Harsha Behavioral Center Inc.

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to follow facility policy for medication administration, failed to complete two patient identifiers prior to administering medications, and failed to maintain documentation of a physician’s order given verbally in 1 of 10 MRs (Medical Records) reviewed. (P2) 1. Facility policy titled Medication Administration, Policy Number: MM230, Last Reviewed: January 2026, under Policy: Medications are verified by the nurse that will be administering the medication. The nurse administering the medication removes the medication from the pyxis or home supply, comparing the medication listed on the patient’s Pyxis profile with the medication listed on EMAR. The medication should not be removed from its packaging prior to scanning the medication and administration time. Two patient identifiers: patient name, picture, birth date or if patient is nonverbal or intellectually challenged, verification can also be made by another staff member as long as that staff also compares the patient to the picture as indicated on both the MAR and/or as stated by the patient are utilized to ensure that the correct medication(s) is/are administered to the correct patient. Patient identifiers should be compared to patient hospital wristbands. Under Procedure: A. Prior to administering medications: 3. Reading from the patient’s medication profile in the MAR the doses of medication are removed from the Pyxis or patient bin and placed in a medication cup. Do not remove unit dose packaging. To properly and safely identify a medication before administering it, the following steps are to be followed: B. When administering the medication(s): 1. Follow the goals of the Treatment Plan and: a. Request the patient come to the day room on the unit. b. Do not take the medication(s) from the original packing yet. 2. Prior to administration, scan the patient’s hospital wristband. Compare the patient to his/her photograph. Ask the patient for his/her date of birth and name and compare to the MAR. 3. Scan each medication with the patient present prior to administration. 4. Remove Medications from unit dose packets and double check against the patient’s medication profile immediately before handling medications to the patient. 5. Hand the medication in the medication cup to the patient. The patient will take the medications, in front of the staff. 2. Facility policy titled Verbal And/Or Telephone Orders, Policy Number: IM130, Last Reviewed: January 2026, under Policy: RNs/LPNs are authorized to take verbal orders and/or telephone orders from LIPs when they are not in the building, in emergency circumstances or in EMR downtime. Under Procedure: 1. The RN/LPN will document the verbal and/or telephone order on the order form. 2. The RN/LPN will document the verbal and/or telephone order in the EMR. 3. A second RN/LPN will verify the order in the EMR. 5. After completion of the order, two nurses will verify that the order is correct and sign it off including signatures, date and time. 6. Documentation of verbal/telephone orders must include the date and names of individuals who gave, received, recorded, read back and confirmed, entered and noted the orders. 8. All verbal/telephone orders must be authenticated within 48 hours. 3. Review of P2 MR indicated: a. On 7/17/26 P2 was admitted to F1 (psychiatric hospital) with diagnosis of Brief Psychotic Disorder. b. On 7/20/26 at 1106 hours N2 (RN [Registered Nurse]) charting note indicated that N2 incorrectly administered medication meant for another patient to P2 during morning medication administration. P2 received Lyrica 200 mg, Omeprazole 40 mg, Cymbalta 30 mg, and Caplyta 21 mg. P2 was ordered and did not receive divalproex sodium DRT 250 mg and Lurasidone 20 mg with allergy to Omeprazole noted in the MR. c. On 7/20/26 at 1355 hours N5 (RN) Nursing Note indicated a Code Blue was called for P2 at approximately 1235 hours. P2 had placed his/her head down on the table. P2 had minimal response to verbal or sternal rub. ordered P2 to be taken to bed, vital signs and nurse to check P2 every 15 minutes and to place P2 on one-on-one observation. While transporting P2 via recliner chair, smelling salts were placed under P2’s nose with only eyelid flutter, eyes did not open. Once P2 was placed in bed the HOB (Head of Bed) was elevated approximately 30 degrees and knees elevated. N5 stayed with P2 due to medical concern. P2 was using