Sempervirens

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 41175 Based on interview and record review, the facility failed to ensure staff implemented their plan of correction to ensure adherence to their policy and procedure on the completion of patient medical records when four of 10 sampled backlog medical records were missing sections upon review (Patients 5, 6, 8, and 10). This failure had the potential to result in medical records missing important patient information, negatively affecting the facilitation of care between providers, which could lead to compromised patient safety. Findings: According to the Plan of Correction (POC) provided by the facility to the Department on 7/17/2025, the POC outlined, “Work is underway by nursing staff to complete the 407 backlog of incomplete clinical documentation ... in accordance with policy ... with 100% completion of all 407 backlogged charts by August 31, 2025 ...” During a concurrent interview and document review on 9/8/25 at 3:49 p.m. with the Medical Records Manager (MRM), the document titled, “SV Charts Needing Completion Summary - SV Staff Not Including MDs”, with the date range 5/20/25-9/5/25 was reviewed. The document’s columns indicated, “Total # (Number) Charts Out-of-Compliance: 9/5/2025 = 53 ...” The MRM stated per their current audit, the facility currently has 53 incomplete charts. During an interview the following day, 9/9/2025 at 9:00 a.m., MRM indicated the oldest incomplete medical record dated back to 4/20/2025. MRM indicated focus is on the “backlog” and not current medical records. MRM further indicated that no one person is focusing on current medical records to ensure completion. MRM stated approximately 5 to 7 medical records were not complete. Upon further discussion with MRM on 9/9/2025 at 10:00 a.m., MRM provided the “SV Charts Needing Completion Summary - SV Staff Not Including MDs” log which MRM indicated was accurate indicating 53 medical records were incomplete dating back to 1/9/2025, not April of 2025 as previously stated. The MRM provided a document identified by the MRM as “the transportation log”. The MRM stated this log is generated by the Senior Medical Records Clerk to account for the patient medical records being taken offsite to be scanned into the electronic medical record. The log revealed the following: January 2025 = 13 discharges with 2 records complete with documents scanned and in the electronic medical record; February 2025 = 16 discharges with 16 records complete with documents scanned and in the electronic medical record; March 2025 = 20 discharges with 4 records complete with documents scanned and in the electronic medical record; April 2025 = 19 discharges with 2 records complete with documents scanned and in the electronic medical record; May 2025 = 17 discharges with 0 records complete with documents scanned and in the electronic medical record; June 2025 = data was not provided as requested; July 2025 = 24 discharges with 0 records complete with documents scanned and in the electronic medical record; August 2025 = 25 discharges with 0 records complete with documents scanned and in the electronic medical record. On 9/9/2025 at 10:00 a.m., the MRM acknowledged the “Transportation Log” indicated there was 88 patient medical records incomplete from January 2025 to August of 2025 but according to the “SV Charts Needing Completion Summary - SV Staff Not Including MDs” log indicated 53 patient medical records were incomplete. The MRM indicated he believed if paper records were waiting to be transported to the offsite facility and scanned that the record was complete even if the documents had not been scanned into the electronic record. MRM indicated he was not aware the facility policy was for medical records to be completed within 14 days after discharge. During a concurrent interview and record review on 9/9/25 at 11:22 a.m. with Ward Clerk (WC), Patient 8’s medical records, dated 2/13/25, were reviewed using the SV Audit Checklist. The medical records indicated Patient 8 was admitted to the facility on a 5150-hold (a legal procedure in California that allows for the temporary detention of individuals who are believed to be a danger to themselves or others due to a mental health crisis) on 2/13/25. WC stated she was unable to locate the “Legal” section in Patient 8’s medical records. The medical records indicated it did not have Patient 8’s Client Information, Important Message from Medicare, Advanced Directive, Involuntary Patient Advisement (a legal form that allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 5150-hold), and Patient Notification of Firearms Prohibition and Right to Hearing forms. The WC stated the forms were not scanned in, and she did not know why they were not scanned in. Further review of Patient 8’s records indicated she was discharged on 3/12/25. During a concurrent interview and record review on 9/9/2025 at 11:00 a.m., with the MRM, Patient 10s medical records dated 3/13/2025 were reviewed using the SV Audit Checklist. The medical records indicated Patient 10 was admitted to the facility on 2/27/2025on a 