Torrance State Hospital

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 36639 Based on a review of the facility’s Emergency Preparedness (EP) Plan, it was determined the facility failed to provide a plan for the role of the facility under a waiver declared by the Secretary of the Department of Health. Findings include: 1. Interview and documentation review on January 30, 2024, at 9:00 a.m., revealed procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials, was not included in the EP plan. Interview with the Safety Manager on January 30, 2024 at 9:00 a.m. confirmed the EP plan lacked a written plan of the facility’s role during a waiver declared by the Secretary of the Department of Health.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 36639 Based on a review of the facility’s Emergency Preparedness (EP) Plan, it was determined the facility failed to fully develop and maintain an EP program for training and testing staff. Findings include: 1. Interview and documentation review on January 30, 2024, at 9:10 a.m., revealed the facility’s EP training and testing policy failed to indicate what type and recurrence of training and testing is required to demonstrate staff knowledge of emergency procedures. Interview with the Safety Manager on January 30, 2024, at 9:10 a.m., confirmed the facility performed required EP training and testing, however the EP training policy does not indicate what the requirement is.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 36639 28 Pa. Code § 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. § 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on observation and interview, it was determined the facility failed to obtain approval from the Division of Safety Inspection, Plan Review Department prior to conducting rehabilitation work in one instance, affecting one of three floors. Findings include: 1. Observation January 31, 2024, at 12:55 p.m. revealed that work was being performed to the ceiling of the entire first floor. Plan Review was not notified and there were no state approved plans on-site. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed that Plan Review had not been contacted prior to beginning the ceiling rehabilitation project.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in three instances, affecting five of eight smoke compartments. Findings include: 1. Observation on January 31, 2024, revealed the following vertical opening enclosure deficiencies: a) 11:40 a.m., there was an unsealed conduit penetration above the door inside pipe chase closet 257; b) 12:32 p.m., there were two large, unsealed penetrations in the concrete deck above, in basement storage room 0053; c) 12:45 p.m., there were multiple unsealed pipe penetrations in the concrete deck above, in basement closet 0025 A, off the kitchen storage room. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed vertical opening enclosure deficiencies.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments. Findings include: 1. Observation on January 31, 2024, at 12:38 p.m., revealed the facility failed to maintain the required one-hour fire rating for hazardous area enclosures in storage room 0021A. There were multiple unsealed penetrations in the walls. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed hazardous area enclosure deficiency.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to install required fire alarm system components in one instance, affecting the entire facility. Findings include: 1. Observation on January 30, 2024, at 10:20 a.m., revealed there was no automatic smoke or heat detector at the main fire alarm control panel on the first floor. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed there was not a smoke detector at the main fire alarm panel.”

“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: 41378 Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in one instance, affecting one of eight smoke compartments. Findings include: 1. Observation on January 31, 2024, at 10:45 a.m., revealed the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic fire alarm system. There was a large section of the ceiling missing in the activities air handler room in the basement. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed automatic fire alarm system deficiency.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to maintain smoke detection systems in three instances, affecting one of eight smoke compartments. Findings include: 1. Observation on January 31, 2024, revealed the following smoke detection deficiencies: a) 10:20 a.m., the smoke detector outside the linen room in the basement was hanging by its wires; b) 10:21 a.m., there were three ceiling tiles missing inside the linen room, which may affect smoke detection; c) 10:30 a.m., the smoke detector near room 0045, in the basement, was covered with plastic and tape. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the smoke detection deficiences.”

“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: 39523 Based on review of documentation, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting the entire building. Findings include: 1. Document review on January 30, 2024, revealed the facility lacked documentation for the following: a) 8:30 a.m., a five-year internal pipe inspection; b) 8:32 a.m., documentation that water pressure gages throughout the building (dated 2015) have been changed or recalibrated within the last five years. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the facility lacked the sprinkler system documentation at the time of the survey. 2. Observation on January 31, 2024, revealed the following automatic sprinkler system deficiencies. The facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system in the following locations: a) 11:12 a.m., there was a large, unsealed gap where the wall meets the ceiling in the dentist’s office; b) 11:17 a.m., there was an unsealed drainpipe in the ceiling of the closet in nurse-station 135; c) 11:28 a.m., there was a large, unsealed gap where the wall meets the ceiling in storage room 241; d) 11:30 a.m., there was a large, unsealed gap where the wall meets the ceiling in the social services office 243; e) 11:55 a.m., there was a large hole in the ceiling of basement office 0055; f) 11:58 a.m., there were multiple missing ceiling tiles in storage/pump room 0054. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed automatic sprinkler system deficiencies.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one instance, affecting one of three floors. Findings include: 1. Observation on January 30, 2024, at 11:10 a.m., revealed there was no Class K fire extinguisher in the canteen kitchen on the ground floor. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the lack of a Class K extinguisher in the kitchen within 30 feet of the cooking equipment.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to maintain corridor walls in one instance, affecting one of eight smoke compartments. Findings include: 1. Observation on January 31, 2024, at 11:35 a.m., revealed holes in the corridor wall outside of Med Room 253, on the second floor. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the unsealed penetrations in the corridor wall.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of eight smoke compartments. Findings include: 1. Observation on January 31, 2024, at 10:15 a.m., revealed one of the 0001 smoke barrier doors was missing in the basement. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the missing smoke barrier door.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of eight smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code...19.5.1.1, NFPA 101. Findings include: 1. Observation on January 31, 2024, at 10:21 a.m., revealed an open electrical junction box above HVAC unit AHU2 in the basement HVAC Room. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed electrical wiring deficiency.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of eight smoke compartments. Findings include: 1. Observation on January 30, 2024, at 10:07 a.m., revealed an outlet within six feet of a sink was not GFCI protected in the canteen storage room on the first floor. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the outlet was not GFCI protected.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, affecting the entire facility. 6.4.1.1.16.2, NFPA 99 Findings include: 1. Observation on January 31, 2024, at 1:47 p.m., revealed the emergency generator remote manual stop station, located outside of the generator enclosure, was not connected. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the remote manual stop switch outside of the generator enclosure was not connected.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 36639 Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility. Findings include: 1. Observation on January 31, 2024, at 1:50 p.m., revealed the only remote generator annunciator was located in a first floor nurse station that is not readily observed due to the unit being closed for renovations. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the remote annunciator was not readily observed by facility personnel.”

