Allegiance Behavioral Health Center of Plainview

“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: 47893 Based on facility documents, observation and staff interview, the facility failed to ensure a patient’s right to receive care in a safe setting when patients were not provided a means to contact facility staff when in their bedroom suite, including bathroom; also, bathrooms located in patient bedrooms were not large enough to accommodate a patient in a wheelchair. Findings were: Review of an invoice, revealed an online order for a wireless calling system with 20 alert call buttons and display for Nurses Station was purchased, and shipped to the Administrator on 3/18/26. Review of an email communication dated 5/20/26, from a corporate executive, entitled “Projects,” documented in part, “... the Plainview project is expected to start in the next 90 days. It will include painting, door and wall repairs, furniture upgrades, and ligature risk remediation. I expect the project will take approximately 3 weeks to complete ...” Observation on 5/20/26, at the time of the facility tour, between 11:50 AM and 1:00 PM revealed the facility had no call system with which patients could contact staff for assistance while in the bedroom suite, including the bedroom bathroom. The facility has 10 patient rooms, 20 beds. In an interview at the time of the facility tour, Staff #1 (Administrator) stated a ligature-free call system had been purchased but not installed. In interview at the time of the tour on 5/20/26, Staff #1 (Administrator), confirmed there was not a means by which the patient could contact staff for assistance while in their bedroom/bathroom, and stated that all patients were identified as at risk for falls. Currently, there is one bedroom (accommodates 4 persons) with a bathroom large enough to accommodate a patient with a wheelchair. Patients not assigned to this room, with mobility issues, use a toilet and shower room located in the hallway. One patient is permitted to use the toilet/shower at a time, and must be supervised by staff.. Staff #1 confirmed the showers in patient rooms are blocked off, fixtures removed, and reported there may be room to expand the toilet area in these rooms”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 47893 Based on review of facility documents and staff interview, the facility failed to ensure adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program for 2 dayshifts in which patient falls occured (Patient #1 on 3/1/26 and Patient #4 on 4/7/26). Findings were: Review of facility policy for Admission Assessment Management - Close Observation, documented in part, “ ... Levels of Observation: ... One-to-One Observation - The staff member must always observe the patient by remaining at an arm’s length distance from the patient.” Review of the acuity tool provided by the facility administrator revealed, in part, quantities of registered nurses (RNs), licensed practical nurses (LPNs) and certified nurse assistants (CNAs)/mental health technicians (MHTs) required to support the patient population, dependent on the shift, - Census of “1 to 20” patients (Day Shift) required 1 RN; and - Census of “7 to 16” patients (Day Shift) required 1 LPN; census of “17 to 20” patients required 2 LPNs; and - Census of “13 to 18” patients (Day Shift) required 3 MHTs; a census of “19 to 20” patients required 4 MHTs. 1) Review of the physician discharge summary for Patient #1 documented, in part, “ ... (History of Present Illness -HPI): [Patient #1] is a 76-year-old female ... She has been requiring one-to-one supervision due to high risk for falling ... She has been exhibiting poor impulse control and standing without assistance despite safety concerns ... The patient has been trying to walk dangerously ... Hospital Course and Progress *Patient condition initially, during treatment, & at discharge: ... During her course of stay, patient was agitated, falls reported ... Patient was placed on 1:1 level of observation. Patient had a fall on 3/1/26 and was transferred to emergency room (ER) ... for further treatment related to fracture of femur ...” Review of the daily staffing schedule dated 3/1/26, documented (Day Shift: 7 AM to 7 PM with a census of 18 patients) 3 RNs were on duty for the first three hours of the shift; 2 RNs on duty for the remaining 9 hours. 0 LPNs were scheduled or documented as on duty. Two MHTs were scheduled (one was on 1:1 with Patient #1). According to their staffing grid, the facility was short by 1 LPN and 2 MHTs. 2) Review of the medical record for Patient #4 revealed a narrative nursing note dated 4/7/26 at 12:33 PM and documented in part, “ ... MHT called for help that [patient #4] was on the floor. Nurse assess patient who stated severe pain to upper left hip. Patient yelling “Don’t touch. I can not get up.” Patient assisted off floor and into wheelchair. [NP] notified and order for X-ray of left hip and CT of head obtained. Patient taken to X-ray at 8:15 AM with MHT escort. MHT back on unit at 9:15 AM stating patient’s hip was broken and radiology suggested patient be transferred to ER from Radiology ...” Patient #4’s “Physician Progress Note,” dated 4/7/26 documented in part, “ ... Provider Assessment: ... Pt had a fall at 8:03 AM Pt. complaint of Left hip pain and report pt hit his head Pt sent for head CT and XR of Left hip XR reveals pt fractured left hip and is being transferred to ER ...” Review of a Midnight Census Report dated 4/7/26 documented there were 15 patients. A census of 15 patients required 1 RN, 1 LPN, and 3 CNAs/MHTs. Staffing was 1 RN and 2 MHTs on duty; according to their staffing grid, the facility was short by 1 LPN and 2 MHTs. In an interview on the morning of 5/20/26, Staff #1 (Administrator) acknowledged the staffing of the unit and reported a current census of “15 patients; all patients were on routine (every 15 minute) observation level.” Staff #1 reported she had recently hired staff.”

“A life safety code LSC survey was conducted on site on 04/03/2025. An entrance conference was held for the hospital ’ s CEO, Quality Director, and Plant Ops Director on the morning of 04/03/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. An LSC exit conference was conducted on 04/03/2025 in the hospital. In attendance were the CEO, Quality Director, and Plant Ops Director . The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 30174 2. VERIFY AND DOCUMENT THAT THE FACILITY IS IN COMPLIANCE WITH THE STATE LICENSING RULES WHICH REQUIRE THAT A “FIRE ALARM CONTROL PANEL” BE INSTALLED AT A “CONTINUOUSLY ATTENDED (24 HOUR) LOCATION”. PHLR 2004, §134.122 (d)(5)(M)(i). “A fire alarm control panel (FACP) shall be installed at a continuously attended (24 hour) location. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and is capable of indicating both visual and audible alarm, trouble and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP.””

