Compass Behavioral Center of Lafayette

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure that a interior access double door had a proper egress method. Special healthcare locking hardware method is prohibited due to this occupancy being classified as a Business Occupancy. During cases of a fire alarm emergency the exterior exit doors provide safe passage to all occupants in need of egress by releasing the magnetic special healthcare locking and remaining unlocked for the duration of the emergency. The deficient practice had the potential to affect twenty of twenty patients. Findings: During the facility tour June 15, 2026 between the hours of 10:15 a.m. to 11:45 a.m. the off-site business occupancy identified as Compass Behavioral Center of Crowley located at 720 North Avenue L Crowley, La. 70526 had a cross corridor double door, located at the rear of the tenant space, utilizing a prohibited method of special care locking. The cross corridor double door was a required exit access door and lacks a acceptable method of providing a properly functioning access control door arrangement. The interview with the on site personnel revealed the facility was not aware that the cross corridor double door located in the rear of facility lacked the proper method for emergency egress.”

“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: 35367 Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect forty of forty patients. Findings: During the facility tour June 15, 2026 between the hours of 9:00 a.m. to 9:30 a.m. the fire alarm lacked a annual certification and a sensitivity test from a licensed fire alarm company. The interview with on site personnel revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.”

“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: 35367 Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect twenty two of twenty two patients. Findings: During the facility tour on June 9, 2026 between the hours of 8”45 a.m. to 10:45 a.m. the fire alarm lacked a sensitivity test from a licensed fire alarm company. The interview with Administrator revealed the facility was not aware that the required fire alarm sensitivity test inspection had not been conducted by a licensed fire alarm company.”

“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: 35367 Based on visual observation the facility failed to assure that the sprinkler system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 25. The sprinkler system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect twenty two of twenty two patients. Findings: During the facility tour on June 9, 2026 between the hours of 8:45 a.m. to 10:45 p.m. the sprinkler system was yellow tagged, lacked a annual certification, lacked a five year internal inspection, lacked a five year FDC hydrostatic test, lacked quarterly inspections. The interview with the Administrator revealed the facility was unaware the sprinkler system was lacking a annual certification from a licensed sprinkler company and the quarterly inspection documentation was lacking for the last year.”

“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. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 35367 Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect twenty two of twenty two patients. There were two of the four quarters in years 2025 to 2026 that were deficient. Findings: During the record review on June 9, 2026 between the hours of 8:45 a.m. to 10:45 a.m. the facility lacked documented fire drill for the 6 p.m. to 6 a.m. shift for first and third quarter of the year 2025. The interview with the Administrator revealed the facility recognized the deficiency and is in the process of ensuring the fire drill policy will be properly executed for each shift of each quarter.”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: 1. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. 2. In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. 3. Smoking by patients classified as not responsible shall be prohibited. 4. The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. 5. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. 6. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 35367 Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect forty of forty patients. Findings: During the facility tour on June 15, 2026 between the hours of 9:00 a.m. to 9:30 a.m. The smoking area lacked noncombustible ashtray with self closing lid. The interview with the on site personnel revealed the facility was not aware the containers in the smoking area did not meet the requirements.”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 35367 Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect twenty two of twenty two patients. Findings: During the facility tour on June 9, 2026 between the hours of 8:45 a.m. to 10:45 a.m. the smoking area lacked noncombustible ashtray with self closing lid. The interview with on site personnel revealed the facility was not aware the containers in the smoking area did not meet the requirements.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 35367 Based on record review the facility failed to provide annual fire door testing documentation. Written annual records demonstrate all fire doors are properly being maintained to ensure protection for life and property. The deficiency has the potential to affect twenty two of twenty two patients. Findings: During the record of review on June 9, 2026 between the hours of 8:30 a.m. to 10:30 a.m. the facility lacked annual fire door inspection for the smoke barrier cross corridor doors and documented inspections of the patient room doors. The interview with the on site personnel revealed the facility was not aware annual fire door inspections were required to be conducted annually.”

