPLIERICLIA (X2) MUWPLE (X3) DATE SURVEY AND PLAN OF CORRECTION - NUMBER: A. BUILDING COMPLETED 504011 3- WING 12121I2016 NAME or PROVIDER OR STREET ADDRESS, CITY, STATE, CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWELA, WA 98168 {x4} ID SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED To THE APPROPRIATE A 724 Continued From page 44 A 724 inspected the unit (4 West) emergency cart and found the following: a. Two 1000 ml 0.9% Sodium Chloride intravenous ?uids with an expiration date of 5l2016. to. Nine 10 ml 0.9% Sodium Chloride pre~frIled syringes with an expiration date of 5l2016. c. Five Tegaderrm intravenous site dressings with expiration dates of 11I2015 and 4/2016. 4. On 12/13l2016 at 1:11 PM Surveyor #2 toured the medication room on the Detox Unit and found three 10 mi 0.9% Sodium Chloride pre-?lled syringes with an expiration date of 512016. a. On 12/1412016 between the hours of 1 :00 PM and 2:25 PM Surveyor #1 found Tegaderm (transparent adhesive ?lm dressing) with an expiration date 42016 in the crash cart located on the Detox unit. 5. On 12/13/2016 at 1:30 PM Surveyor #2 inspected the emergency cart on the Rehab Unit and found the following: a. Two 1000 ml 0.9% Sodium Chioride intravenous ?uids with an expiration date of 512016. b. Nine 10 ml 0.9% Sodium Chloride pre-?tled syringes with an expiration date of 5/2016. 6. On 12l14/2016 between the hours of 1:00 and 2:25 PM Surveyor #1 interviewed central suppiy staff (Staff Member During the course of the interview Surveyor #1 asked how often the supplies in the crash carts are Checked. The FORM cmsassrroz-se) Previous Versions Obsolete zrovn ?continuation sheet Page 45 of 53 Printed: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF OEFICIENCIES Ix1) 0?2) (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 504011 B. wiNG 12!21!2016 NAME OF OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98163 {x4} ID SUMMARY STATEMENT or DEFICIENCIES if) PLAN OF CORRECTION (st PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE magic? TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE A 7?24 Continued From page 45 A 724 724 central supply person was unaware that it was #2 Ice Machines part of hisiher responsibilities to Check the crash The Plant Operations Director has obtained a carts Helshe stated that tie/She had certified contractor to perform the checked the carts 4 months PFBVIOUSIY- manufacturer recommended maintenance and cleaning for the Ice machines. All machines Item #2 ice Machines \Nere serviced during the week of1/16/17 to 2/10/17 1/20/17.This certified contractor wiil also train Plant Operations Staff on proper cleaning techniques. Based on observation, document review and interview the hospital faiied to follow manufacturer?s instruction for preventive maintenance. installation and routine cleaning of its ice machine Person Responsible: Director of Plant Operations Faiiure to foilow manufacturer's instruction for preventive maintenance. routine Cleaning and The Plant Operations installation, promotes the growth of Director/designee will perform microorganisms, which places patients health at inspections Of all ice machines to monitor risk. cleanliness and Operations. Any deficiencies will be addressed during the Reference: Foliett Seriele. MCD400ANV. environmentai round. Results of the R400ANV. D400NW Ice Machines environmental rounds will be reported in the Installation, Operation and Service Manual Serial numbers above D25455 stated on page 15 provided a diagram of incorrect installation. Information on incorrect instaliation as followed: Pl committee and quarterly MEC meetings. Dips in tube where water can collect Spiice or tight bend that restricts ice flow Uninsulated tube that results in wet ice and potential dispensing problems Reference: Follett Plus: On page 4 the foilowing was noted: "Water Shut-Off recommended within 10 fl. (3 m) Of dispenser. Drain to be hard-piped and insulated. Maintain that at least 1l4" per foot (slope." Reference: Foliett ice machine 400 Series and Follett ice Machine Manual stated the FORM Previous Versions Obsolete 2TOV11 If continuation Sheet Page 45 Of 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICAED SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 following cleaning frequency for both models on page 14 and 17: "the frequency in cleaning and sanitizing ice machine according to the schedule below:" Semi-annually preventive maintenance Drain Line weekly Drain Pan/Drip Pan -week y Findings: 1. On 12l13/2016 between the hours of and Surveyor #1 observed a drain-line from a Foilett ice Machine was not stops to grade to the ?oor drain. The ice machine was located in