“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: 30174 1. GENERATOR “GEN SET” MUST BE POWERED FROM THE LIFE SAFETY BRANCH OF THE EES - During the Re-Survey the Facility was not able to confirm compliance and will need to engage the services of a professional Electrical Engineer or Master Electrician to verify in writing the current status for whether the required “GEN-SET” is properly installed and powered from the LIFE SAFETY BRANCH of the Essential Electrical System. The required components of the GEN-SET include the following: A light with a charger to provide 90-minute battery backup lighting (on LIFE SAFETY BRANCH). A red receptacle (on LIFE SAFETY BRANCH). NFPA 99, 2012: 6.4.2.2.3.2. The life safety branch shall supply power for the lighting, receptacles, and equipment as follows: (4) Generator Set Location as follows: (a) Task illumination (b) Battery charger for emergency battery-powered lighting unit(s) (c) Select receptacles at the generator set location and essential electrical system transfer switch locations”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 36594 Based on review of facility documents and staff interview, the facility failed to ensure staff were trained and able to demonstrate competency in restraint and seclusion procedures as part of orientation when Staff #28, MHT, and Staff #32, agency RN, were working independently prior to training. Findings were: Review of the Daily Staffing Schedule revealed Staff #28, MHT [Mental Health Technician] worked the unit on 12/30/24, 12/31/24, 1/3/25, 1/4/25, and 1/6/25 with no indication Staff #28 was on orientation. On 1/7/25, the second day of the survey, the Staffing Schedule stated Staff #28 was on orientation. Staff #28, in an interview on 1/6/25, reported they received computer training regarding restraint and seclusion but there was no competency or hands-on training. Review of Staff #28’s personnel file revealed on-line training that included restraint and seclusion but no documented “Competency - Therapeutic Use of Seclusion & Restraints - CNA/MHT.” Review of the Daily Staffing Schedule revealed Staff #32, agency RN, worked the unit on 1/6/25 and 1/7/25. Review of Staff #32’s personnel file revealed no documented computer, competency, or hands-on restraint and seclusion training. Staff #2, CNO, in an interview on 1/7/25, reported Staff #28 was placed back on orientation because they had not received competency training related the prevention and use of restraint and seclusion. Staff #2 verified Staff #32 was working independently without completing training related to the prevention and use of restraint and seclusion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 36594 Based on review of facility documents and staff interview, the facility failed to ensure Staff #28 and #32, prior to working independently, demonstrated knowledge in: (i) techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. (ii) in the use of nonphysical intervention skills prior to working independently (iii) in choosing the least restrictive intervention based on an individualized assessment of the patient’s medical, or behavioral status or condition (iv) in the safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia) (v) in clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary (vi) in monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation (vii) the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. Findings were: Review of the Daily Staffing Schedule revealed Staff #28, MHT worked the unit on 12/30/24, 12/31/24, 1/3/25, 1/4/25, and 1/6/25 with no indication Staff #28 was on orientation. On 1/7/25, the Staffing Schedule stated Staff #28 was on orientation. Staff #28, in an interview on 1/6/25, reported they received computer training regarding restraint and seclusion but there was no competency or hands-on training. Review of Staff #28’s personnel file revealed on-line training that included restraint and seclusion but no documented “Competency - Therapeutic Use of Seclusion & Restraints - CNA/MHT.” Review of the Daily Staffing Schedule revealed Staff #32, agency RN, worked the unit on 1/6/25 and 1/7/25. Review of Staff #32’s personnel file revealed no documented computer, competency, or hands-on restraint and seclusion training. Staff #2, CNO, in an interview on 1/7/25, reported Staff #28 was placed back on orientation because they had not received competency training related the prevention and use of restraint and seclusion. Staff #2 verified Staff #32 was working independently without completing training related the prevention and use of restraint and seclusion.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36594 Based on review of medical records, review of facility documents, and staff interview, the facility failed to protect and promote each patient’s rights when the facility failed to: A. appropriately and effectively address voluntary requests for discharge at the facility when Patient #1 requested to be discharged and was detained beyond four hours without the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of filing the request for release and an application for court-ordered mental health services was not filed or obtained by 4 pm on the next succeeding business day (11/01/24). Cross-refer A0129. B. appropriately file an application for court-ordered mental health services for 1 of 3 patients reviewed for involuntary status when Patient #6 presented to the hospital on emergency detention on 09/19/24 but the facility neither released Patient #6 nor filed for court-ordered mental health services within 24 hours. Cross-refer A0129. C. notify 2 of 2 patients (Patient #1 and #9) of intent to detain nor document the reasons for the decision to detain when the facility decided to file for court-ordered mental health services. Cross-refer A0131 D. ensure each patient or his or her representative had the right to make informed decisions regarding his or her care when it is not specifically disclosed there are no physicians on-site at any time. Physicians only see patients via telemedicine services. Cross-refer A0131. E. ensure patients received care in a safe setting for 3 out of 14 inpatients reviewed when Patient #3, 5, and 7’s “Close Observation” sheets did not accurately reflect the physician’s current observation order. Cross-refer A0144.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. 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); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 30250 Based review of documentation and interviews, the facility is not in substantial compliance with the Condition of Participation of QAPI (Quality Assurance Performance Improvement) CFR 482.21 as evidence by failing to: 1. To take actions aimed at performance improvement, as evidence by failing to monitor 2 of 4 self-identified Performance Improvement Projects. The facility also failed after implementing other actions, to measure its success, and track performance to ensure that improvements are sustained. Cross-refer to A0283.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 28422 Based on a review of clinical records, facility documentation, credentialing files and an interview with staff, the facility failed to ensure that the medical staff operate under bylaws approved by the governing body, as evidenced by: *6 of 6 Medical Staff members did not live within the 60 minute distance specified in the bylaws. *3 of 3 patients did not receive a psychiatric evaluation within 24 hours, as specified in the bylaws. *2 of 4 active-staff physicians did not carry the required amount of liability coverage specified in the bylaws. Cross-refer to A0353”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 30250 Based review of documentation and interviews, the facility is not in substantial compliance with the Condition of Participation of Infection Prevention Control Abx Stewardship CFR 482.42, to have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, as evidence by failing to: 1. Ensure an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention. Cross-refer to A0748. 2. Use of antibiotics were optimized through an antibiotic stewardship program with appointed leadership of the antibiotic stewardship program. Cross-refer to A0760 and A0761. 3. Infection prevention and control problems were not being addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. Cross-refer to A0774. 4. Maintain a clean and sanitary environment when infection control issues were observed during tours of the facility. Cross-refer to A0750.”