5150 -hold. MRM was unable to locate the history and physical, laboratory results and medication advisement. MRM indicated the records “might” be paper and not yet scanned. MRM indicated he did not know why the records had not been scanned. Further review of Patient 10’s medical record indicated she was discharged on 3/13/2025. During a concurrent interview and record review on 9/9/2025 at 11:00 a.m., with the MRM, Patient 6’s medical records dated 3/24/2025, were reviewed using the SV Audit Checklist. The medical records indicated Patient 6 was admitted to the facility on 3/7/2025 on a 5150-hold. The suicide risk assessment was present but only had partial documentation with none of the required questions answered to determine Patient 6’s risk of committing suicide. The MRM confirmed the suicide risk assessment was blank and the questions had not been answered. MRM did not know why the suicide risk assessment had not been completed. Further review of Patient 6’s records indicated she had been discharged 3/24/2025. During a concurrent interview and record review on 9/9/2025 at 11:00 a.m., with the MRM, Patient 5’s medical records dated 4/25/2025 were reviewed using the SV Audit Checklist. The medical records indicated Patient 5 was admitted to the facility on 4/10/2025 on a 5150- hold. MRM indicated the medical record was not complete because the treatment plan nursing progress notes, legal documents, discharge documents and laboratory results were not present in the medical record. MRM stated he though the paper version might not yet be scanned into the electronic medical record. Further review of Patient 5’s medical record indicated Patient 5 was discharged on 4/25/2025. During a concurrent interview and policy review on 9/9/25 at 3:09 p.m. with MRM, the facility’s policy titled, “TIMELINES FOR COMPLETION AND CORRECTION OF INPATIENT CHARTS”, dated 7/20/20, was reviewed. The policy indicated, “Policy: Inpatient charting will be complete and correct within 14 days of patient discharge, in accordance with MediCare/MediCal guidelines ... Procedure: ...3. The Ward Clerk will audit the EHR and paper chart for completion and clerical accuracy ... 4. Any identified corrections are completed by the original author, or supervisor if author is not available. If correction cannot be made, form #1226 - Request to File Chart as Incomplete is to be completed by Medical Records staff, signed by the Director of Nursing (for Nurses and Mental Health Worker staff corrections) or Medical Director (for Physician corrections) and scanned to the chart. 5. All the above steps shall be completed within 14 days of patient’s discharge...” The MRM confirmed scanning was part of the 14-day process of completing a chart.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 35598 Based on interviews and document reviews, the hospital failed to ensure there was an effective governing body that was responsible for the conduct of the hospital and it’s operations when: 1. The governing body failed to ensure an ongoing Quality Assessment Process Improvement (QAPI) program was implemented and showed measurable improvement of indicators with potential quality outcomes and set priorities for performance improvement activities for problem prone areas including a medical record completion process (refer to A-0263); and 2. The governing body failed to ensure a total of 407 patient medical records, including documentation of observations, treatments, nursing care, outcomes, and physician’s orders, were complete and accurate (refer to A-0431). These failures prevented all members of the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care for a vulnerable mental health patient population. The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Governing Body. Findings: During an interview on 6/5/2025 at 8:40 A.M., Deputy Director (DD) confirmed a document titled Psychiatric Health Facility (PHF) Governing Body Bylaws, dated April 2024, were the most recent Governing Bylaws for the facility. The DD indicated the Governing Body meets every quarter and includes himself, the Director of Nurses (DON), Quality Director (QD), and two members of the Board of Supervisors and the Hospital Administrator (HD). The DD acknowledged the governing body was responsible for operations and quality of patient care provided in the facility. Review of the document titled, [Hospital Name] Psychiatric Health Facility (PHF) Governing Body Bylaws”, dated April 2024, indicated, “The PHF Governing Body that is legally responsible for the conduct of the hospital...(a) Assure that all services, including care and treatment provided to patients, is adequate and safe at all times... (d) Provide for the control and use of appropriate physical and financial resources and personnel required to meet the need of [Hospital Name] patients. (e) Assure that [Hospital Name] facility and its operation conforms to all applicable federal, state and local law laws and regulations, including those relating to licensure...(f) Additional duties include:...review the [Hospital Name] continuous quality improvement work plans...””

