Initial Comments:
This report is the result of a full Medicare recertification survey conducted on January 8, 2024, through January 10, 2024, at Torrance State Hospital. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.21 STANDARD
QAPI GOVERNING BODY, STANDARD TAG
Name - Component - 00
... The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.
Observations:
Based on review of facility documentation, and staff interview (EMP), it was determined the facility failed to ensure that all hospital departments and services, including those services furnished under contract or arrangement, were included in the QAPI program.
Findings include:
On January 9, 2024, at 11:30 PM, review of the facility's Governing Body Bylaws, dated April 26, 2018, revealed: " ... Performance Improvement activities are interrelated and cover the full spectrum of the facility's operations and services ... ".
During interview with EMP1, on January 9, 2024, at approximately 10:00 AM, EMP1 revealed that services such as radiology and laboratory services are provided through a contractual arrangement with external providers.
During review of the facility's QAPI minutes on January 9, 2024, at approximately 2:00 PM, no evidence was identified to demonstrate that services provided under contract were included in the QAPI program.
During an interview on January 9, 2024, at approximately 2:00 PM, EMP4 confirmed that the facility's QAPI program does not include services furnished under contract.
Plan of Correction:The Performance Improvement Department will begin engaging and monitoring outside vendors through the use of a QAPI monitoring template altered from a sister hospital (NSH). The template and process will be reviewed at the 1/29/24 PI Committee. The assigned contract monitors will complete this form for each of the vendors and will present their updates on a random quarterly basis to be noted in the PI Committee minutes each time reviewed. This QAPI template will include the planned actions and indicators to be monitored with details regarding dimensions of staff performance considered, time frames for the Targeted Area for Improvement , disposition and analysis at identified intervals as well as Action Plans and interventions as needed. by 1/29/24
482.22(a)(1) STANDARD
MEDICAL STAFF PERIODIC APPRAISALS
Name - Component - 00
The medical staff must periodically conduct appraisals of its members.
Observations:
Based on a review of facility documents, credential files (CF) and employee interview (EMP), it was determined that the facility failed to ensure the timely reappraisal of its medical staff in seven of 10 credential files reviewed (CF1, CF2, CF3, CF4, CF6, CF7 and CF10).
Findings include:
On January 8, 2024, a review of the "Torrance State Hospital Governing Body Bylaws" dated 7/26/2023 reviewed, "Article VII- Specific Responsibilities and Authority of Governing Body Members in the chain of Command: D. The Chief Executive Officer, who is appointed by the Secretary of Human Services, is the Governing Body's Onsite Representative at the facility level. 5. Establishes and maintains an organized Medical Staff body whose members meet the standards for credentialing and privileging. 6. Approves all appointments and reappointments to the organized Medical Staff body. Article VIII- Integration of Medical Staff and Governing Body: 6. The CEO approves all appointments and reappointments to the Medical Staff body. Article IX- Responsibilities of the Medical Staff: A. The responsibilities of the Medical Staff as they relate to the Governing Body are as follows: 1. Recommend to the CEO appointment or reappointment of qualified individuals to the Medical Staff, as well as renewal or change of clinical privileges."
On January 10, 2024, a review of CF1 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 28, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 11, 2023. Thus, the clinical privileges for CF1 were lapsed for 72 days.
On January 10, 2024, a review of CF2 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 24, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 11, 2023. Thus, the clinical privileges for CF2 were lapsed for 72 days.
On January 10, 2024, a review of CF3 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 17, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 11, 2023. Thus, the clinical privileges for CF3 were lapsed for 72 days.
On January 10, 2024, a review of CF4 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 26, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 1, 2023. Thus, the clinical privileges for CF4 were lapsed for 62 days.
On January 10, 2024, a review of CF6 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 12, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 1, 2023. Thus, the clinical privileges for CF6 were lapsed for 62 days.
On January 10, 2024, a review of CF7 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 28, 2023. The reappointment application was approved by the Credentialing Committee, and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 1, 2023. Thus, the clinical privileges for CF7 were lapsed for 62 days.
On January 10, 2024, a review of CF10 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 26, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the "Privileging Action Form" on September 1, 2023. Thus, the clinical privileges for CF10 were lapsed for 62 days.
On January 10, 2024. between 9:45 AM and 11:00AM, the above findings were confirmed by EMP12.
Plan of Correction:In order to meet the requirements for credentialing providers, Torrance State Hospital Performance Improvement Department will be responsible for the verification and credentialing of the medical staff. This will include the medical doctors, psychiatrists and CRNP's. The credentialing process change will include starting the re-credentialing process earlier, at least 60 days prior to expiration, and will have the process completed within 7 calendar days of expiration. This will also include a letter to the practitioner from the CEO regarding the status of the credentialing/recredentialing. by 2/29/2024
482.23(b)(6) STANDARD
SUPERVISION OF CONTRACT STAFF
Name - Component - 00
All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).
Observations:
Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to document 15 minute observations and continual visual observation (CVO) for four of eight medical records reviewed (MR2, MR4, MR6, MR8).
Findings include:
On January 9, 2024, a review of the facility's "Policy 25-32: Policy/Procedure for Psychiatric Medical Record Documentation" dated 11/03/2022, revealed, "I. Policy Statement: A. A complete and accurate medical record must be maintained for each individual who is treated at Torrance State Hospital. The quality of the medical record depends, in part, on the timeliness, meaningfulness, authentication and legibility of the informational content documented by all those authorized to make entries in it. IV. Responsibilities: K. When making record entries, continuous entries are necessary in order to minimize problem of improper chronological sequence and to avoid suspicions relative to inappropriate alterations in the record ..."