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 36594 Based on review of facility documents and staff interview, the facility failed to have adequate numbers of qualified professional and supportive staff when: A. the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site. (Cross refer A1691) B. the facility failed to provide adequate numbers of staff necessary under each patient’s active treatment program staffing is not based on acuity and there is only 1 RN available on nightshift. (Cross refer A1704)”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 36594 Based on review of medical records, review of facility documents, and staff interview, the facility failed ensure each patient were able to exercise their rights as evidenced by failing to: A. appropriately and effectively address voluntary requests for discharge at the facility when Patient #1 requested to be discharged and was detained beyond four hours without the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of filing the request for release and an application for court-ordered mental health services was not filed or obtained by 4 pm on the next succeeding business day (11/01/24).; and B. appropriately file an application for court-ordered mental health services for 1 of 3 patients reviewed for involuntary status when Patient #6 presented to the hospital on emergency detention on 09/19/24 but the facility neither released Patient #6 nor filed for court-ordered mental health services within 24 hours. Findings were: A. Review of the medical record for Patient #1 revealed they were admitted to the facility voluntarily on 10/30/24 at 7:40 pm. Patient #1 submitted a formal request to discharge on 10/30/24 at 10:53 pm. The nurse notified the psychiatrist of the request to discharge on 10/30/24 at 10:55 pm. The psychiatrist did not respond until 10/31/24 at 6:37 am, over 7 hours after the request for discharge, and reported to “change patient to involuntary status.” Although Patient #1’s application for court-ordered mental health services titled “Physician’s Certificate of Medical Examination for Mental Illness” stated it was signed on 11/01/24, this was not signed by the physician until 11/06/24 at 8:00 am and was not filed with the court until 11/06/24, 2 business days after the deadline of 4 pm on the next succeeding business day (11/01/24). In an interview on the morning of 11/06/24, Staff #2, CNO, reported there continues to be no physician on-site at their facility, everything is via telemedicine services. Staff #2 verified Patient #1 requested to be discharged, but the physician did not respond within 4 hours of the request and although the psychiatrist completed the psychiatric evaluation on 10/31/24 at 3:32 pm, the facility had no ability for a physician to see a patient in-person for an examination. In an interview on the afternoon of 11/06/24, Staff #1, CEO, reviewed the paperwork for Patient #1 and clarified the physician signed the “Physician’s Certificate of Medical Examination for Mental Illness” on 11/06/24 at 8:00 am. Staff #1, CEO, confirmed the physician did not respond to the request for discharge within 4-hours nor was an application for court-ordered mental health services filed nor obtained by 4 pm on the next succeeding business day (11/01/24). The facility held Patient #1 beyond the 4-hour right to be discharged, did not allow them the right to be seen in-person by a physician within 24 hours of request to be discharged, and held them for several days without filing the appropriate paperwork for court-ordered mental health services. Review of the facility-based policy titled “Patient Leaving Facility Against Medical Advice [AMA]” with an effective date of 07/01/2022 stated in part, “Procedure: ...If the request takes place when the attending psychiatrist is not present and available: -If present and available, the medical director or his/her designee shall be informed and shall evaluate the patient. -All means to convince the patient to stay until his/her attending psychiatrist is available shall be attempted. *If this is unsuccessful: -The mental status of the patient shall first be evaluated. If he/she is considered to be immediately dangerous to self, imminently dangerous to others or gravely disabled, the procedure for institution of 72-hour detention shall begin immediately. -If the patient is not considered any of the above, the attending psychiatrist or medical doctor (if the attending psychiatrist cannot be reached) shall be informed by telephone.” B. Review of the medical record for Patient #6 revealed they arrived to the facility on 09/19/24 at 6:50 pm on a warrant of apprehension and detention dated 09/19/24 at 1:33 pm that stated in part, “You are hereby commanded to take into custody [Patient #6] ... and immediately transport to [Facility] for a preliminary examination, as provided in the Texas Mental Health Code, SEC. 573.012 ...” Patient #6’s psychiatric evaluation completed 09/20/24 at 1:39 pm indicated admission status of “Voluntary” but stated in part, “Justification for 24-hour care - Patient has a psychiatric diagnosis indicated by the DSM-V diagnosis AND Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24 hr medical supervision due to acute decompensation. Treatment at a lower level of care would place the patient ‘AT RISK’: Yes Patient is gravely disabled due to inability to care for self, hallucinations, delusions, agitation, anxiety, depression, or other factors resulting in severe loss of functioning: Yes ...This patient requires hospitalization. This patient could not be adequately and appropriately treated in a less restrictive environment. I have based my decision on the above information ...” Patient #6’s medical record was reviewed with Staff #2, CNO, who reported the facility should have filed for court-ordered mental health services within 24-hours, on 09/20/24 by 1:33 pm, however, the facility did not file until 09/27/24, 5 business days after the original 24-hour warrant of apprehension and detention. Patient #6 was held at the facility without the appropriate paperwork from 09/20/24 at 1:33 pm until the facility filed on 09/27/24 at an unknown time, almost a full week.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36594 Based on review of documents and staff interview, the facility failed to: A. notify 2 of 2 patients (Patient #1 and #9) of intent to detain nor document the reasons for the decision to detain when the facility decided to file for court-ordered mental health services. B. ensure each patient or his or her representative had the right to make informed decisions regarding his or her care when it is not specifically disclosed there are no physicians on-site at any time. Physicians only see patients via telemedicine services. Findings were: A. Review of the medical record for Patient #1 revealed they were admitted to the facility voluntarily on 10/30/24 at 7:40 pm. Patient #1 submitted a formal request to discharge on 10/30/24 at 10:53 pm. Patient #1’s application for court-ordered mental health services was filed 11/06/24. There was no notification by physician of intent to detain nor documentation of the reasons for the decision to detain Patient #1. Review of the medical record for Patient #9 revealed they were admitted to the facility voluntarily on 10/30/24 at 4:45 pm. Patient #9’s application for court-ordered mental health services was filed 11/06/24. There was no notification by physician of intent to detain nor documentation of the reasons for the decision to detain Patient #9. In an interview on the afternoon of 11/06/24, Staff #2, CNO, confirmed there was no notification nor documentation of the reasons for the decision of intent to obtain a court order for further detention for Patients #1 and #9. B. Review of facility patient’s initial admission packet revealed two documents: -Document titled “Telemedicine Informed Consent” stated in part, “Telemedicine services involved the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. ...2. I understand that I will not be physically in the same room as my health care providers. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.” -Document titled “Informed Consent, Notice of Privacy Policy, and Notice Regarding complaints for Telemedicine Services” stated in part, “Telemedicine Physician Disclosures: I have been disclosed required disclosures about my provider whom shall provide telemedicine services: 1) I will be seeing [Physician #16] ... 2) the physician’s specialty is in Psychiatry ...” There is no written disclosure or signed acknowledgement by patients that a MD/DO [Doctor of Medicine or Osteopathy] is not present in the facility. In an interview the morning of 11/05/24, Staff #2, CNO, reported there have been no updates to the telemedicine disclosure statements.”