accessory stomach muscles when breathing, and pupils were 2 mm (millimeter) with sluggish reaction to light. NP1 gave an order to transfer P2 to F2 (Acute Care Facility). At approximately 1325 hours firefighters arrived taking over care, and at approximately 1330 hours EMS (Emergency Medical Services) arrived. P2 was transported out of the unit at 1335 hours. d. On 7/20/26 P2 was discharged from F1. e. Provider Charting note on 8/4/2026 at 1532 hours (late entry) indicated on 7/20/26 NP1 (Nurse Practitioner) note indicated NP1 was notified by N2 that P2 was given the wrong medications with a list of medications P2 received and vital signs that were within normal limits. N2 was advised to monitor P2 for any change in condition and notify NP1 accordingly. Approximately 30-40 minutes after being NP1 was notified of the error, NP1 was asked by the ADON (Assistant Director of Nursing) to assess P2 in the cafeteria. NP1 arrived to find P2 hypersomnolent. P2’s vitals were within normal limits and verbal order was given to let P2 sleep it off with the HOB (head of bed) elevated under one-on-one observation with RN getting vital signs every 15 minutes. f. MR lacked documentation of verbal order to elevate the HOB, one-on-one observation and vital signs every 15 minutes. 4. Review of facility Incident Reports from 2/4/26 through 8/4/26 indicated the following incident involving P2: Incident Report dated 7/20/2026 at 1102 hours indicated a medication error. N2 incorrectly administered medication meant for another patient to P2 during morning medication administration. P2 received Lyrica 200 mg, Omeprazole 40 mg, Cymbalta 30 mg, and Caplyta 21 mg. 5. In interview on 8/4/26 at 1225 hours with N2, he/she confirmed on the morning of 7/20/26 that he/she did not check P2’s armband, did not ask P2 his/her name or DOB (date of birth) and proceeded to place P1’s medications in P2’s mouth. N2 indicated while she was administering the medication to P2, he/she looked at P2’s armband and realized he/she was administering the wrong medications to P2. N2 confirmed the proper technique for medication administration was to print out the patient’s medication sheet, take medications prescribed out of the Pyxis, place wrapped medications in a cup, take cart with medications to the patient, scan patients’ armband, ask patient their name and DOB, scan each medication, unwrap them, and administer the medication to the patient. N2 confirmed that he/she did not enter the order for the one-on-one observation, vital signs every 15-minutes, and HOB (head of bed) elevated 45 degrees in the EMR. 6. In interview on 8/4/26 at 1245 hours with N1 (LPN [Licensed Practical Nurse]), he/she confirmed on the morning of 7/20/26 they were running behind with medications and to make it quicker, he/she went ahead and pulled the medications, scanned them in the system, unwrapped them and placed them in cups with the patient’s name on them. N1 was passing the medications when he/she got called to treatment team. N1 pushed the medication cart back into the medication room and he/she would finish passing the medications after treatment team. N2 decided to pass the medications to help while N1 was off the unit and administered the wrong medications to P2. N1 confirmed he/she did not follow the medication administration policy.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to maintain a central log for a patient coming to the facility seeking psychiatric care in 1 instance. (P1) Findings include: 1. Facility policy titled Admission Intake System, no policy number, Last Reviewed: Feb 2023, under Policy: F1 (psychiatrtic hospital) will provide a responsive coordinated intake system that includes a direct telephone line for information, assessment, and admission of potential patients. 2. P1 MR (medical record) review for 2/9/26 visit indicated patient presented to F1 on 2/9/26 at 0505 hours from F2 (acute care hospital) with diagnosis of Major depressive disorder, single episode, unspecified. Psychiatric Evaluation entry on 2/9/26 at 1131 hours indicated under Reason for Admission: P1 was initially transported to F1 by PD1 (college police department) on 2/8/26 for concerns of Suicidal Ideation, P1 was unwilling /unable to verify insurance status on arrival and F1 recommended P1 to be transported to F2 to avoid P1 assuming financial responsibility for admission. 3. Review of facility denial log from 8/25/26 through 2/25/26 lacked documentation of P1 entered on the log for 2/8/26 with reason P1 was denied admission. 