the patient kitchen area on the Rehab unit. The preventive maintenance sticker was past due 9/2016 and the grate on the drip pan had residue build-up. 2. On 1211412016 between the hours Of 8:30 AM and 10:00 AM, Surveyor #1 interviewed the hospitat plant manager (Staff Member Staff Member #19 stated in part that the ice machine maintenance was behind so they contracted with a company to get them caught up. When asked how often they get preventive maintenance, helshe said, annualty. In review of work orders from the company, "MacDonald-Milter? it showed several machines received preventive maintenance between the months Of July through September but the work order did not indicate which machines were done and what was included in the preventive maintenance. In addition, Surveyor #1 reviewed a work order generated from the hospital system that indicated a "Follett" ice machine on S-North unit was scheduled for preventive maintenance on 2f11/2015. was crossed out and a hand written date Of8110116 was provided to indicate when the STATEMENT OF OEFICIENCIES (X1) 9(2) (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED NAME OF OR STREET ADDRESS. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (XS) PREFIX (EACH MUST BE PRECEOEO BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG OR TAG CROSS-REFERENCED To THE APPROPRIATE A 724 Continued From page 46 A 724 FORM Previous Versions Obsolete 27QV11 lf continuation sheet Page 47 of 53 Printed: 01 109/2017 DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICARE 8t MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (X1) (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. COMPLETED 504011 12f21f2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12344 MILITARY ROAD SOUTH TUKWILA, WA 98168 (M) In SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION tx5t (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH SHOULD BE TAG OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE TE A 724 Continued From page 47 A 724 work was done. 3. On 12/14/2016 between the hours of1:00 PM and 2:45 PM Surveyor #1 observed soil buildup on the drip pan and drain line of the ice machine located in the Detox unit. A 726 482.41 VENTILATION. LIGHT, A 726 A 0725 Corrective Actions 2/10/17 TEMPERATURE CONTROLS The Dietary Manager purchased new digital thermometers and provided training on use Of the new thermometers. The Dietary Manager reeducated ail dietary staff on the proper techniques and requirements of obtaining food There must be proper ventilation, light, and temperature controts in pharmaceutical, food preparation. and other appropriate areas. This Standard is not met as evidenced by: Based on observation, the hospital staff failed to temperatures and maintaining refrigerator and implement policies and procedures consistent freezer temperatures. required with the Washington State Retail Food Code, temperature requirements wilt be logged daily. WAC 246-215 and Federal Food and Drug Administration. Person Responsible: Director of Dietary Failure to follow the food code places patients. staff, and visitors at risk for foodborne illness. Monitoring: The Dietary Director/designee wiil perform weekly inspections Of all food, refrigerator, and freezer temperatures logs to monitor adherence to the WAC 246-215-03515 and FEMS-501.14 codes. The Dietary Director/designee wit! perform weekly random Observation monitors of staff performing Findings: 1. On 12/12/2016 between 11:00 AM and 12:15 PM, Surveyor #1 Observed two containers of pasta greater than 2 inches in the walk-in cooling refrigerator. For foods with a depth greater than 2 inches, staff must document. temperature dates temperatu re checks. AW deficiencies be and times to ensure foods cool within the required addressed during the monitor. cooling time-frame as speci?ed by Washington 0f the teeth monitors be reported in the State Retail Food Code. The hospital did not monthiy Pi committee and quarterly MEC document cooling times for the pasta. meetings. Reference: Washington State Retail Food Code WAC 246-215-03515. FDA Food Code 3601.14 2. On 12/12/2016 between 11:00 AM and 12:15 PM Surveyor #1 observed dietary staff (Staff FORM Previous Versions Obsolete 270V11 If continuation sheet Page 48 of 53 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE SERVICES Printed: 01f09l2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) (X2) MUWPLE (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 504011 B-WING 1212112016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH TUKWILA, WA 98168 {x4} ID SUMMARY STATEMENT OF DEFICIENCIES 1D PLAN OF CORRECTION (Xe (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE COMPLEVON TAG OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE A 726 Continued From page 48 A 726 Amendment 2/1/2017: Daiiy audits are Member #20) using a food probe thermometer being conducted in the kitchen. The policy inaccurately when taking the temperature of a is under revision. Staff education is in "Ruben Sandwich". The thermometer process. The dietary manager will be temperature indicator is located half way up the responsible for monitoring reai?time stem; the staff inserted only the tip into the compliance related to food temperatures sandwich thereby potentially giving an inaccurate throughout the department. The Infection reading. The type of thermometer used by the Control nurse will double Check, on a staff was not designed to temp thin foods such as hveekly basis, to make sure staff are meat patties. fish ?llets. and other thin food items. complying with standards. The resuits of those audits first go to the weekly Pl In addition, Surveyor #1 checked to see the Committee on Wednesday, February 1, thermometer's accuracy by placing the 2017. The target compliance is 90%. Any thermometer with 2 other thermometers in an score below 90% wiil require remediation ice-bath registered at 32 degrees Fahrenheit. The pvith the affected employee and/or further thermometer used to temp the "Ruben Sandwich" analysis of possible system issues. registered at 20 degrees Fahrenheit, 12 degrees Off calibration. Dietary staff (Staff Member #20) con?rmed this. Reference: Washington State Retail Food Code, A 0749 Correctlve Actions WAC 246-215-04335 2/10/17 Reference: Washington State Retail Food Code, 1) The Infection Control PractItIoner WAC 246-215-04580 reeducated the staff on the importance of hand hygiene per policy during medication administration. Education was provided during A 749 INFECTION CONTROL PROGRAM A 749 staff meetings through verbal and written The infection control of?cer or of?cers must communication. develop a system for identifying, reporting, . investigating. and controliing infections and Persons Communicable diseases of patients and infection Control Practitioner personnei. Monitoring On a monthiy basis, the infection Control This Standard is not met as evidenced by: Practitioner/designers monitor hand . hygiene during medication administration with Item #1 Hand Httgiene a minimum of 10 medication passes per unit. . . Any deficiencies wili be addressed during the Based on observation and reylew 0f hOSP'tai medication pass. Monitoring results will be whey and procedure. Staff failed to perform hand reported during the PI and quarterly hygiene prior to and after administering EC meetings. FORM Previous Versions Obsoiete move If continuation sheet Page 49 0? 53 Printed: 01/09/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDECARE SERVICES OMB NO. 0938-0391 STATEMENT or DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION . (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. COMPLETED 504011 B. WING 12l21i2016 NAME or OR SUPPLIER . STREET ADDRESS, CITY. STATE, CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES In PROVIDERS PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE mfg?? TAG OR TAG TO THE APPROPRIATE DEFICIENCY) A 749 Continued From page 49 A 749 2) The Dietary Manager obtained new medications thermometers designed to measure food temperatures properly. The Dietary Manager Failure to perform hand hygiene puts patients and educated the dietary staff on the proper use of Staff at risk for infection. the food thermometers with an emphasis on . accurate insertion. The education was provided Findings: during staff meetings with the use of verbal and .. . . written communications 1. Facrlity policy titled "Hand Hygiene", reviewed 10l2016 read in part: ili. FOR HANDWASHING AND C. Decontaminate hands before having direct or indirect contact with F. Person Responsible: Dietary Manager Decontaminate hands after contact with a Monitoring patient's intact G. Decontaminate hands The Dietary Manager Perform a minimum after contact with body ?uids or excretions, 0? 