“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: 36594 Based on review of medical records and staff interview, the facility failed to ensure patients received care in a safe setting for 3 out of 14 inpatients reviewed when Patient #3, 5, and 7’s “Close Observation” sheets did not accurately reflect the physician’s current observation order. Findings were: Review of the medical record for Patient #3 revealed they were placed on fall precautions on 10/25/24 and bleeding precautions on 10/27/24. Patient #3’s Close Observation sheets for the day shift of 11/05/24 revealed no bleeding precautions marked. The Close Observation sheet for the day shift of 11/06/24 revealed fall and bleeding precautions were not checked. Suicide precautions were marked on Patient #3’s Close Observation sheet on the dayshift of 11/06/24, but were not ordered. Review of the medical record for Patient #5 revealed they were placed on risk for sexually acting out precautions [SAO] on 10/26/24 at 7:49 pm through the current survey. Patient #5’s Close Observation sheets for the day shifts of 11/05/24 and 11/06/24 revealed SAO was not marked as a precaution. Review of the medical record for Patient #7 revealed they were placed on suicide precautions on 10/27/24 through 11/01/24. Patient #7’s Close Observation sheets for the day shifts of 11/05/24 and 11/06/24 revealed suicide precautions were marked as a precaution, but were not ordered. The above was verified in an in interview on the afternoon of 11/06/24 with Staff #2, CNO, who reported they were monitoring these Close Observation sheets.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interview, the facility failed to take actions aimed at performance improvement, as evidence by failing to monitor 2 of 4 self-identified Performance Improvement Projects. The facility also failed after implementing other actions, to measure its success, and track performance to ensure that improvements are sustained. Findings were: Facility Quality Program stated in part, “2.4 PLAN-DO-CHECK-ACT (POCA) APPROACH TO PROCESS IMPROVEMENT The Plan, Do, Check, Act (POCA) cycle developed by Shewhart is the most familiar quality assurance approach to process improvement and is the methodology used by the BTQM system and its Committee. The POCA model has two (2) parts: A. Three (3) fundamental questions, which can be addressed in any order. B. The Plan-Do-Check-Act (POCA) cycle to test process revisions in actual hospital environment. The POCA cycle guides the test of a process revision to determine if the revision is an improvement. The two (2) parts of the POCA Model are combined to give a consistent workflow as shown below: 1) Setting the Target Expectation (PLAN - What Needs to Happen?) To improve anything, a target expectation must be set. The target expectation should be time-specific and measurable. It should also define whom it will include and what other processes it will affect. 2) Establishing Measures (PLAN - What is an Acceptable Score Range?) Develop a quantitative measure for the target expectation so that it can be determined if the process revision produces and improvement. 3) Selecting Process Revisions (DO - What are the Right Indicators?) Indicators represent the revised actions to be performed to reach the target expectation. These will be monitored in the form of questions that will be scored for compliance. Indicator ideas may come from experience of coworkers, from change concepts initiated by regulatory agencies, or by other creative critical thinking techniques. 4) Monitors are testing tools that are made up of indicators and are used to evaluate a process. Indicators are steps in a standing or revised process that are measured for compliance or improvement. The monitoring tool collect the necessary data needed to analyze the measures compared to the target expectation. 5) Implement and Update (ACT by Implementing Process Revisions & Updating the Policy) After the successful outcome of the monitoring activity of a process revision, the hospital can implement the new process and update the policy to the more successful procedure .... IV. QUALITY - Pl PROJECT 5.1 I&O - WITH A HYDRATION FOCUS ON GERIATRIC PATIENTS o Based on previous Pl project on THLOC - trend observed of the pts that were transferred out having decreased hydration. o What could have been done on the front end to minimize this? o Proper documentation/monitoring of intake/output? o Proper interventions implemented to prevent decline? o Establish, implement, and monitor processes and effects of focused efforts. 5.2 FALLS- WITH/WITHOUT INJURY o Monitor the number of staff on each shift o Monitor with the assistance of the DON that each Charge Nurse knows what is going on, on the unit always o Monitor Fall Program is being utilized o Monitor that all MHT/Nursing groups are being completed 5.3 PERSONAL BELONGINGS o Deep dive focus/look into patient belonging processes for needed modifications and/or compliance due to continued issues with some items not being logged on admission and/or patients not leaving with all belongings at discharge. 5.4 MED VARIANCES o Consistent Staffing o Monitor and review Psych Consents o Monitor and review Pharmacy o Monitor and review MAR o Monitor and review refill orders” Review of facility Quality Meeting Minutes for June 2024-October 2024 revealed the only of the 2 identified facility Performance Improvements Projects were being tracked. Only Medication Variance and Falls were currently being tracked and reported at Quality Meetings. Personal Belongings and Hydration were not being tracked and reported at the Quality Meetings. Review of facility Quality Meeting Minutes for June 2024-October 2024 also revealed that only employee health issues and the following health issues: UTIs, pneumonia, and skin issues were being tracked reported. In interview on 11/05/24, staff member #2 (Infection Control Coordinator) verified that they tracked urinalysis after antibiotic administration to ensure infections clear before discharge, and also complete culture and sensitivity testing on patients. However, the facility was unable to produce evidence that this information was coordinated with the QAPI program and pharmacy services. Staff member #2 was also asked if any Environment of Care Round were conducted to ensure the facility was cleaned effectively. Staff member #2 “Once a week, we enter what we find in a form, we check if housekeeping cleans the rooms and disinfect. Staff are required to disinfect the unit twice a day.” Staff member #2 verified this information was not being presented to quality in meetings. In interview with staff members #1 and 2 on 11/ 05/24, they verified that all infection control surveillance and data is not currently reported during QAPI meetings. The staff members also verified that currently the collected information has no measurable metric set to monitor the effectiveness of the surveillance date that is conducted, to evaluate if there need to be adjustments to ensure performance improvement. The facility The Plan, Do, Check, Act (POCA) Cycle includes, “4) Monitors are testing tools that are made up of indicators and are used to evaluate a process. Indicators are steps in a standing or revised process that are measured for compliance or improvement. The monitoring tool collect the necessary data needed to analyze the measures compared to the target expectation.” By failing to collect all data to QAPI, particularly related to Infection Control, the facility cannot effectively identify and set actions aimed at performance improvement. By failing to monitor 2 of 4 Performance Improvement Projects, they are unable to measure success for these projects and/or track performance to ensure that improvements are sustained.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 28422 Based on a review of clinical records, facility documentation, credentialing files and an interview with staff, the medical staff failed to enforce the bylaws to carry out its responsibilities: Findings were: Facility Medical Staff Bylaws state, in part (page 11): “4.2 ACTIVE STAFF 4.2 (a) Qualifications he Active Staff shall consist of practitioners, each of whom shall: (1) Meet the basic qualifications set forth in Section 3.2 (a); (2) Have his/her primary office and residence located within sixty (60) minutes response distance to the Hospital in order to provide continuous care to his/her patients. In an interview with staff #1 on 11-5-24, staff #1 stated that staff #16 and #21 have their primary office in a city 334 miles (5.5 hours) away, staff #17, #18 and #20 have their primary office 310 miles (5.25 hours) away and staff #19 has a primary office in a city 599 miles (9-10 hours) away. Staff #1 furnished the surveyor with written documentation of the primary office addresses. Facility Medical Staff Bylaws state, in part (beginning page 5): “Medical Records ... 2. A complete history and physical examination, as well as a complete Psychiatric Evaluation shall be dictated or recorded within twenty-four (24) hours of admission. If a complete history has been recorded and a physical examination performed by a member of the Medical Staff at Allegiance Behavioral Health Center of Plainview, L.L.C. or his designee within seven (7) days prior to the patient’s admission, a durable, legible copy may be used in the medical record. In such instances, an interval admission note, which includes all additions to the history and any subsequent changes in the physical findings, must be recorded.” A review of 3 clinical records was conducted (patients #2 - #4). *Patient #2 was admitted on 10-25-24 at 5:05 pm. The psychiatric evaluation was not performed until 10-28-24 at 11:33 pm. *Patient #3 was admitted on 10-25-24 at 5:39 pm. The psychiatric evaluation was not performed until 10-28-24 at 11:33 pm. *Patient #4 was admitted on 10-26-24 at 5:30 am. The psychiatric evaluation was not performed until 10-28-24 at 10:11 am. Facility Medical Staff Bylaws state, in part (beginning page 6): “3.2 BASIC QUALIFICATIONS FOR MEMBERSHIP 3.2 (a) Basic Qualifications The only people who shall qualify for membership on the Medical Staff are those practitioners legally licensed in the State of Texas; who: ... (4) Maintain professional liability insurance of at least 1,000,000/3,000,000 aggregate, through a company who is licensed to provide insurance in the State of Texas.” A review of credentialing files for 4 active-staff physicians (staff #16 - #19) was conducted. Staff #17 & #18 only carried liability insurance in the amounts of $500,000/$1,000,000 aggregate. The above was confirmed in an interview with staff #1 on 11-5-24”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility failed to ensure an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention. Findings were: The facility identified staff member #3 as the current Infection Control Coordinator as of November 2024. Prior to November 2024, staff member #2 was the facility Infection Control Coordinator prior to November 2024. Staff member # 2 stated she had taken online training for infection control, including passing a test, however staff #2 was unable to produce evidence they had education, training, experience, or certification in infection prevention and control to ensure they were qualified for the role of Infection Coordinator, prior to the survey exit date of 11/07/24.”