On January 9, 2024, a review of the facility's "Policy 125-31: Procedures for Utilization of Level One 1:1" dated July 21, 2022, revealed, "V. General Procedures: The Treatment Plan Must Specify: I. ...In addition, frequency of documenting on the Level One 1:1 Patient Observation Record will be every 15 minutes for CVOVI. Procedures for Increased Levels of Observation: 3. Observations times, made at prescribed intervals, are to be documented on the Patient Observation Record by the assigned staff."
On January, 9, 2024, a review of MR2 was completed. MR2 was ordered every 15 minute observations by the staff. Fifteen minute observations were not documented on the Special Observation record for the following time periods:
December 9, 2023, from 12:00 AM to 6:45 AM
December 10, 2023, at 10:00AM and 10:15 AM
December 11, 2023, at 11:00 AM, 11:15 AM, 11:30 AM, and 11:45 AM
December 12, 2023, from 12:00 AM to 6:45 AM
December 13, 2023, at 10:00 AM and 10:15 AM
December 14, 2023, at 10:15 AM
On January 9, 2024, a review of MR4 was completed. MR 4 was ordered every 15 minute observations by the staff. Fifteen minute observations were not documented on the Special Observation record for the following time periods:
November 29, 2023, at 6:30 AM
November 29, 2023, at 6:00 PM and 6:15 PM
December 2, 2023, at 6:00 PM and 6:15 PM
December 3, 2023, at 11:00 PM, 11:15 PM, 11:30 PM, and 11:45 PM
December 4, 2023, at 6:00 AM and 6:15 AM
December 5, 2023, at 12:30 PM and 12:45 PM
On January 9, 2024, a review of MR6 was completed. MR 6 was ordered every 15 minute observations by the staff. There was no documentation of the ordered 15 minute observations in the medical record (Special Observation Record). The Special Observation record was requested from EMP3. On January 9, 2023, EMP3, at approximately 1:45 PM, stated that the observation record/documentation could not be located.
On January 9, 2024, a review of MR8 was completed. MR 8 was ordered every 15 minute observations by the staff. Fifteen minute observations were not documented on the Special Observation record for the following time periods:
December 1, 2023, at 11:15 AM, 11:30 AM, and 11:45 AM
December 2, 2023 from 12:00 AM to 6:45 AM; and at 10:00 AM and 10:15 AM
On January 9, 2024, a review of MR8 an order for Constant Observation of 2:1. There was no documentation of MR8s behavior and location on the "Level I Observation Record" for the following time periods:
December 15, 2023, 7:00 AM, 7:30 AM, 9:00 AM, 9:30 AM, 11:00 AM, 11:30 AM, 1:00 PM, and 1:30 PM.
The above findings were confirmed on January 9, 2024, between 12:04 PM and 1:45 PM, by EMP3.
Plan of Correction:Policies 25-32 and 135-31 will be reviewed and revised to accurately reflect the process for CVO and physician ordered 15 minute check documentation. by 1/31/24
Re-education will occur with all medical staff regarding orders and documentation requirements for physician ordered 15 minute checks and any level of CVO (continuous visual observation). This will occur at the Medical Staff Committee. by 2/1/24
Re-education of all Nursing Supervisors and Nursing staff regarding documentation requirements and form completion, to include the review process and filing in the medical record. Documentation will include location, behavioral observations, interventions and responses. by 2/29/24
Daily monitoring of staff completion of forms will be completed for all patients ordered to be on CVO or 15 minute checks for one month. Any deficiencies will be addressed immediately to address and correct the issue. by 2/29/24
Compliance will be tracked by the Performance Improvement Department by completion of chart audits for 3 months to assure compliance with documentation requirements related to physician ordered 15 minute checks and CVO. This will begin 2/1/24.
482.42(c)(2)(ii) STANDARD
IC PROFESSIONAL DOCUMENTATION
Name - Component - 00
[The infection preventionist(s)/infection control professional(s) is responsible for:]
(ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities.
Observations:
Based on review of facility documentation, and staff interview (EMP), it was determined the that the Infection Control coordinator failed to provide documentation of attendance at the Infection Control Committee meetings for five of twelve meeting minutes reviewed.
Findings include:
A review, on January 9, 2024, at 11:50 A.M., of the facility's policy, "Torrance State Hospital Policy/Procedure for Infection Control Committee, Policy NO. 20-01, review date March 28, 2023, " revealed ...I.V. RESPONSIBILITIES A. Committee members consist of a general physician as chairperson, Infection Control coordinator (represents Employee Health) and staff representatives ... . "
During an interview on January 9, 2024, at 12:10 P.M., EMP3 confirmed that the Infection Control coordinator name was not present on the sign in sheets or in the minutes for the following dates: June 1, 2023, July 27, 2023, August 31, 2023, October 26, 2023, and November 30, 2023.
Plan of Correction:At the 1/25/24 meeting the IC RN will change the format of the meeting minutes to include their signature on the attendance sheet and the minutes will revert back to the prior format. The prior format for meeting minutes includes documentation of all present and absent/excused. This includes the Infection Control RN. by 1/25/24
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