“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: 35367 Based on visual observation the facility failed to assure that the generator sets are required to be tested/ inspected weekly, monthly and in some cases a load bank conducted on the emergency generator. The monthly load tests must be conducted a min. of 12 times a year under load for a min. of 30 minutes. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect twenty of twenty patients there were twelve of twelve months that were deficient. Findings: During the facility tour on June 15, 2026 between the hours of 10:15 a.m. to 11:45 a.m. the generator weekly and monthly load documentation was lacking at time of survey. The interview with the on site personnel revealed the facility was not aware that generator documentation was not completed properly regarding the inspection/testing of the emergency generator.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 35367 Based on visual observation, the facility failed to assure that areas with greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of 300 cubic feet are not required to be stored in an enclosure. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS (ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. This deficient practice could potentially affect twenty two of twenty two patients. Findings: During the facility tour on June 9, 2026 between the hours of 8:45 a.m. to 10:45 a.m. the storage room had a total of seven oxygen cylinders of approximately 25 cubic feet in capacity that were not secured in the upright position, nor were they segregated with signage identifying “full” and “empty”. The corridor access to door to the room also lacked, “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING” signage. The interview with the on site personnel revealed the facility was not aware that the stored oxygen cylinders were required to be chained or racked in a segregated full and empty orientation to ensure rapid retrieval in the event of a emergency.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 53243 Based on observation, record review, and interview the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use, as evidenced by the presence of opened multi-dose medication without documented opened date and expired open multi-dose medication available for patient use. Findings: Review of the hospital’s policy titled “Expiration of Medications” revised date 06/03/2021, revealed in part, all multi-patient use medications shall be considered expired 30 days after opening. All such medications shall be labeled with “date opened” upon opening. A tour of the medication room on 05/18/2026 from 2:58 PM - 3:15 PM revealed the following opened multi-dose medications without documented opened dates: a) 1 opened bottle of Ibprofen 200 milligram (mg) b) 1 bottle of Antacid tablets 500 mg c) 1 tube of Aquaphor ointment 14 oz. d) 1 tube of Mupirocin ointment 2% The same medication room tour conducted from 2:58 PM - 3:15 PM further revealed the following expired open multi-dose medication available for patient use: a) 1 opened bottle of Ibprofen 200 mg labeled with an opened date of 11/21/2025 b) 1 tube of Orajel 3x Max oral pain labeled with an opened date of 08/12 Interview with S2QC on 05/18/2026 at 3:07 PM, confirmed that all multi-patient use medications were required to be labeled with the “date opened” upon opening and discarded 30 days after opening. S2QC confirmed the above listed medications were multi-use medications. S2QC further confirmed the medications should have been discarded and should not have been available for patient use.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 44763 Based on observation and interview, the infection control officer failed to ensure the hospital’s system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment. Findings: Observations were conducted in the hospital on 01/28/2025 between 1:00 PM and 2:17 PM, accompanied by SF2DON, SF3QC, and SF4CCO and on 01/29/2025 between 2:57 PM and 3:20 PM, accompanied by SF2DON. Observations revealed there were dead bugs located in 17 of 24 light fixtures located in the hallways of the unit. In interview during the observations, SF2DON verified the above stated findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient received care in a safe setting. The deficient practice was evidenced by the hospital failing to ensure the patient care area was free of ligature risks. Findings: A review of hospital policy, “PC-1020: Ligature Risk,” effective 08/02/2023 and no revisions, revealed in part: “Policy: (The hospital) is committed to maintaining a safe and therapeutic environment for all patients, including those with psychiatric conditions. This Ligature Risk Policy aims to identify, assess, and mitigate potential hazards relate to ligature points that could pose a risk of self-harm or harm to others. This policy applies to all areas within the hospital, including patient rooms, common areas, bathrooms, and outdoor spaces. Procedure: 1. Ligature Assessment: a. A comprehensive ligature risk assessment will be conducted throughout the hospital by a multidisciplinary team, including representatives from nursing, psychiatry, facility management, and safety officers. b. The ligature risk assessment will be repeated annually and whenever there are significant changes to the hospital’s environment. 2. Ligature Risk Mitigation: a. All identified high-risk ligature points will be promptly addressed, either by removal, replacement, or modification of the item to minimize the risk. d. any existing ligature-resistant fixtures and equipment will be regularly inspected and maintained to ensure their effectiveness.” Observations during a hospital walk-thru on 12/18/2024 from 1:00 PM to 2:15 PM revealed the toilets in 14 (f - p, r - t) of 20 (a - t) patient restrooms have an open space between the toilet bowl and the wall and contain non-secured toilet seats creating ligature risks and the potential for injurious behavior. Further observation revealed sleigh bed style bed frames (plastic head board and foot board attached to the floor and are connected via an above floor plastic platform for mattress placement) in 16 (a - p) of 20 (a - t) patient bedrooms. This style frame creates multiple ligature risk and the potential for injurious behaviors. In an interview on 12/182024 and present during the hospital walk-thru, S2DON confirmed the above mentioned findings.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... 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. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital’s Governing Body failed to ensure the Quality Assurance and Performance Improvement (QAPI) Program reflects the complexity of the hospital’s organization and services, which includes all hospital departments and services, including services furnished under contract or arrangement, within its QAPI Program. This deficient practice was evidenced by the hospital failing to ensure Plant Operations including Environment of Care and Preventative Maintenance were part of the hospital’s QAPI Program to ensure these services are tracked and analyzed to promote quality improvement and patient safety. Findings: A review of the hospital’s, “Performance Improvement Plan,” effective 07/2012 and no revision, revealed in part, no documentation related to Plant Operations including Environment of Care and Preventative Maintenance being on the, “Performance Improvement Master List of Indicators” as part of the hospitals QAPI Program to ensure these services are tracked and analyzed. In an interview on 12/18/2024 at 3:10 PM, S1CEO confirmed the hospital’s current QAPI Program does not track and analyze Plant Operations.”