“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: 39523 Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months. Findings include: 1. Review of documentation on January 30, 2024, revealed the facility lacked documentation verifying that the following items were performed in the last twelve months: a) 9:40 a.m., the annual fuel quality test; b) 9:45 a.m., the three year four hour test. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the required annual generator testing documentation was not available at the time of the survey.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eight smoke compartments. Findings include: 1. Observation on January 31, 2024, at 10:19 a.m., revealed a microwave and a refrigerator plugged into a power strip in the basement HVAC room. Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed electrical wiring systems and equipment deficiency.”

“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: 42809 Based on review of facility documentation, and staff interview (EMP), it was determined the facility failed to ensure that all hospital departments and services, including those services furnished under contract or arrangement, were included in the QAPI program. Findings include: On January 9, 2024, at 11:30 PM, review of the facility’s Governing Body Bylaws, dated April 26, 2018, revealed: “ ... Performance Improvement activities are interrelated and cover the full spectrum of the facility’s operations and services ... “. During interview with EMP1, on January 9, 2024, at approximately 10:00 AM, EMP1 revealed that services such as radiology and laboratory services are provided through a contractual arrangement with external providers. During review of the facility’s QAPI minutes on January 9, 2024, at approximately 2:00 PM, no evidence was identified to demonstrate that services provided under contract were included in the QAPI program. During an interview on January 9, 2024, at approximately 2:00 PM, EMP4 confirmed that the facility’s QAPI program does not include services furnished under contract.”

“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: 45574 Based on a review of facility documents, credential files (CF) and employee interview (EMP), it was determined that the facility failed to ensure the timely reappraisal of its medical staff in seven of 10 credential files reviewed (CF1, CF2, CF3, CF4, CF6, CF7 and CF10). Findings include: On January 8, 2024, a review of the “Torrance State Hospital Governing Body Bylaws” dated 7/26/2023 reviewed, “Article VII- Specific Responsibilities and Authority of Governing Body Members in the chain of Command: D. The Chief Executive Officer, who is appointed by the Secretary of Human Services, is the Governing Body’s Onsite Representative at the facility level. 5. Establishes and maintains an organized Medical Staff body whose members meet the standards for credentialing and privileging. 6. Approves all appointments and reappointments to the organized Medical Staff body. Article VIII- Integration of Medical Staff and Governing Body: 6. The CEO approves all appointments and reappointments to the Medical Staff body. Article IX- Responsibilities of the Medical Staff: A. The responsibilities of the Medical Staff as they relate to the Governing Body are as follows: 1. Recommend to the CEO appointment or reappointment of qualified individuals to the Medical Staff, as well as renewal or change of clinical privileges.” On January 10, 2024, a review of CF1 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 28, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 11, 2023. Thus, the clinical privileges for CF1 were lapsed for 72 days. On January 10, 2024, a review of CF2 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 24, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 11, 2023. Thus, the clinical privileges for CF2 were lapsed for 72 days. On January 10, 2024, a review of CF3 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 17, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 11, 2023. Thus, the clinical privileges for CF3 were lapsed for 72 days. On January 10, 2024, a review of CF4 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 26, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 1, 2023. Thus, the clinical privileges for CF4 were lapsed for 62 days. On January 10, 2024, a review of CF6 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 12, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 1, 2023. Thus, the clinical privileges for CF6 were lapsed for 62 days. On January 10, 2024, a review of CF7 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 28, 2023. The reappointment application was approved by the Credentialing Committee, and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 1, 2023. Thus, the clinical privileges for CF7 were lapsed for 62 days. On January 10, 2024, a review of CF10 revealed that the approved credential term was July 1, 2023 to June 30, 2025. The reappointment application was completed by the applicant and submitted on July 26, 2023. The reappointment application was approved by the Credentialing Committee and the Medical Executive Committee on August 16, 2023. The Chief Executive Officer (on site governing body) signed the “Privileging Action Form” on September 1, 2023. Thus, the clinical privileges for CF10 were lapsed for 62 days. On January 10, 2024. between 9:45 AM and 11:00AM, the above findings were confirmed by EMP12.”