4. In interview on 2/25/26 at 1130 hours with A3 (COO [Chief Operating Officer]), he/she confirmed that P1 was not listed on the denial log for 2/8/26 with the reason P1 was denied admission.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to complete an MSE (Medical Screening Exam) on a patient seeking psychiatric care in 1 instance. (P1) Findings include: 1. Facility titled EMTALA, no policy number, Last Revision: Sept 2023, under Emergency Medical Treatment and Labor Act (EMTALA), no policy number, Last Revision: Sept 2023, If you have a medical emergency or are in labor, you have the right to receive within the capabilities of this hospital’s staff and facilities, an appropriate medical screening examination, necessary stabilization treatment (including treatment for an unborn child) and, if necessary, an appropriate transfer to another facility even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid. 2. Facility policy titled Admission Intake System, no policy number, Last Reviewed: Feb 2023, under Policy: Facility will provide a responsive coordinated intake system that includes a direct telephone line for information, assessment, and admission of potential patients. Under Procedure: 1. All clinical staff is trained to perform required initial assessments and intake functions. The hospital accepts referrals and admissions 24 hours a day, 7 days a week providing all guidelines of the admission criteria have been followed and the proper chain of command has been notified. 2. All inquiries should be documented within the EMR or using our written tools AP190 (youth) and G-AP130 (Savera). 3. Coordination of referrals is managed by the Intake Coordinator/RN staff. The initial assessment is completed for every intake or admission. Data is collected from potential patient, family, caregiver interviews, charts and/or other pertinent records. 3. Review of P1 Medical Records (MRs) indicated: a. No entries were found in MR for patient facility visit on 2/8/26 seeking psychiatric care. No evidence of a MSE was performed. b. P1 presented to F1 (psychiatric hospital) on 2/9/26 at 0505 hours from F2 (acute care hospital) with diagnosis of Major depressive disorder, single episode, unspecified. c. Psychiatric Evaluation entry on 2/9/26 at 1131 hours indicated under Reason for Admission: P1 was initially transported to F1 (psychiatric hospital) by PD1 (college police department) for concerns of Suicidal Ideation, P1 was unwilling /unable to verify insurance status on arrival and F1 recommended P1 to be transported to F2 to avoid P1 assuming financial responsibility for admission. 4. In interview on 2/25/26 at 1145 hours with A5 (Director of Admissions), he/she confirmed N2 (Admissions Coordinator) did not fill out the required admission screening form and a Medical Screening Examination was not completed by a provider when P1 presented to F1 (psychiatric hospital) on 2/8/26. 5. In phone interview on 2/25/26 at 1149 hours with N2, he/she confirmed he/she did not complete the required admission form on P1, and P1 did not have a Medical Screening Examination performed on 2/8/26.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to uphold patient’s rights of confidentiality per facility policy for 2 of 10 MR’s (Medical Records) reviewed. (P1, P2) Findings include: 1. Facility document titled Adult Unit Patient Handbook, under Patient Rights, the patient has the right to confidentiality of communications by the patient to staff and all information in the case record. 2. Review of P1 MR indicated: a. Patient admitted to facility 7/16/24 through 7/24/24 for diagnosis of Brief Psychotic Disorder. b. MR indicated P2 signature on P1’s Prescription Manifest Form to take Haloperidol prescription home on 7/23/24, signature was lined out, error marked, and P1 signed form at discharge on 7/24/24. 3. In interview on 10/7/24 at approximately 1055 hours with N6, he/she indicated signing for P1’s medication when pharmacy delivered them to the facility, and he/she placed them on P1’s chart in medication room. N6 indicated he/she went on break and upon returning P2 had discharged to home and he/she’s chart was gone. Approximately one hour later P2 phoned facility reporting he/she was sent home with another patient’s medications, N6 instructed P2 to return medication to facility and P2 returned medication. N6 confirmed wrong medication was sent home with P2. N6 also confirmed P2 did sign a copy of P1’s medication form with confidential information on it on 7/23/24 at 1430 hours, and the following day P2’s name was crossed off Prescription Manifest form and P1 signed the same form with P2’s name on it the following day on 7/24/23 with incorrect discharge date and time for P1. 