30 random 3Udit5 per month 3 months to mucous ensure proper temperature monitoring. Any deficiency wiil be addressed. Results 2. On 12/13/2016 at 9:00 AM Surveyor #4 of the audit wiil be reported in the Pi observed a registered nurse (Staff Member #14) and quarteriy MEC meetings. administer oral medications to a patient. Slhe did perform hand hygiene (HH) before preparing 3) The Infection Control Practitioner the medications, and though slhe came in contact with the patient's oral secretions during administration, did not perform i-iH afterward. reeducated the housekeeping staff on the following procedures for proper cieaning of patient care areas: -Allowing for a 10-minute contact time when 3. On 12/13/2016 at 9:45 AM Surveyor #4 . . . usmg Vlrex 256 dismfectant solution. observed a registered nurse (Staff Member #15) administer orai medications to a patient. S/he did -Avoidance 0f cross-contamination when ?Sing not perform HH prior to or foiiowing cleaning bFUShes. administration, despite numerous contacts with -Proper dusting procedures to avoid patient the patient's skin. exposure. ?Maintaining possession of carts at ail times. Item #2 Dietary Sanitation Person Responsibie: Based on observation, the hospital failed to plant Operations Director impiement policies and procedures to ensure compiiance with the Washington State Retaii Food Code (246-215 WAC) and the Federal Food and Drug Administration. FORM Previous Versions Obsolete "continua?im Sheet Page 50 0f 53 Printed: 01/09/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICAID SERVICES OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES (XI) (X2) CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 B. WING 1 2121I2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TU KWILA, WA 98168 (x4) ID SUMMARY STATEMENT OF in PROVIDERS PLAN OF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE SHOULD BE COMPLETION TAG OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 50 A 749 Monitoring Failure to follow best food practices places The Plant Operations Director will perform patients, staff, and visitors at risk for foodborne environmental rounds of the patient illness. care units to monitor contact times, proper use of cleaning brushes and dusting, and maintenance of cleaning carts. Any deficiencies will be addressed during the environmental round. Results of the environmental rounds will be reported in the to ECG and Pl committees and quarterly MEC meetings. 1. On 12112/2016 between 11:00 AM and 12:15 PM Surveyor #1 used a Chlorine Indicator test paper to evaluate the Chlorine concentration level in the sanitizer bucket for in-use wiping cloths. The chlorine exceeded the tolerance limit of 200 paris?per-miilion (ppm) for sanitizer. Reference: Washington State Retail Food Code, WAC 246-215-03339(2) (2009 FDA Food Code 3304.14) 2. On 12l12/2016 between 11:00 AM and 12:15 PM Surveyor #1 observed signs of algae growth on the interior plastic panel of the ice machine located in the main kitchen. Reference: Washington State Retail Food Code. WAC Item #3 Housekeeping Cleaning Based on observation, review of hospital's policy and manufacturer's instructions for use, the hospital staff failed to follow procedures when cleaning patient rooms. Failure to follow manufacturer's instructions for use and hospital polices and procedures increases the risk of infection/illness to patients, staff and visitors. Reference: Virex ii 256 Diversey: "Apply use solution to hard, non-porous environmental surfaces. All surfaces must remain wet for 10 FORM Previous Versions Obsolete zrovn "continuation sheet Page 51 0f 53 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Printed: 01/09/2017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF AND PLAN OF CORRECTION (Xi) IDENTIFICATION NUMBER: 504011 B. WING (X2) MULTIPLE CONSTRUCTION A. (X3) DATE SURVEY COMPLETED 12/21/2016 NAME OF PROVIDER OR SUPPLIER CASCADE BEHAVIORAL HOSPITAL STREET ADDRESS, CITY. STATE. ZIP CODE 12844 MILITARY ROAD SOUTH TUKWILA, WA 98168 (x4) :9 SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (X5) PREHX (EACH MUST BE PRECEDED sv FULL REGULATORY (EACH CORRECTIVE ACTION SHOULD BE Gill-$530? TAG OR IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE A 749 Continued From page A 749 Addendum 2/1/2017: Daily audits are minutes. Wipe surfaces and let air dry." Findings: in review of hospital's policy and procedure titled: ?Daily Cleaning of Patient Area" (Revised 8/2016) stated in part "Take cart with you into the room to clean. Cart should be within eyesight at all times." 2. On 12/13/2016 at 8:30 AM Surveyor #1 observed a housekeeper (Staff Member #21) during a daily clean of a patient room. applied "Virex 256 disinfectant solution" on a patients hand sink then proceeded to wipe it off with a dry cloth. The housekeeper did not allow 10-minute contact time as required per manufacturer's instruction for use. 3. On 12/13/2016 at 9:38 AM Surveyor #1 observed a housekeeper (Staff Member #22) during a daily clean of a patient room. The surveyor observed the housekeeper use a brush to clean a shower floor after cleaning a toilet with the same brush. 4. On 12/13/2016 at 9:45 AM Surveyor #1 observed a housekeeper (Staff Member #22) during a daily clean of a patient room. The surveyor observed the housekeeper dusting a light ?xture over the patient's head while a patient was sleeping, potentialiy exposing the patient to dust particles. 