“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: 36594 Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment when infection control issues were observed during tours of the facility. Findings were: The following was observed during a tour of the facility with Staff #1, CEO, on the morning of 11/05/24: *Missing tile and chipping paint throughout *Conference room: several ceiling tile with water damage *Laundry Room: -weather stripping missing between hallway and room leaving a residue and making it impossible to clean -Chips in floor tile -build-up of dust/lint on high horizontal surfaces including washing machine, dryer, hand sanitizer dispenser -mop, detergent, and other items stored on the floor -visible dirt in washing machine *Dining room: -ceiling tile not flush allowing a hole where pests could enter room -trays delivered on a dining cart with visible dirt along outside crease, indicating this was inappropriately cleaned The following was observed during a tour of the Intensive Outpatient Program with Staff #1, CEO, on the morning of 11/07/24: -Chipping paint and visible dirt/discoloration of walls and floors throughout -Fire extinguisher that had not been checked since 02/19/2022 -Discolored wood TV tray -Room with access to the attic exposed and not covered, allowing access by pests and other organisms -Back door with frame chipping from wall Staff #1, CEO, accompanied during the tours on 11/05/24 and 11/07/24 and verified the above findings.”

“ANTIBIOTIC STEWARDSHIP PROGRAM CFR(s): Antibiotic stewardship program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program and that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership, This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility failed to demonstrate that an individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program. Findings were: The tab in the survey readiness binder for the antibiotic stewardship program was empty. In interview on 11/05/24, staff members #2 verified there currently was no antibiotic stewardship program and that the contracted pharmacist/pharmacy provider was designated by the facility as the leader of the antibiotic stewardship program but was not providing for any antibiotic stewardship program. The appointed the leaders of the antibiotic stewardship program (the contracted pharmacist/pharmacy provider) has not provided any form of antibiotic stewardship program for any of the calendar year 2024.”

“ANTIBIOTIC STEWARDSHIP COORDINATION CFR(s): §482.42(b)(2) The hospital-wide antibiotic stewardship program: (i) Demonstrates coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services; This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility failed to demonstrate coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services. Findings were: In interview on 11/05/24, staff member #2 (Infection Control Coordinator) verified that they tracked urinalysis after antibiotic administration to ensure infections clear before discharge, and also complete culture and sensitivity testing on patients. However, the facility was unable to produce evidence that this information was coordinated with the QAPI program and pharmacy services. The facility was unable to coordinate with pharmacy service regarding antibiotic use and resistance, due to the fact the contracted pharmacist/pharmacy provider had not developed/implemented an antibiotic stewardship program or participated in quality meetings for the 2024 calendar year. Review of Quality Meeting minutes from June 2024-September 2024 supported that the contracted pharmacist/pharmacy provider did not participate in the meetings. The above findings were verified with staff member #2 on 11/05/24.”

“IC PROFESSIONAL COMMUNICATION QAPI CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iii) Communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility to ensure that the infection preventionist/infection control professional had effective communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. Findings were: Facility based, “INFECTION CONTROL AND PREVENTION IC - 8010 PREVENTION CONTROL AND MONITORING” stated in part, “PROCEDURE Infection Prevention and Control activities include the following: o Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management: o Healthcare acquired/Community acquired infections o Respiratory potentials o Medical equipment device-related infections o Antibiotic-resistant organisms (MORO) / wound infections o HCA1: TB o Other communicable diseases, particularly preventable vaccine proven to be infectious o Employee health trends including increasing hand hygiene compliance. o Disinfecting of needed equipment, devises and supplies. o Facilitating a multidisciplinary approach to the prevention and control of infections. o Collaborating with all organizational ... Monthly Quality data collection reports: o Monitoring o Review of positive culture, infectious cases, clusters and outbreaks.” Review of facility Quality Meeting Minutes for June 2024-October 2024 revealed that only employee health issues and the following health issues: UTIs, pneumonia, and skin issues were being reported. In interview on 11/05/24, staff member #2 (Infection Control Coordinator) verified that they tracked urinalysis after antibiotic administration to ensure infections clear before discharge, and also complete culture and sensitivity testing on patients. However, the facility was unable to produce evidence that this information was coordinated with the QAPI program and pharmacy services. Staff member #2 was also asked if any Environment of Care Round were conducted to ensure the facility was cleaned effectively. Staff member #2 “Once a week, we enter what we find in a form, we check if housekeeping cleans the rooms and disinfect. Staff are required to disinfect the unit twice a day.” Staff member #2 verified this information was not being presented to quality in meetings. In interview with staff members #1 and 2 on 11/ 05/verified that all infection control surveillance and data is not currently reported during QAPI meetings. The staff members also verified that currently the collected information has no measurable metric to met to monitor the effectiveness of the surveillance date that is conducted, to evaluate if there need to be adjustments to ensure performance improvement.”

