Suncoast Behavioral Health Center

“STAFF EDUCATION CFR(s): 482.45(a)(5) Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues; This Standard is not met as evidenced by: 28028 Based on review of facility documents and staff interviews it was determined the facility failed to ensure the hospital worked cooperatively with the designated OPO (Organ Procurement Organization), tissue bank and eye bank in educating staff on donation and includes quality improvement activities for one of one agreement reviewed. Findings included: Review of the facility’s current written agreement with the OPO revealed section G. Activity Data Review, Reporting and Quality Assessment (QA) and Improvement (QI) stated “G.1 At least annually, the Foundation shall provide Donor Hospital specific data with the appropriate Donor Hospital personnel for the purposes of quality assessment (QA) and improvement (QI), process evaluation, and to analyze outcomes of potential referral/donor situations, allowing for a collaborative plan of corrective action when indicated.” Staff education on organ procurement roles and processes, as outlined in the contract, was not evidenced. Requested evidence to ensure integration into the hospital’s QAPI (Quality Assurance Performance Improvement) program was not provided during survey. Review of the facility’s Board Quality and Patient Safety Committee meeting minutes revealed the last meeting in which specific data was provided to the committee was 1/19/2017. Review of requested documentation revealed the OPO provided data for calendar years 2017 and 2018. There was no evidence the data was provided to the facility’s Board Quality and Patient Safety Committee for integration into the hospital’s QAPI program. On 3/20/2024 at 2:06 PM the Director of Clinical Services was interviewed. She stated she was not aware of who the facility designee was for communication with the OPO. On 3/20/2024 at 3:44 PM she stated the designee of the facility was the Director of Risk Management. On 3/21/2024 at 10:16 AM the Director of Risk Management was interviewed. She confirmed she was assigned the role but had not yet received the necessary education.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 42154 Based on review of staffing schedules, medical record review, policies, video review and staff interviews it was determined the facility failed to maintain sufficient staffing levels to adequately supervise a patient ordered one to one observation for one (#12) of twenty-four patients sampled. Findings included: Review of the facility staffing sheets revealed that on 03/18/2024 at 11:00 PM, night shift (11:00 PM- 7:30 AM), there was one Mental Health Tech (MHT) assigned to Dolphin Bay Unit (Acute unit). The census was 10 patients with physician ordered observation status of every 15 minutes and one patient with physician ordered observation status of 1:1 (continuous staff observation to safeguard patient from self-harm or harm to others.) Review of the facility staffing sheets for 03/19/2024 night shift (11:00 PM- 7:30 AM) revealed one Mental Health Tech (MHT) assigned for Dolphin Bay Unit (Acute unit). The census was 10 patients with physician ordered observation status of every 15 minutes and one patient with physician ordered observation status of 1:1. Review of the Medical records for Patient #12 the Physician orders revealed on 03/14/2024 at 10:00 PM observation status changed to a 1:1 observation. Review of the Medical Records for Patient #2 the Physician orders revealed on 02/28/2024 at 10:00 PM observation status as an every 15 minutes observation. Review of the Medical Records the Patient observation record for Patient # 12 and Patient #2 revealed the patient room on opposite ends of the hall and the MHT signing their initial both 1:1 observation and every 15 minutes observation. Review of the facility policy and procedure title, “Level of Observation/ Patient Safety Rounds”, #PC-53, revised 04/2023. Policy: It is the policy of Suncoast Behavior Health Center (SBHC) to use Levels of Observation based on the assessment of patient’s need for observation in order to provide for safety, security and interaction. At a minimum, all patients are observed every 15 minutes ...every 15 minutes safety observation are placed when they need routine observation cheeks ... 1:1 observation when a patient need arm’s length supervision due to suicidal, homicidal, elopement risk or disorganization problems ... Review of the video for 03/18/2024 at 10:00 PM through 03/19/2024 2:00 AM revealed that patient #12 was not in constant supervision of staff. An interview was conducted with Staff RN I, on 03/20/2024 at 8:01 AM. Staff RN I said an order for patient #12 for a 1:1 (one staff with one patient for close observation) and they did not have the staff to have the 1:1. An interview was conducted with the Chief Medical Officer (CMO) on 03/20/2024 at 11:14 AM. The CMO said that if he ordered a patient to be 1:1 observation then his expectation is that the Mental Health Tech (MHT) to be with the patient at all times. An interview was conducted with Staff MHT H on 03/21/2024 at 8:01 AM. Staff MHT H disclosed that they have a 1:1 patient he disclosed that the RN told him to just check the patient every 5 minutes because he was the only MHT on the unit. An interview was conducted with The Chief Executive Officer (CEO) on 03/21/2024 8:35 AM. The CEO reviewed the facility policy, staffing sheets, and the medical records and disclosed that it was unacceptable not to have the staffing for patient #12 on the 1:1 observation per the physician orders. Video evidence provided.”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 38951 Based on record review and interview, the facility failed to establish a comprehensive Emergency Preparedness Program (EPP) in accordance with the Code of Federal Regulations (CFR) 42, Part 482.15, Condition of Participation for Hospitals. Findings included: On 03/19/2024 between 9:30 AM and 3:00 PM, during the record review with the Director of Plant Operations, the facility failed to provide evidence of an EPP. During the exit conference, the Chief of Operations and the Director of Risk Management concurred that the facility had no idea about their EPP or its requirements.