“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: 48537 Based on record review, observation and an interview, the hospital failed to ensure the medical record was complete for 1 (#3) of 3 (#1-#3) patients’ medical records reviewed. Findings: Review of the hospital’s policy titled number “HIM-17: Documentation Completion Time Frames” last revised in June of 2023, indicated the following, in part: “Purpose: To ensure timely and accurate entries in the medical record. Policy: Health record documentation will be completed in an ongoing manner throughout the inpatient stay. All dictated and handwritten reports on patients will immediately be placed on the patients’ charts. When data entries are not completed by the time of discharge the following time frames and definitions will apply: - incomplete status: any record incomplete within 30 days of discharge - delinquent status: any record incomplete beyond 30 days of discharge Health Record Completion Time Frames: Document Type, Completion Time & Authentication, Verbal Orders, Within 10 days of order written, Discharge Summary, Within 30 days of discharge. Procedure: Each medical record shall be completed within 30 days after discharge or the patient, or the record becomes delinquent.” A review of Patient #3’s discharge record revealed he was discharged from the hospital on 11/12/2024. Further review revealed Patient #3’s Admission Orders dated 11/10/2024 at 5:15 PM and Discharge Orders dated 11/12/2024 at 10:00 AM were not signed by the physician. On 12/18/2024 at 4:20 PM, an observation was made during record review of Patient #3’s discharge record of where the physician needed to sign admission and discharge orders being marked with flagged stickie tabs on the right long edge of the page. The admission order sheets had a date of 11/10/2024 and the discharge order sheets had a date of 11/12/2024. On 12/18/2024 at 4:22 PM, an interview was conducted with S2DON. He confirmed both the admission and discharge order sheets had not been signed and dated by the physician. He confirmed without the signatures, the medical record was not complete due to the missing signatures. He confirmed Patient #3 had discharged more than 30 days ago from the hospital and the medical record should have been completed by this time with all provider signatures and dates properly documented.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48537 Based on record review, observation and an interview, the hospital failed to ensure the medical record was complete for 1 (#3) of 3 (#1-#3) patients’ medical records reviewed. Findings: Review of the hospital’s policy titled number “PC-1407: Verbal/Phone Orders” effective July 10th, 2012, indicated the following in part: “Objective: To maintain a high level of accuracy and safety in following physician’s or Licensed Independent Practitioner’s (LIP) orders. Procedure: 8. All phone orders are to be signed during the next physician or LIP face to face with patient or within 10 days.” Review of the hospital’s policy titled number “HIM-17: Documentation Completion Time Frames” last revised in June of 2023, indicated the following, in part: “Purpose: To ensure timely and accurate entries in the medical record. Policy: Health record documentation will be completed in an ongoing manner throughout the inpatient stay. All dictated and handwritten reports on patients will immediately be placed on the patients’ charts. When data entries are not completed by the time of discharge the following time frames and definitions will apply: - incomplete status: any record incomplete within 30 days of discharge - delinquent status: any record incomplete beyond 30 days of discharge Health Record Completion Time Frames: Document Type, Completion Time & Authentication, Verbal Orders, ithin 10 days of order written, Discharge Summary, Within 30 days of discharge. A review of Patient #3’s discharge record revealed he was discharged from the hospital on 11/12/2024. Further review revealed Patient #3’s Admission Orders dated 11/10/2024 at 5:15 PM and Discharge Orders dated 11/12/2024 at 10:00 AM were not signed by the physician. On 12/18/2024 at 4:20 PM, an observation was made during record review of Patient #3’s discharge record of where the physician needed to sign admission and discharge orders being marked with flagged stickie tabs on the right long edge of the page. The admission order sheets had a date of 11/10/2024 and the discharge order sheets had a date of 11/12/2024. On 12/18/2024 at 4:22 PM, an interview was conducted with S2DON. He confirmed both the admission and discharge order sheets had not been signed and dated by the physician. He confirmed the admission and discharge orders did not have a physician’s signature and were TORB/VORBs. He confirmed all TORB/VORBs must be signed by the provider within 10 days and Patient #3’s admission and discharge orders were not.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are ensured. This deficient practice was evidenced by the hospital failing to ensure the ventilation system’s return and exit vents were routinely cleaned and free of brown and grey substances. Findings: Observations during a hospital walk-thru on 12/18/2024 from 1:00 PM to 2:15 PM revealed the hospital’s ventilation system having vents being discolored brown, with a rough surface resembling rust located at the main entry of the unit and the hallway vents at Rooms “g” and “k.” Further observations revealed a grey, fuzzy substance resembling dust accumulation on 2 vents located at Room “v” next to the nurses’ station. In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by failing to ensure all staff had current CPR training as per hospital policy for 6 (S3MHT, S4LMSW, S5LPN, S7PA, S8MHT, S9HK) of 8 (S2DON, S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, S8MHT, S9HK) personnel records reviewed. Findings: Review of the hospital’s policy titled “HR-003: Personnel Files”, revised 08/2020, revealed in part, The personnel file should include, but not necessarily be limited to, the following: Licensure/Certifications: -Copy of Professional Licensure; -Verification of Professional Licensure; -Education Verification; -Current CPR Certification; -Current CPI Certification. Review of S3MHT, S4LMSW, S5LPN, S7PA, S8MHT, S9HK’s personnel records failed to reveal current CPR certification. In multiple interviews on 10/29/2024 at 12:52 p.m. - 2:01 p.m. S1CEO verified there was no documentation of current CPR certificates in the above stated personnel records. S1CEO verified all employees are required to have CPR training.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44763 Based on observation, record review, and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment. Findings: Review of the hospital’s policy titled “IC-300: Cleaning, Disinfection and Sterilization”, revised 12/2020, revealed in part, Routine Cleaning: Area: Work Surfaces Procedure: To ensure worksites are maintained in a clean and sanitary condition and to implement an appropriate method of decontamination based upon the location, type of surface to be cleaned, type of contaminant present, and tasks or procedures being performed in the area. Observation on 10/28/2024 at 1:21 p.m. - 1:40 p.m. of the outpatient facility revealed there were 18 out of 62 chairs throughout the 5 group rooms that the leather covering was peeling off the seat and/or back of the chair and could not be disinfected. In an interview during the observation S1CEO verified the above stated findings.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the infection control preventionist failed to provide competency-based training and education of hospital personnel and staff on the practical applications of infection prevention and control guidelines, policies, and procedures. This deficient practice was evidenced by failing to have documentation of skill competencies that included infection control practices for 7 (S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, S8MHT, S9HK) of 7 (S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, S8MHT, S9HK) personnel records reviewed for staff that were responsible for cleaning of the outpatient facility. Findings: Review of S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, and S8MHT’s personnel records failed to reveal documentation of skill competency that included infection control practices. Review of S9HK’s personnel record failed to reveal documentation of skill competency for the position of housekeeper. In an interview on 10/29/2024 at 9:36 a.m. S1CEO verified all staff were responsible to clean the outpatient facility when there was no housekeeper. In an interview on 10/29/2024 at 12:52 p.m. S1CEO stated every position has a skill competency required. In an interview on 10/29/2024 at 1:47 p.m. S1CEO verified the skill competencies for the MHTs/drivers, therapists, and nurses of the outpatient facility did not include infection control practices. In an interview on 10/29/2024 at 2:01 p.m. S1CEO verified S9HK’s personnel record did not include documentation of skill competency for the position of housekeeper.”