“Adequate MDs and DOs CFR(s): The number and qualifications of doctors of medicine and osteopathy must be adequate to provide essential psychiatric services. This Standard is not met as evidenced by: 36594 Based on review of facility documents and staff interview, the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site. Findings were: Texas Administrative Code 404.157(b)(1) states, “(b) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual’s treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention. (1) Each such person detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. All such persons have the right not to be detained beyond the completion of the in-person examination...” Review of the medical record for Patient #1 revealed they were admitted to the facility voluntarily on 10/30/24 at 7:40 pm. Patient #1 submitted a formal request to discharge on 10/30/24 at 10:53 pm. The nurse notified the psychiatrist of the request to discharge on 10/30/24 at 10:55 pm. The psychiatrist did not respond until 10/31/24 at 6:37 am, over 7 hours after the request for discharge, and reported to “change patient to involuntary status.” In an interview on the morning of 11/06/24, Staff #2, CNO, reported there continues to be no physician on-site at their facility, everything is via telemedicine services. Staff #2 verified Patient #1 requested to be discharged, but the physician did not respond within 4 hours of the request and although the psychiatrist completed the psychiatric evaluation on 10/31/24 at 3:32 pm, the facility had no ability for a physician to see a patient for an in-person examination. In an interview on the morning of 11/05/24, Staff #10, RN, reported they make rounds with the physician via telemedicine which could take about an hour to an hour and a half and up to 5 hours. In an interview on the afternoon of 11/05/24, Staff #1, CEO, reported physicians are 100% telemedicine and they have been actively trying to obtain staff. She verified an RN was not on the unit while doing rounds with the physician.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 36594 Based on review of facility documentation and staff interview, the facility failed to the facility failed to provide adequate numbers of staff necessary under each patient’s active treatment program when and staffing is not based on acuity and there is only 1 RN available on nightshift. Findings were: Review of the facility staffing plan revealed a grid based on the number of patients only and stated in part: *# of patients 1-6: 1 RN, 0 LVN/LPN, 1 Tech (MHT) *# of patients 7-12: 1 RN, 1 LPN, 2 Tech *# of patients 13-16: 1 RN, 1 LPN, 3 Tech *# of patients 17-18: 1 RN, 2 LPN, 3 Tech *# of patients 19-20: 1 RN, 2 LPN, 4 Tech In an interview on the morning of 11/04/24, Staff #2, CNO, reported there remained mostly only 1 RN on nightshift and reported that RN does not get breaks unless there is another RN scheduled, which is not often, as there always has to be an RN on the unit. In a follow-up interview on the morning of 11/05/24, Staff #2, CNO, reported staffing was still in accordance with the provided staffing grid and the facility has not yet developed an acuity tool. Staff #2 reported they were not “flexing” staff off and updated the staffing sheets to accurately reflect their staffing. Staff #2 reported the “Patient Information Sheet” was developed to monitor observation and precaution levels of each patient but did not factor into the staffing. Review of the “Patient Information Sheet” for 11/05/24 revealed a census of 13 patients, 7 of which were on high fall precautions (Patients #1, 2, 6, 9, 10, 11, and 21) while the other 6 (Patients #4, 3, 5, 7, 8, and 12) were on fall precautions. Other precautions included: 12 patients on Assault (Patients # 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 21), 4 on Elopement (Patients #6, 9, 10, 12), 3 on Bleeding (Patients #3, 6 and 9), 2 on Seizure (Patients #3 and 11), 2 on SAO (Patients 5 and 9) and one on Diabetic (Patient #7). Review of the “Patient Information Sheet” for 11/06/24 revealed a census of 13 patients, 8 of which were on high fall precautions (Patients #1, 2, 6, 9, 10, 11, 13, and 21) while the other 6 (Patients #4, 3, 5, 7, 8, and 12) were on fall precautions. Other precautions included: 13 patients on Assault (Patients # 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 13, and 21), 4 on Elopement (Patients #6, 9, 10, 12), 3 on Bleeding (Patients #3, 6 and 9), 2 on Seizure (Patients #3 and 11), 2 on SAO (Patients 5 and 9) and one on Diabetic (Patient #7). In a telephone interview on the evening of 11/05/24, Staff #11, nightshift RN verified they do not get breaks unless another RN is scheduled as there always has to be an RN on the unit and reported RNs are technically never relieved of their duties. Staff #11 reported if an admission or transfer happens during their shift, the LVN or MHT will leave the unit to pick up or accompany a patient, the RN will be on the unit at all times. With only 1 RN scheduled, especially at nights, there is no RN back-up available to monitor patients or relieve the one scheduled RN for breaks or lunch. If there is a restraint, there is no other RN to monitor patients or complete the 1 hour face-to-face. Facility-policy titled “General Staffing” effective 07/01/22 stated in part, “Each unit or area where patient care is provided will have a staffing plan to provide a sufficient number of professional nursing staff (RNs, LPNs/LVNs, CNAs) and professional ancillary staff (registered physical therapists, registered respiratory therapists, etc.) to carry out at least the following activities: -Prescription of care, treatment and services care for patients based on: *Assessment data and other relevant information *Identified patient needs/problems *Appropriate healthcare interventions as specified in standards, policies, and procedures, protocols or as determined by professional judgment *The patient’s response to healthcare interventions ...Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36594 Based on review of records and staff interview, the facility failed to protect and promote each patient’s rights or provide care in a safe setting when: A. the facility failed to monitor each patient at the level of monitoring most recently specified in the patient’s medical record for 3 of 5 patients (Patients B, C, and H) reviewed for observation levels when each patient’s “Close Observation” sheets did not accurately reflect the physician’s observation order and failed to have a policy guiding the observation levels. (Cross refer A0144) B. patients were not reassessed for pain relief after receiving pain medications for 4 of 5 patients reviewed (Patients A, D, E, G). (Cross refer A0144) D. emergency behavioral medication administered IM (intramuscular) for behavioral emergencies were not identified nor monitored as chemical restraints in one of one patient charts reviewed (Patient A) for emergency medication administration. (Cross refer A0160) E. the facility failed to ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 1 of 1 patient charts reviewed (Patient A). (Cross refer A0160) F. the facility failed to ensure chemical restraints were added to the restraint log nor were monitored through Risk and Quality in 1 of 1 patient charts reviewed (Patient A). (Cross refer A0160) G. the facility failed to ensure each patient or his or her representative had the right to make informed decisions regarding his or her care as it is not specifically disclosed there are no physicians on-site at any time; physicians only see patients via telemedicine services. (Cross refer A0131)”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 36594 Based on review of documents and staff interview, the facility failed to have adequate numbers of qualified professional and supportive staff when: A. the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site. (Cross refer A1691) B. the facility failed to provide adequate numbers of staff necessary under each patient’s active treatment program when three of three staffing sheets (09/06/24, 09/09/24, and 09/11/24) reviewed revealed inadequate staff that did not reflect the accurate staffing for that day and staffing is not based on acuity. (Cross refer A1704)”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36594 Based on review of documents and staff interview, the facility failed to ensure each patient or his or her representative had the right to make informed decisions regarding his or her care as it is not specifically disclosed there are no physicians on-site at any time. Physicians only see patients via telemedicine services. Findings were: Review of facility patient’s initial admission packet revealed two documents: -Document titled “Telemedicine Informed Consent” stated in part, “Telemedicine services involved the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. ...2. I understand that I will not be physically in the same room as my health care providers. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.” -Document titled “Informed Consent, Notice of Privacy Policy, and Notice Regarding complaints for Telemedicine Services” stated in part, “Telemedicine Physician Disclosures: I have been disclosed required disclosures about my provider whom shall provide telemedicine services: 1) I will be seeing [Physician #10] ... 2) the physician’s specialty is in Psychiatry ...” There is no written disclosure or signed acknowledgement by patients that a MD/DO [Doctor of Medicine or Osteopathy] is not present in the facility. In an interview on the morning of 09/11/24, Staff #2, CNO, reported there was one document for the medical doctor’s telemedicine agreement and one document for the psychiatrist’s services, but nothing specifically that notifies a patient there is not a MD/DO present in the facility. She reported there is no physician on-site at their facility, everything is via telemedicine services. In an interview on the afternoon of 09/11/24, Staff #1, CEO, reported the physicians are 100% telemedicine for about a year now, due to COVID and being a rural area. She reported they’ve been having difficulty getting someone full-time, but they have been working on it.”