“QAPI CFR(s): 482.21 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 reflects 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 QAPI program for review by CMS. This Condition is not met as evidenced by: 47138 Based on interviews and document review, the hospital failed to maintain a Quality Assurance Process Improvement (QAPI) program when the hospital failed to implement a process to track, monitor, and create actionable plans to complete documentation for 407 patient medical records that were incomplete (refer to A-0283). This failure to develop a comprehensive program that identified opportunities for improvement of a high- volume and problem-prone area resulted in the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care and potential to compromise patient outcomes. The cumulative effects of these systemic problems resulted in the hospital’s inability to maintain an effective quality assessment and performance program in accordance with the statutorily-mandated Conditions of Participation for Quality Assessment and Performance Improvement Program.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 35598 Based on interviews and record review, the hospital failed to ensure complete and accurate patient medical records were kept in accordance with hospital policy when: 1. 2 of 19 sampled medical records (Patient 15 and 9) reviewed were incomplete (Refer to A-0450); and 2. The Medical Records Department had a backlog of 407 incomplete patient medical records lacking documentation, and were left stored in boxes and on shelves in the Medical Records Department. (Refer to A-0450). These failures prevented all members of the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care for a vulnerable mental health patient population. These failures hinder effective communication between providers resulting in gaps in patient care that negatively affect coordinated care for the patients, which could lead to compromised patient safety. The cumulative effect of these systemic problems resulted in the hospital’s failure to meet statutorily mandated compliance with the Condition of Participation for Medical Records Services.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 35598 Based on interviews and document review, the hospital failed to ensure a Quality Assurance Process Improvement (QAPI) plan was developed, thoroughly implemented, assessed and monitored by the QAPI Committee when the hospital failed to investigate and implement a process towards the completion of 407 patient medical records stored in boxes and on shelves in the Medical Records Department. This failure prevented all members of the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care for a vulnerable mental health patient population. Findings: During an interview on 6/4/25 at 9 a.m., Medical Records Manager (MRM) stated the facility maintains a log of charts with outstanding corrections and/or completions. A log of incomplete medical records from the past 12 months was requested and provided. During an interview on 6/4/24 at 11:20 a.m., Ward Clerk (WC) stated after a patient’s discharge, the ward clerks audit the paper charts while two staff working offsite audit the electronic charts. WC stated the incomplete medical records were usually due to missing signatures, initials or dates, and misplaced forms or pages. WC stated while ward clerks enter their findings of chart incompleteness on an Excel spreadsheet, she was not sure if anybody has tracked or analyzed the numbers in greater detail, but added the spreadsheet was accessible by “almost everyone in Management”. WC stated the facility currently has about “400” incomplete charts. WC stated she was not aware, nor have been involved, with any performance improvement project to improve the ongoing issues with the medical records. A review of the graph titled, “Monthly Count Charts Waiting for Completions”, indicated the following: 1. 5/31/2024 = 350, 2. 6/28/2024 = 359, 3. 7/19/2024 = 367, 4. 8/30/2024 = 394, 5. 9/20/2024 = 399, 6. 10/25/2024 = 426, 7. 11/22/2024 = 455, 8. 12/20/2024 = 472, 9. 1/31/2025 = 460, 10. 2/28/2025 = 441, 11. 3/28/2025 = 424, 12. 4/25/2025 = 432, 13. 5/30/2025 = 407. During a concurrent interview and document review on 6/4/24 at 3:19 p.m., the Director of Nursing (DON) stated she was part of the QAPI Committee, and the committee meets monthly and quarterly. The DON stated she was aware of the ongoing problem with the incomplete medical records. The DON stated to ensure timely completion of medical records, Nurse Supervisors were expected to complete a daily checklist to review all medical records to make sure that everything was signed and completed, as well as night shift staff conducting nightly chart audits to further catch any misses. During a review of the “Monthly Count Charts Waiting for Completions”, the DON confirmed the number of incomplete charts rose from 350 to 407 in a 12-month period. The DON stated there has been no formal process to analyze the numbers to determine specific opportunities for improvement. The DON stated to help improve the numbers, since 2023, the audit reports and policy reviews were discussed during the monthly nursing huddles, emails were sent to staff on Fridays to remind them to complete their charts, and the Nurse Supervisors had taken some staff off the unit to let them complete their charts but had not been happening often due to staffing limitations. The DON stated she and her Assistant Director of Nursing had started a new plan to address the charting issues in the past two months; details of said plan were requested but were not provided. The DON stated she expected staff to complete their charts by the end of their shift, and added it was “not fair to the patients” when their care was not fully documented on their medical records. During an interview on 6/5/2025 at 8:40 A.M., Deputy Director (DD) indicated the