5. On 12/13/2016 at 9:50 AM Surveyor #1 observed housekeeper (Staff Member #21) enter a patient room at the end of the hallway leaving the housekeeping cart in the hallway unattended. 6. On 12/15/2016 at 4:00 PM, Surveyor #1 being conducted in the kitchen. The policy is under revision and will be presented to the Pl Committee for approval on February 17, 2017. Staff education is in process. The dietary manager will be responsible for monitoring real-time compliance related to proper sanitation throughout the department. The will double Icheck staff's compliance related to the use Iof chlorine solution, on a weekly basis, to make sure staff are complying with standards. The results of those audits first go to the weekly Pl Committee on I ednesday, February 8, 2017. The target compliance is 90%. Any score below 90% I ill require remediation with the affected employee and/or further analysis of possible system issues. Additionally, daily audits are being - conducted throughout the hospital, Iobserving housekeepers in their daily routines. Staff education is in process. The facilities director will be responsible for monitoring real-time compliance related to procedures when cleaning patient rooms. he Infection Control nurse will double check, on a weekly basis, to make sure staff are complying with standards. The results of those audits first go to the weekly Pl Committee on Wednesday, February 1, 2017. The target compliance is 90%. Any score belOw 90% will require remediation with the affected employee and/or further analysis of possible system issues. FORM Previous Versions Obsolete 27OV1 1 if continuation sheet Page 52 of 53 Printed: 01/09/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8r MEDICAID SERVICES OMB NO. 0933-0391 STATEMENT OF DEFICIENCIES (x1) (X2) (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 504011 BI 12r21r2016 NAME OF OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH TUKWILA, WA 98163 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY pREFrx (EACH CORRECTIVE ACTION SHOULD BE TAG OR IDENTIFYING TAG TO THE APPROPRIATE DEFICIENCY) A 749 Continued From page 52 A 749 reviewed a facility document titled, "infection Prevention" the document provides a line list Of indicators for 2016. One Of the indicators identi?ed was Patient Room Cleaning with a "Target" of Success of 95% or better. For the entire year of 2016, January through November, no Observations were made. FORM Previous Versions Obsolete 27QV11 If mn?nualion sheet Page 53 0f 53 Behavioral Health February 18, 2017 Karen Roe CMS Re: Extension Request Air Conditioning in Partial Hospital Program (PHP) Ms. Roe: lam writing to request an extension for the following findings related to ventilation during our December 12-21, 2016 survey: 0 A701 PHP rooms too hot (no a/c) no ventilation 0 Two issues exist for this area: ventilation and temperature control. They are addressed separately below. Ventilation Temperature Control During the winter, the department is ventilated by fan-forced heaters. In the spring, free?standing fans will be more than adequate to maintain proper ventilation. During the winter, the department is heated by fan-forced heaters. In the spring, free- standing fans wiil be more than adequate to maintain a comfortable temperature as much of this building is below grade. Before temperatures reach 80 degrees, air conditioning will be installed. Anticipated installation date: May 1, 2017 or earlier if an early summer heat wave occurs. Heaters 8: fans already in place. It would be disruptive to the heating in this department to install air conditioning at present as it will be necessary to open an exhaust to the outside for the two portabie air conditioners. We make this installation when heating is no longer needed but certainly weil in advance of the summer heat. Cascade Behaviorai Hospitai 12844 Military Road South Tukwila, WA 98168 206.244.0180 Ventilation needs are already addressed through use of fan forced heat oscillating fans. 0 The revised date of instaliation of portable air conditioners is May 1, 2017, well in advance of the summer heat. Air conditioning will not be needed in that area until then. If i can be of any further assistance, please do not hesitate to contact me at 206-248?4565 or iohnbeallc?bcascadebhcom Sincerely, Dr. John Beall, RN, DNP, NEA-BC . Chief Operating Officer Chief Nursing Officer Cascade 'Behaviorai Heaith Hospital CCN 504011 Hospital License HPSY.FS.60429197 Cascade Behavioral Hospital 12844 Military Road South Tukwila, WA 98168 206.244.0180