“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: 36594 Based on review of medical records, review of facility documents, and staff interview, the facility failed to ensure patients received care in a safe setting when: A. the facility failed to monitor each patient at the level of monitoring most recently specified in the patient’s medical record for 3 of 5 patients (Patients B, C, and H) reviewed for observation levels when each patient’s “Close Observation” sheets did not accurately reflect the physician’s observation order and failed to have a policy guiding the observation levels. B. patients were not reassessed for pain relief after receiving pain medications for 4 of 5 patients reviewed (Patients A, D, E, G). Findings were: A. Review of the medical record for Patient B revealed they were placed on Line-of-Sight [LOS] observation level on 09/06/24 at 6:25 pm. Patient’s B’s Close Observation sheets for the evening shifts of 09/06/24 and 09/08/24 and both shifts of 09/07/24 and 09/09/24 had “Level I - Observation every 15 minutes” checked as the level of precaution. The morning shift of 09/08/24 was unable to found and was not provided. Review of the medical record for Patient C revealed they were placed on 1:1 observation on 09/01/24 for hitting staff and poor impulse control. Patient C’s Close Observation sheets were not consistently documented as 1:1. 09/04/24 through 09/09/24 day and night shifts, either “Level I - Observation every 15 minutes” or “Level II - Line of Sight” was checked. On 09/08/24, “Level I - Observation every 15 minutes” was checked and “1:1” was written on the top of the sheet and circled. Review of the medical record for Patient H revealed they were placed on LOS observation on 08/31/24 at 6:08 pm until 09/08/24 at 11:28 am. Patient H’s Close Observation sheets for the evening shift of 08/31/24 and both shifts of 09/01/24 through 09/03/24 had “Level I - Observation every 15 minutes” checked as the level of precaution. In an interview on the morning of 09/11/24, Staff #2, Chief Nursing Officer, verified there were no policies guiding level of precautions including LOS, 1:1, aggressive, or high fall risk precautions. Staff #2 provided the policy titled “Safety Precautions / Rounds” with an effective date of 07/01/22 and reported this was the only policy guiding observation levels. Facility policy titled “Safety Precautions / Rounds” effective date 07/01/22 stated in part, “Purpose: -To have established rules and guidelines regarding safety concerns and incidents -To ensure a safe and secure environment of care... Procedure: -All safety concerns regarding patients and their treatment will be documented and communicated during nursing shift reports. ...Patient rounds will include the following identifications: *Potential for assaultive behavior ...*Fall risks ...*Medical conditions that require close observation” In an interview on the afternoon of 09/11/24, Staff #1 and #2 verified facility policy titled “Safety Precautions / Rounds” effective date 07/01/22, was the only policy guiding observation levels. B. Review of the medical record for Patient A revealed they received Acetaminophen-codeine #3 tablet every 6 hours PRN [as needed] pain on 09/08/24 at 9:38 am and 09/10/24 at 11:30 pm with no assessment of pain prior to or after administration. Staff #2, CNO stated, “They should have assessed the pain prior to and after administration.” Review of the medical record for Patient D revealed no reassessment of pain after administration of hydrocodone-acetaminophen 5-325 mg tab on: -09/07/24 at 3:44 am for pain level 6 -09/08/24 at 9:33 am for pain level 7 -09/08/24 at 11:23 pm for pain level 5. Review of the medical record for Patient E revealed they received a dose of acetaminophen 650 mg 8 hour extended release on 09/02/24 at 1:04 am for a pain of 6 with no reassessment. Review of the medical record for Patient G revealed they received a dose of Acetaminophen 500 mg on 09/11/24 at 12:42 pm for a pain level of 3 and was not reassessed. In an interview on the afternoon of 9/11/24, Staff #2, CNO reported pain should be assessed prior to administration of medications, reassessed after administration, and documented. Facility policy titled “Pain Assessment and Pain Scale” effective date 07/01/22 stated in part, “Policy: The facility shall respect and support the patient’s right to optimal pain assessment and management. Pain shall be assessed in all patients in the organization. The organization shall also address the appropriateness and effectiveness of pain management. Procedure: ...The patient shall undergo reassessment of pain at least once per shift and after every pain control mechanism employed by patient care providers. *Any patient care provider, from any department, who has implemented a pain control mechanism shall reassess the patient within one-half (1/2) hour to determine amount of pain control or relief achieved. -Pain control mechanisms shall include, but are not limited to: *Medications administered for the control or relief of pain ... Ongoing Reassessment: -As part of the reassessment, the multidisciplinary team shall assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics. ...-This ongoing reassessment shall be performed at least every shift and more often if the patient’s pain has not been controlled.” Facility policy titled “Patient Rights and Responsibilities” effective date 07/01/22 stated in part, “Rights of Persons Suffering from Mental Illness and Substance Abuse ...You have the right to: ...Appropriate education, assessment, and management of pain.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 36594 Based on review of medical records, review of facility policies, and confirmed in staff interview, the facility failed to ensure: A. emergency behavioral medication administered IM for behavioral emergencies were identified and monitored as chemical restraints in one of one patient charts reviewed (Patient A) for emergency medication administration. B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 1 of 1 patient charts reviewed (Patient A). C. ensure chemical restraints were added to the restraint log and were monitored through Risk and Quality in 1 of 1 patient charts reviewed (Patient A). Findings were: Review of the medical record for Patient A revealed 2 (two) orders for Emergency Administration of Psychoactive Medication: *08/29/24 at 7:45 pm for Haldol 5 mg [milligrams] IM [intramuscular] X 1 [times one] [Haldol is an antipsychotic medication] (it was documented family was not informed of this administration of medication) *09/05/24 at 2:15 pm for Zyprexa 5 mg IM once [an atypical antipsychotic] The Seclusion/Restraint/Emergency Administration of Psychoactive Medication form stated in part, “Emergency administration of psychoactive medication must be assessed/monitored every 15 minutes X 4 (1 hour) at minimal and documented.” The physician (Staff #10) who ordered the above emergency medications did not document the medication was treating a psychiatric disease process nor assisting the patient to a therapeutic level. The patient’s behavior necessitating use of intervention was documented as “Immediate & Serious Danger to Others.” During review of the medical record on the afternoon of 09/11/24, Staff #2, CNO verified there was no assessment or reassessment of Patient A after medication administration and there was no 1 hour face-to-face. She was unaware that emergency behavioral medication could be considered as restraints but acknowledged that it should be safely monitored once given. She confirmed these were not added to the restraint log nor were monitored through Risk and Quality. According to the FDA.gov Black Box Warning Zyprexa is not approved for older adults with dementia-related psychosis as the drug can increase the risk of death in this population by 60% to 70%. The FDA placed a black box warning on all antipsychotics (atypical and typical) due to this increased mortality risk. Black Box warnings for psychotropic medications revealed causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug, as opposed to some characteristic(s) of the patients, is not clear. Facility policy titled “CMS Regulation of Use” section “Restraint & Seclusion” effective 07/01/22 stated in part, “Definitions: A restraint is also defined as: A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. ...Policy: ...Note: A medication or chemical restraint may NEVER be administered without the prior order of an authorized licensed prescriber. ...Continuous observation is maintained on any patient in Restraint or Seclusion. The staff member monitoring the patient has been trained in observation of the patient in Restraint or Seclusion. The staff member is able to identify potential problems and/or signs and complaints of symptoms that may occur, and actions to be taken in response to ensure the safety and security of the patient. The monitoring staff member will observe the patient continuously and document the patient’s condition every 15 minutes on the Restraint or Seclusion Observation Flowsheet. Procedure: ...4. The registered nurse enters the occurrence in the Restraint or Seclusion log 5. A qualified staff member is assigned to provide continuous monitoring ... 6. If the patient permits, the patient’s family member or designated representative will be notified of the intervention and of the precipitating event ... 7. Within one hour of initiation, the patient will undergo a face-to-face assessment by a registered nurse, a physician assistant, an advanced practice registered nurse or a physician.” This policy goes on to describe debriefing of the patient and staff members.”