“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: 45574 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to document 15 minute observations and continual visual observation (CVO) for four of eight medical records reviewed (MR2, MR4, MR6, MR8). Findings include: On January 9, 2024, a review of the facility’s “Policy 25-32: Policy/Procedure for Psychiatric Medical Record Documentation” dated 11/03/2022, revealed, “I. Policy Statement: A. A complete and accurate medical record must be maintained for each individual who is treated at Torrance State Hospital. The quality of the medical record depends, in part, on the timeliness, meaningfulness, authentication and legibility of the informational content documented by all those authorized to make entries in it. IV. Responsibilities: K. When making record entries, continuous entries are necessary in order to minimize problem of improper chronological sequence and to avoid suspicions relative to inappropriate alterations in the record ...” On January 9, 2024, a review of the facility’s “Policy 125-31: Procedures for Utilization of Level One 1:1” dated July 21, 2022, revealed, “V. General Procedures: The Treatment Plan Must Specify: I. ...In addition, frequency of documenting on the Level One 1:1 Patient Observation Record will be every 15 minutes for CVOVI. Procedures for Increased Levels of Observation: 3. Observations times, made at prescribed intervals, are to be documented on the Patient Observation Record by the assigned staff.” On January, 9, 2024, a review of MR2 was completed. MR2 was ordered every 15 minute observations by the staff. Fifteen minute observations were not documented on the Special Observation record for the following time periods: December 9, 2023, from 12:00 AM to 6:45 AM December 10, 2023, at 10:00AM and 10:15 AM December 11, 2023, at 11:00 AM, 11:15 AM, 11:30 AM, and 11:45 AM December 12, 2023, from 12:00 AM to 6:45 AM December 13, 2023, at 10:00 AM and 10:15 AM December 14, 2023, at 10:15 AM On January 9, 2024, a review of MR4 was completed. MR 4 was ordered every 15 minute observations by the staff. Fifteen minute observations were not documented on the Special Observation record for the following time periods: November 29, 2023, at 6:30 AM November 29, 2023, at 6:00 PM and 6:15 PM December 2, 2023, at 6:00 PM and 6:15 PM December 3, 2023, at 11:00 PM, 11:15 PM, 11:30 PM, and 11:45 PM December 4, 2023, at 6:00 AM and 6:15 AM December 5, 2023, at 12:30 PM and 12:45 PM On January 9, 2024, a review of MR6 was completed. MR 6 was ordered every 15 minute observations by the staff. There was no documentation of the ordered 15 minute observations in the medical record (Special Observation Record). The Special Observation record was requested from EMP3. On January 9, 2023, EMP3, at approximately 1:45 PM, stated that the observation record/documentation could not be located. On January 9, 2024, a review of MR8 was completed. MR 8 was ordered every 15 minute observations by the staff. Fifteen minute observations were not documented on the Special Observation record for the following time periods: December 1, 2023, at 11:15 AM, 11:30 AM, and 11:45 AM December 2, 2023 from 12:00 AM to 6:45 AM; and at 10:00 AM and 10:15 AM On January 9, 2024, a review of MR8 an order for Constant Observation of 2:1. There was no documentation of MR8s behavior and location on the “Level I Observation Record” for the following time periods: December 15, 2023, 7:00 AM, 7:30 AM, 9:00 AM, 9:30 AM, 11:00 AM, 11:30 AM, 1:00 PM, and 1:30 PM. The above findings were confirmed on January 9, 2024, between 12:04 PM and 1:45 PM, by EMP3.”

“IC PROFESSIONAL DOCUMENTATION CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 46390 Based on review of facility documentation, and staff interview (EMP), it was determined the that the Infection Control coordinator failed to provide documentation of attendance at the Infection Control Committee meetings for five of twelve meeting minutes reviewed. Findings include: A review, on January 9, 2024, at 11:50 A.M., of the facility’s policy, “Torrance State Hospital Policy/Procedure for Infection Control Committee, Policy NO. 20-01, review date March 28, 2023, “ revealed ...I.V. RESPONSIBILITIES A. Committee members consist of a general physician as chairperson, Infection Control coordinator (represents Employee Health) and staff representatives ... . “ During an interview on January 9, 2024, at 12:10 P.M., EMP3 confirmed that the Infection Control coordinator name was not present on the sign in sheets or in the minutes for the following dates: June 1, 2023, July 27, 2023, August 31, 2023, October 26, 2023, and November 30, 2023.”