“Director of Nursing Qualifications CFR(s): The director of psychiatric nursing services must be a registered nurse who has a master’s degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to have a qualified director of psychiatric nursing services. This deficient practice was evidenced by the director of psychiatric nursing services failed to have a master’s degree in psychiatric or mental health nursing or be qualified by education and experience in the care of the mentally ill. Findings: Review of S2DON’s personnel record revealed a hire date of 01/23/2023. Review of S2DON’s application and resume failed to reveal prior experience of psychiatric nursing or care of the mentally ill. Further review of S2DON’s personnel record revealed an Associate of Science in Nursing Degree. In an interview on 10/29/2024 at 2:26 p.m. S2DON verified he has an associate’s degree in nursing. S2DON verified he does not have a master’s degree. S2DON stated he was an employee at ‘hospital A’ in the nineties. He then stated from 1995-2001. S2DON stated while he was employed there he did some shifts in the adult psychiatric unit. S2DON stated he was a pool nurse and was pulled to the psychiatric unit during that time. S2DON stated while he was employed at ‘hospital B’ in 2010-2012 he was the House Supervisor. S2DON stated he was always going to the psychiatric unit as the house supervisor. S2DON verified he had not been employed by a psychiatric hospital or psychiatric unit prior to being hired as the DON at this psychiatric hospital. S2DON verified this hospital had not implemented a contract with a nurse with a Master’s degree in Psychiatric Nursing.”