5. In interview on 10/7/24 at approximately 1130 hours, A1 (Chief Nursing Officer) and A5 (Chief Operating Officer), they confirmed a breach in patient rights of confidentiality for P1 and P2.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) 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). This Standard is not met as evidenced by: 50584 Based on document review and interview, Nursing Services failed to complete an incident report per facility policy for 2 of 10 patient MR’s (medical records) reviewed. (P1 & P2) Findings include: 1. Facility policy titled Medication Errors, no policy number, last reviewed 12/2022, under Policy: It is the responsibility of all clinical staff to report medication errors utilizing an Incident Report (form CS29OA). Under Procedure: 2. Clinical staff documents the description of the incident, action, and notification of physician and/or supervisor on the Incident Report (CS290A). The original form will be sent to the CNO (Chief Nursing Officer) and/or the Director of Quality to be reviewed and report on Quality and Process Improvement Committee meeting. 4. All incident report forms are reported by the clinical staff to the CNO or Director of Quality within 24 hours of identification. 2. Facility policy titled Incident and Regulatory Reporting, no policy number, last reviewed 1/2023, under Policy: The responsibility for completing an Incident report rests with any hospital staff member, volunteer, student or physician who witnesses, discovers or has direct knowledge of any incident. Incidents are defined as any happening not consistent with the routine care and/or operation of the facility at increased risk for liability. Under Procedure: 1. Any hospital staff member who witnesses, discovers or has direct knowledge of an occurrence should complete an Incident Report as soon as practical after the incident is witnessed or discovered, before the end of the shift/workday. E. An event occurs which, by standards, appears unexpected and/or unintended (i.e., medication error, medical emergency, exposure to allergen). 2. Information to be entered on the Incident Report includes (items with * MUST be completed). A. Patient label if applicable. B.*Date and time of occurrence. C.*Shift during which the incident occurred (i. e. 7 a.m.-7 p.m.). D.*Location occurrence took place. E.*Person(s) involved (patient, employee, volunteer, visitor, student, etc.). F.*Name of individual involved. G. If the individual is not a patient, the address and telephone number of the individual. H. Type of occurrence (accidental injury, elopement, fall, etc.). I. *Brief description of the incident, resulting, if any and outcome. The individual completing the Incident Report should provide a narrative description of the occurrence to include facts witnessed, discovered or of which the individual has direct knowledge. No assumption of facts or opinions should be stated. Comments made by the party involved should be documented as quotes by the individual completing the report. Print and attach documentation of the incident from the EMAR. J.*Immediate correction actions taken when the incident occurred, or was discovered. K.*How the writer became aware of the incident (witness to incident, discovered after the incident, told of incident by patient, etc.). L.*Notification of supervisor, MD, administrator on-call, and/or family to include who was contacted, when and by whom. The unit nurse should determine whether the incident warrants contacting the administrator on-call, risk manager and/or the family member based on the severity of the incident and the Communication Protocol (CS1055) policy which specifies notification will occur for all Acute Changes in Condition, ER Transfers, Falls, injuries, Seclusions and Restraints, Medication Errors, and Psychotropic Medication Changes in Youth. M.*Name of any witnesses to the actual occurrence. N.*The signature of the staff person completing the report. 3. Review of P1 MR indicated: a. Patient admitted to facility 7/16/24 through 7/24/24 for diagnosis of Brief Psychotic Disorder. b. MR indicated P2 signature on P1’s Prescription Manifest Form to take Haloperidol prescription home on 7/23/24; signature was lined out, error marked, and P1 signed form at discharge on 7/24/24. 