Brook Lane Health Services

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43028 Based on a review of 10 medical records, policy, procedure, and other pertinent documents, it was determined that the hospital failed to: (1) provide the patients and/or their representatives with the required Federal rights contained within the Patient Rights condition and the behavioral health rights as required by Maryland State law, (2) inform the patient and/or patient’s representative of the address and phone number for the Office of Health Care Quality (OHCQ, Maryland’s State Agency), (3) ensure a locked door seclusion was ordered by a provider for a maximum of 2 hours for an individual who was between 9 and 17 years of age, (4) ensure a face-to-face assessment was completed within 1 hour of the initiation of restraint/seclusion for 1 patient, and (5) ensure the Registered Nurse (RN) consulted the provider who was responsible for the care of 1 patient following completion of the face-to-face assessment. The cumulative effect of these failures created an environment of care that did not protect or promote the rights of patients in the hospital and resulted in a finding of the hospital being out of compliance with the Condition of Participation of Patient Rights. The findings included: (1) The hospital failed to provide the patients and/or their representatives with the required Federal rights contained within the Patient Rights condition and the behavioral health rights as required by Maryland State law. Cross reference tag A-0117. (2) The hospital failed to inform the patient and/or patient’s representative of the address and phone number for the Office of Health Care Quality (OHCQ, Maryland’s State Agency). Cross reference tag A-0118. (3) The hospital failed to ensure a locked door seclusion was ordered by a provider for a max of 2 hours for an individual who was between 9 and 17 years of age. Cross reference tag A-0171. (4) The hospital failed to ensure a face-to-face assessment was completed within 1 hour of the initiation of restraint/seclusion for 1 patient. Cross reference tag A-0178. (5) The hospital failed to ensure the Registered Nurse (RN) consulted the provider who was responsible for the care of 1 patient following completion of the face-to-face assessment. Cross reference tag A-0182.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 43028 This STANDARD was not met as evidenced by: Based on a review of policy, procedure, and other documentation, it was determined that the facility failed to provide the patients and/or their representatives with the required notice of their Federal rights contained within the Patient Rights condition and the behavioral health rights as required by Maryland State law. The findings included: On days 1 through 5 of the onsite survey, the surveyor reviewed policy, procedure, and other various documents. A review of the Adult and Tween Welcome Packets showed that admission information provided to the patient and/or the patient’s representative did not include the behavioral health rights required by Maryland State. It did include a document created by the Behavioral Health Administration (BHA) that included involuntary/voluntary patient rights; however, this document was not inclusive of all these sections were not inclusive of the Federal rights contained within the Patient Rights condition or the behavioral health rights items required by Maryland State law as of 2019. During the exit conference on day 5 of the onsite survey, hospital leadership stated the information was contained in a document that perhaps was not provided during the onsite survey. The surveyor informed the hospital that they could provide any additional documentation that would contain the address and phone number for OHCQ to the surveyor via email. Following the onsite survey, the surveyor received and reviewed a document titled “The Patient’s Bill of Rights.” This document contained sections titled: - Information Disclosure - Choice of Providers and Plans - Participation in Treatment Decisions - Respect and Nondiscrimination - Confidentiality of Health Information - Complaints and Appeals These sections were not inclusive of the Federal rights contained within the Patient Rights condition or the behavioral health rights items required by Maryland State law as of 2019.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 43028 Based on a review of policy, procedure, and other documentation, it was determined that the facility failed to inform the patient and/or patient’s representative of the address and phone number for the Office of Health Care Quality (OHCQ, Maryland’s State Agency). The findings included: On days 1 through 5 of the onsite survey, the surveyor reviewed policy, procedure, and other various documents. A review of the Adult and Tween Welcome Packets showed that admission information provided to the patient and/or the patient’s representative did not include the address and phone number for OHCQ. During the exit conference on day 5 of the onsite survey, hospital leadership stated the information was contained in a document that perhaps was not provided during the onsite survey. The surveyor informed the hospital that they could provide any additional documentation that would contain the address and phone number for OHCQ to the surveyor via email. Following the onsite survey, the surveyor received and reviewed a document titled “The Patient’s Bill of Rights.” This document contained a section titled “Complaints and Appeals” which stated in part, “ ...You may contact The Joint Commission at [number] or CMS (Centers for Medicare and Medicaid Services) at [number].” There was no address or phone number for OHCQ listed on the piece of documentation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 43028 Based on a review of 10 medical records, policy, procedure, and other pertinent documents, it was determined that the facility failed to ensure a locked door seclusion was ordered by a provider for a maximum of 2 hours for an individual who was between 9 and 17 years of age. The findings included: On days 1 through 5 of the onsite survey, the surveyor reviewed policy and procedure. The surveyor reviewed the policy titled “Restraint and Seclusion.” Section “Seclusion Process” stated, “3. The order for seclusion needs to be dated and timed by the provider and should not exceed more than 1 hour for a client under the age of 9, 2 hours for client’s 9-17 and 4 hours for clients 18 and older.” On day 3 of the onsite survey, the surveyor reviewed Patient #3’s (P3) medical record. P3 was an individual who was between the ages of 9 and 17 at the time of the onsite survey. Documentation revealed that a provider entered an order for locked door seclusion for 4 hours into P3’s medical record. Medical record documentation of this physical hold/seclusion episode received following the onsite survey stated, “Most Recent Violent Restraint Order: None.