Governing Body meets every quarter and includes himself, the Director of Nurses (DON), Quality Director (QD), two members of the Board of Supervisors, and the Hospital Administrator (HD). The DD acknowledged the governing body was responsible for operations and quality of patient care provided in the facility. When asked about the missing documentation in patient medical records dating back to 2022, the DD indicated the DON was responsible for the records, stating “that is her job”. The DD stated his expectation was the nursing supervisors were checking the records every night for complete documentation but acknowledged that he had not verified the medical record checks were being completed. A review of the document, “[Hospital Name] Continuous Quality Improvement Work Plan Fiscal Year 2024-25”, approved 10/14/25, included, “ 4. Scope of CQI (Continuous Quality Improvement) Activities... The CQI program review, tracks, trends and evaluates the following quality assurance and improvement activities:...Medical records monitoring...”. A policy and procedure titled, “Quality Improvement Tracking Process”, revised 3/28/22, stipulated, “ Quality Improvement (QI) ensure continuous improvement by providing a feedback system to programs; the following procedure will be used to track concerns discovered during QI review process.””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 47138 Based on interviews and record review, the hospital failed to ensure patient medical record were complete and accurate, in accordance with hospital policy. The facility further failed to ensure staff adhered to the facility’s policy and procedure to promptly complete all medical records within 14 days of patient discharge when: 1. 2 of 19 sampled medical records reviewed were incomplete (Patient 15 and 9); and 2. The Medical Records Department had a current log of 407 incomplete medical records. This failure had the potential to result in medical records lacking vital patient health information, hinder an effective communication between providers resulting in gaps in patient care that negatively affect coordinated care for the patients, which could lead to compromised patient safety. Findings: During an interview and record review on 6/3/25 at 9:05 a.m. with Medical Records Manager (MRM), Patient 15’s medical records during his facility admission from 6/7/24-10/2/24 was reviewed. MRM stated Patient 15’s restraint orders were still with the rest of his paper chart, which was yet to scanned into the electronic medical records system. MRM stated patient charts cannot be scanned into the electronic medical records until they were complete. During an interview on 6/5/25 at 8:25 a.m., Senior Medical Office Assistant (SMOA), SMOA stated Patient 15’s medical records were still missing staff signatures and initials on several forms, 244 days after his discharge date on 10/2/24. During a concurrent interview and record review on 6/4/25 at 10:36 a.m. with the Sr. Medical Office Assistant (SMOA), Patient 9’s electronic health record (EHR) and paper medical Chart Audit Report were reviewed. The Chart Audit Report noted 198 paper chart errors and 4 EHR errors which SMOA stated, “The errors have not yet been resolved.” SMOA stated, “We stopped documenting the type of error noted as it was taking too much time, so we only track the number of chart errors. The types of errors were things like signatures or initials were missing. The management team is aware we were only tracking the number of chart errors.” SMOA also stated she is not aware of what actions the management team takes to resolve errors as she and her colleagues only audit charts to track the number of incomplete charting errors found. During a concurrent observation and interview on 6/4/25 at 11 a.m. with SMOA in the Medical Records Department, two shelves spanning a wall of the room contained numerous plastic binders. SMOA stated the binders were the incomplete patient records which await corrections and/or completions. SMOA stated staff were expected to complete patient records within 14 days of their discharge. SMOA stated the facility has a log of incomplete charts, with the oldest chart still incomplete 254 days after the patient’s discharge on 9/22/24. During an interview on 6/4/25 at 11:20 a.m., Ward Clerk (WC) stated the incomplete medical records were usually due to missing signatures, initials or dates, and misplaced forms or pages. During an interview on 6/4/25 at 2:26 p.m., MRM stated as of 5/30/25, the facility has 407 charts awaiting completions. During an interview on 6/4/25 at 3:19 p.m., the Director of Nursing (DON) stated she was aware of the ongoing problem with the incomplete medical records. The DON stated most of the nursing staff were travelers, which made corrections/completions very difficult as they were hard to reach once their contracts were up. During an interview on 6/5/25 at 8:25 a.m. SMOA stated she could only recall two complete charts during her audits, during her eight-year employment in the facility. A review of the facility policy and procedure titled, “TIMELINES FOR COMPLETION AND CORRECTION OF INPATIENT CHARTS”, dated 7/20/20, indicated, “Policy: Inpatient charting will be complete and correct within 14 days of patient discharge, in accordance with MediCare/MediCal guidelines ... Procedure: ...3. The Ward Clerk will audit the EHR and paper chart for completion and clerical accuracy ... 4. Any identified corrections are completed by the original author, or supervisor if author is not available. If correction cannot be made, form #1226 - Request to File Chart as Incomplete is to be completed by Medical Records staff, signed by the Director of Nursing (for Nurses and Mental Health Worker staff corrections) or Medical Director (for Physician corrections) and scanned to the chart. 5. All the above steps shall be completed within 14 days of patient’s discharge...””