4. Review of facility Incident Reports on 10/7/24 at approximately 1005 hours, lacked documentation of an incident report on 7/23/24 regarding wrong medication sent home with P2. 5. In interview on 10/7/24 at approximately 1055 hours with N6, he/she indicated signing for P1’s medication when pharmacy delivered them to the facility, and he/she placed them on P1’s chart in medication room. N6 indicated he/she went on break and upon returning P2 had discharged to home and his/her chart was gone. Approximately one hour later P2 phoned facility reporting he/she was sent home with another patient’s medications, N6 instructed P2 to return medication to facility and P2 returned medication. N6 confirmed wrong medication was sent home with P2. N6 confirmed there was not an incident report filled out on the medication error. N6 also confirmed P2 did sign a copy of P1’s medication form with confidential information on it on 7/23/24 at 1430 hours, and the following day P2’s name was crossed off form and P1 signed the same form with P2’s name on it the following day on 7/24/23 with incorrect discharge date and time for P1. 7. In interview on 10/7/24 at approximately 1130 hours, A1 (Chief Nursing Officer) and A5 (Chief Operating Officer), they confirmed a breach in patient rights of confidentiality for P1 and P2, no incident report was filed, and facility administration was unaware of the incident”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to complete and document every 15 minute observation checks per facility policy for 5 of 10 MRs reviewed. (P1, P4, P5, P8 and P10) Findings include: 1. Facility policy titled Observation Level, no policy number, last revised 1/2024, indicated under Definitions: a. 15-Minute Observation 1. Minimum observation level for all patients from admission until discharge. 2. Patients will be visually monitored every fifteen (15) minutes, 24 hours a day. 3. All patients’ location and behavior/activity are documented every fifteen (15) minutes on the Close Observation Form (CS470A). 2. Review of P1 MR indicated: a. Patient admitted to facility 9/11/24 through 9/17/24 for diagnosis Other Persistent Mood Disorder and ADHD (Attention Deficit Hyperactivity Disorder). b. Lack of documentation of every fifteen-minute patient observations completed and documented on 9/16/24 from 0930 hours through 1530 hours. 3. Review of P4 MR indicated: a. Patient admitted to facility 9/13/24 through 9/18/24 for diagnosis of ADD (Attention Deficit Disorder), Developmental Delay and Other Persistent Mood Disorder. b. Lack of documentation of every fifteen-minute patient observations completed and documented on 9/18/24 from 0000 hours through 0901 hours. 4. Review of P5 MR indicated: a. Patient admitted to facility 9/13/24 through 9/16/24 with diagnosis of Other Mood Disorder and Autism. b. Lack of documentation of every fifteen-minute patient observations and documented on 9/16/24 from 0000 hours through 2245 hours. 5. Review of P8 MR indicated: a. Patient admitted to facility 9/15/24 through 9/19/24 with diagnosis of Other Persistent Mood, Autistic, ADHD and Conduct Disorder. b. Lack of documentation of every fifteen-minute patient observations and documented on 9/16/24 from 0000 hours through 2245 hours. 6. Review of P10 MR indicated: a. Patient admitted to facility 09/17/24 and is a current inpatient with diagnosis of Aggression, Other Mood Disorder and ADHD. b. Lack of documentation of every fifteen-minute patient observation and documentation on 9/20/24 from 1800 hours through 1915 hours, 9/21/24 from 2000 hours through 2245 hours and on 9/22/24 from 1440 hours through 1530 hours. 6. In interview on 9/24/24 at approximately 1253 hours with A1 (Chief Administrative Officer), A3 (Chief Operating Officer) and A4 (Chief Nursing Officer), they confirmed the lack of documentation on Close Observation Form in P1 MR of every fifteen-minute observation checks on 9/16/24 from 0930 hours through 1530 hours, P4 on 9/16/24 from 0000 hours through 2245 hours, P5 on 9/16/24 at 0000 hours to 2245 hours, P8 on 9/16/24 from 0000 hours through 2245 hours and P10 on 09/20/24 from 1800 hours through 1915 hours, 9/21/24 from 2000 hours through 2245 hours and 9/22/24 from 1440 hours through 1530 hours. A4 also confirmed it is facility policy for every patient in facility to be checked every fifteen minutes.”