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 38951 Based on record review and interview, the facility failed to develop and maintain an Emergency Preparedness Program (EPP) in accordance with the Code of Federal Regulations (CFR) 42, Part 482.15, Condition of Participation for Hospitals Findings include: On 03/19/2024 between 9:30 AM and 3:00 PM, during the record review with the Director of Plant Operations, the facility failed to provide evidence of an EPP development or maintenance of the program that meets the requirements of this section, utilizing an all-hazards approach. During the exit conference, the Chief of Operations and the Director of Risk Management concurred that the facility had no idea about their EPP or its requirements.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 38951 Based on record review and interviews, the facility failed to maintain battery back-up emergency lighting. Battery back-up emergency lighting is required to insure the safety of maintenance personnel in the event of a simultaneous failure of the public utility and the emergency generator. Findings include: On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility’s emergency lighting records with the Director of Plant Operations (DOPO), it was revealed the emergency battery back-up lighting annual testing had not been completed with a 90 minute test interval. An interview was conducted with the maintenance staff concurrent with the observations and the staff member said that he just does a 30 second check for the annual testing. Per NFPA 101 (2012 Edition) 19.2.9.1, 7.9.3, 7.9.3.1.1 (3)”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 NEW Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 18.2.10.1 This Standard is not met as evidenced by: 38951 Based on observations and interviews the facility failed to maintain exit signage in accordance with NFPA 101. The findings include: On 03/19/2024 between the hours of 9:30 a.m. and 11:30 a.m., during the tour of the dietary kitchen with maintenance staff and the Director of Risk Management, it was observed that the emergency exit sign above the dietary kitchen exit door was not illuminated. An interview was conducted with the maintenance staff concurrent with the observations and confirmed the findings. Photographic evidence obtained. per NFPA 101 (2012 Edition) 19.2.10.1, 7.9.2, 7.9.2.1, 7.10, 7.10.5, 7.10.5.1, 4.2.3, 4.6.12”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 38951 Based on record review and interviews, the facility failed to maintain the Automatic Fire Alarm System (AFAS). This in the event of a fire could fail to activate the AFAS endangering the occupants in the event of an emergency. Findings include: On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility’s AFAS inspection records with the Director of Plant Operations (DOPO), it was revealed the facility failed to provide documentation for a semi-annual testing and visual inspection report for the current AFAS inspection cycle. In an interview, the DOPO acknowledged concurrent with the findings. Per NFPA 101 (2012 Edition) 19.3.4.4, 9.6.5, 9.6.5.1 Per NFPA 72 (2010 Edition) 14.3.1, (table 14.3.1), 14.4.5, (table 14.4.5)”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 38951 Based on observations and interviews the facility failed to maintain the automatic fire sprinkler system (AFSS). Findings include: On 03/19/2024 between the hours of 9:30 a.m. and 11:30 a.m., during the tour of the facility with the maintenance staff and Director of Risk Management, it was observed that there was no inventory list of the sprinkler heads installed at the facility posted in the spare sprinkler head box. An interview was conducted with the maintenance staff concurrent with the observations and confirmed the findings. per NFPA 101 (2012 Edition) 19.7.6, 4.6.12, 4.6.12.1, 9.7, 9.7.5 per NFPA 25 (2011 Edition) 5.2.1, 5.2.1.4 (1), 5.4.1.4, 5.4.1.4.1, 5.4.1.5”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. 18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3 Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 38951 Based on observations and interviews the facility failed to maintain interior walls to be fire and smoke resistant in accordance with NFPA 101. The findings include: On 03/19/2024 between the hours of 9:30 a.m. and 11:30 a.m., during the tour of the Normal Electrical room with the maintenance staff and Director of Risk Management, observations were made of an improperly patched penetration in the 1-hour fire wall. An interview was conducted with the maintenance staff concurrent with the observations and confirmed the findings. Photographic evidence obtained. per NFPA 101 (2012 Edition) 19.3.7.3, 8.3.4, 8.3.4.1, 8.3.4.2, 4.6.12”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 38951 Based on record review and interviews, the facility failed to conduct fire drills as required by NFPA 101 (2012 Edition). Fire drills are essential to the training of staff and residents in proper procedure in emergency situations. Untrained staff can allow confusion and possible delays in proper procedure in an emergency and jeopardize all within the facility. Findings include: On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility’s fire drills with the Director of Plant Operations (DOPO),it was revealed that the facility had not performed a drill for the 4th Quarter -3rd shift in 2023. An interview was conducted with the DOPO concurrent with the observations and confirmed the findings. per NFPA 101 (2012 Edition) 19.7.1.6”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 38951 Based on record review and interviews, the facility failed to protect the fire barriers in accordance with NFPA 101 (2012 Edition) and NFPA 80 (2010 Edition). In the event of a fire, this condition could put occupants attempting shelter or evacuate in an unsafe environment. Findings include: On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility’s Fire Door inspection records with the Director of Plant Operations (DOPO), it was revealed the facility could not provide documentation for an annual fire door inspection. An interview was conducted with the DOPO concurrent with the observations and confirmed the findings.. per NFPA 101 (2012 Edition) Chapter 8.3.3.1 per NFPA 80 (2010 Edition) Chapter 5.2, 5.2.1”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 38951 Based on record review and interview, the facility failed to maintain the diesel fuel for the generator. Proper maintenance and inspection of the emergency power supply system helps to ensure proper functioning in an emergency situation. Findings include: On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility’s generator maintenance program with the Director of Plant Operations (DOPO), it was reveal that the facility could not provide a current diesel fuel quality testing report. In an interview, the DOPO acknowledge concurrent with the findings. per NFPA 99 (2012 Edition) 6.4.1.1, 6.4.1.1.16 per NFPA 110 (2010 Edition) 8.3.8”