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 43028 Based on a review of 10 medical records, policy, procedure, and other pertinent documents, it was determined that the facility failed to ensure a face-to-face assessment was completed within 1 hour of the initiation of restraint/seclusion for 1 patient. The findings included: On days 1 through 5 of the onsite survey, the surveyor reviewed policy and procedure. The surveyor reviewed the policy titled “Restraint and Seclusion.” Section “Seclusion Process” stated, “When a patient is placed in seclusion a one hour face to face client evaluation must be conducted in person by a specialty trained registered nurse (RN). If a client’s violent or self-destructive behavior resolved and the seclusion intervention is discontinued before the practitioner arrives to perform the one hour face to face evaluation, the RN is still required to see the patient face to face and conduct the evaluation within one hour after the initiation of the intervention.” On day 3 of the onsite survey, the surveyor reviewed Patient #3’s (P3) medical record. P3 was again placed into a physical hold for approximately 20 minutes, given intramuscular medication (IMs) and transitioned into locked door seclusion approximately 43 days after their admission for provoking a peer, cursing, and attempting to assault others. P3 remained in locked door seclusion for approximately 30 minutes. A review of the locked door seclusion documentation revealed that the face-to-face assessment was completed approximately 1 hour and 7 minutes after the initiation of the interventions.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 43028 Based on a review of 10 medical records, policy, procedure, and other pertinent documents, it was determined that the facility failed to ensure the Registered Nurse (RN) consulted the provider who was responsible for the care of 1 patient following completion of the face-to-face assessment. The findings included: On days 1 through 5 of the onsite survey, the surveyor reviewed policy and procedure. The surveyor reviewed the policy titled “Restraint and Seclusion.” Section “Seclusion Process” discussed the RN performing the face-to-face assessment within an hour and the required elements of a face-to-face assessment; however, it did not state that the provider responsible for the care of the patient should be notified after the completion of the face-to-face assessment. On day 3 of the onsite survey, the surveyor reviewed Patient #3’s (P3) medical record. P3 was placed into a physical hold for approximately 2 minutes and transitioned into locked door seclusion approximately 34 days after their admission for banging their head and hitting staff. P3 remained in locked door seclusion for approximately 55 minutes. A review of the locked door seclusion documentation revealed that the face-to-face assessment was completed approximately 40 minutes after the initiation of the interventions. There was no documentation indicating that the responsible provider was consulted following the completion of the face-to-face assessment. P3 was again placed into a physical hold for approximately 20 minutes, given intramuscular medication (IMs) and transitioned into locked door seclusion approximately 43 days after their admission for provoking a peer, cursing, and attempting to assault others. P3 remained in locked door seclusion for approximately 30 minutes. A review of the locked door seclusion documentation revealed that the face-to-face assessment was completed approximately 1 hour and 7 minutes after the initiation of the interventions. There was no documentation indicating that the responsible provider was consulted following the completion of the face-to-face assessment.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 48657 Based on a review of the document and staff files, the facility failed to ensure that Staff #9 (S9), a Nurse Practitioner (NP), practiced with a valid and current Controlled Dangerous Substance (CDS) license. Failure to ensure that practitioners maintain valid and current credentials and licensure represents a breakdown in the facility’s medical staff oversight and credentialing process. This poses a risk to patient safety and violates regulatory requirements for the accountability of the medical staff to the governing body. Findings include: A review of S9’s credentialing files revealed that S9’s Controlled Dangerous Substances (CDS) license expired on February 28, 2025. There was no evidence of renewal on file. The facility’s Medical Staff Bylaws, revised February 2025, require verification of a DEA-controlled drug licensure as assigned to any provider who prescribes DEA-controlled drugs.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 48657 Based on a review of medical staff files, Medical Staff Bylaws, and other documents, it was determined that the facility failed to ensure that medical staff privileges were current and valid for S14, a psychiatrist who also served as the interim Chief Medical Officer (CMO). This resulted in the individual providing administrative oversight to facility’s providers without current delineation of privileges. This failure poses a risk to patient safety and violates regulatory requirements for the accountability of the medical staff to the governing body. Findings included: A review of S14’s credentialing file revealed that the last delineation of privileges was approved on November 23, 2022, with an expiration on November 29, 2024. No documentation was found in the file to indicate renewal or reappointment of privileges beyond the expiration date of November 29, 2024. The nurse surveyor was given updated privileges for S14 on April 3, 2025. The review of this document determined that temporary privileges were issued on March 18, 2025. The Board of Directors is not scheduled to meet until April 23, 2025, at which time a decision will be made for Medical Staff Privileges. The facility’s Medical Staff Bylaws, revised February 2025, require that privileges be renewed every two years.”