“Adequate MDs and DOs CFR(s): The number and qualifications of doctors of medicine and osteopathy must be adequate to provide essential psychiatric services. This Standard is not met as evidenced by: 36594 Based on review of documents and staff interview, the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site. Findings were: Texas Administrative Code 404.157(b)(1) states, “(b) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual’s treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention. (1) Each such person detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. All such persons have the right not to be detained beyond the completion of the in-person examination...” Review of facility patient’s initial admission packet revealed two documents: -Document titled “Telemedicine Informed Consent” stated in part, “Telemedicine services involved the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. ...2. I understand that I will not be physically in the same room as my health care providers. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.” -Document titled “Informed Consent, Notice of Privacy Policy, and Notice Regarding complaints for Telemedicine Services” stated in part, “Telemedicine Physician Disclosures: I have been disclosed required disclosures about my provider whom shall provide telemedicine services: 1) I will be seeing [Physician #10] ... 2) the physician’s specialty is in Psychiatry ...” In an interview on the morning of 09/11/24, Staff #2, CNO, reported there was one document for the medical doctor’s telemedicine agreement and one document for the psychiatrist’s services. She reported there is no physician on-site at their facility, everything is via telemedicine services. She reported at times, they do get voluntary patients who request to be discharged, but that is not something that quality tracks and no list of patients who have requested to be discharged could be provided. Staff #2 confirmed, if a voluntary patient were to request discharge, there would be no physician to complete an in-person examination within 24 hours of filing a request for release as all physicians were telemedicine only. She stated the examination would be via “telemedicine.” In an interview on the afternoon of 9/11/24, Staff # 1, CEO, reported the physicians are 100% telemedicine for about a year now, due to COVID and being a rural area. She reported they’ve been having difficulty getting someone full-time, but they have been working on it. She reported she has been requesting for more staff for about a year and verified an RN was not on the unit while doing rounds with the physician. She reported RN nightshift do not get a break as they cannot leave the unit. She verified the facility only had one policy related to observations titled “Safety Precautions/Rounds.””

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 36594 Based on review of facility documentation and staff interviews, the facility failed to provide adequate numbers of staff necessary under each patient’s active treatment program when three of three staffing sheets (09/06/24, 09/09/24, and 09/11/24) reviewed revealed inadequate staff that did not reflect the accurate staffing for that day and staffing is not based on acuity. Findings were: Review of the facility staffing plan revealed a grid based on the number of patients only and stated in part: *# of patients 1-6: 1 RN, 0 LVN/LPN, 1 Tech (MHT) *# of patients 7-12: 1 RN, 1 LPN, 2 Tech *# of patients 13-16: 1 RN, 1 LPN, 3 Tech *# of patients 17-18: 1 RN, 2 LPN, 3 Tech *# of patients 19-20: 1 RN, 2 LPN, 4 Tech Review of the staffing sheet for dayshift 09/06/24 revealed 2 RNs (one on orientation), 1 LVN, and 4 MHTs with a census of 19 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN. There was an incident between two patients on 9/6/24 at approximately 2:00 pm. Patient A had to be transferred to the ER and was off the unit with one MHT from 2:00 pm until 4:30 pm, leaving the unit with 3 MHTs, one of which was assigned as 1:1 with Patient C. According to the staffing grid, the staffing was short by 1 LVN and 1 MHT from 2:00 pm until 4:30 pm. In interview on the morning of 09/11/24, Staff #2, CNO, reported the census on 09/09/24 was 19 with one 1:1 (Patient C). According to the staffing grid for 19 patients, there should be 1 RN, 2 LVNs, and 4 MHTs. Staff #2 reported there were two RNs present that day, but one was on orientation and did not count toward the staffing and reported she worked the unit and the unit clerk worked as an MHT to cover staffing; this was not reflected on the staffing sheet. Review of the sheet for nightshift 09/06/24 revealed 1 RN, 1 LVN, and 4 MHTs with a census of 19 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN. Review of the staffing sheet for dayshift 09/09/24 revealed 1 RN, 1 LVN, and 4 MHTs with a census of 18 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN. Review of the staffing sheet for nightshift 09/09/24 revealed one RN, one LVN, and 3 MHTs; the census was 18 with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN. Review of the staffing sheet for dayshift 09/11/24 revealed 1 RN, 1 LVN, and 4 MHTs with a census of 19 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN. In an interview on the morning of 09/11/24, Staff #2, CNO reported staffing was in accordance with the provided staffing grid with the number of patients and no acuity, characteristics of patients, or administrative activities were used to determine staffing. When asked if there was a certain number of LOS patients a MHT could have at one time, she reported there was not. When asked if there was an acuity tool used with the facility staffing grid, she stated, “I talk to the doctors, and we discuss it. If needed, I, or transportation, is the extra person, if we have a lot of acuity on the unit.” She reported there was no acuity taken into account when staffing and stated, “I just go help, if that makes sense. There’s a lot of confused and restless patients and they wander ... And everyone’s a fall risk. So I assist out there [on the unit].” She stated, “Usually, there’s only 1 RN and she’s not on the unit if she’s making doctor rounds, she’s with the patients.” In an interview on the morning of 09/11/24, Staff #3, RN reported if she needed help, the CNO was available, and she always had an LVN. She reported during doctor rounds, she was in the room with the patients and the LVN has to watch the unit without her and stated it “takes about 2 hours when there aren’t any new patients” but has taken 3-5 hours at times. In a follow-up interview on the afternoon of 09/11/24, Staff #2, CNO, reported she does help out on nightshifts at times and had to work a nightshift last week because the RN called in sick. She reported RNs on nightshift do not get breaks unless there is another RN scheduled, which is not often, as there always has to be an RN on the unit. She stated, “She doesn’t get a lunch and the time doesn’t get taken out ... For the most part, they can’t get a break because they can’t leave.” She reported, in the last few months, they’ve had more aggressive male patients than usual. With only 1 RN scheduled, especially at nights, there is no RN back-up available to monitor patients or relieve the one scheduled RN for breaks or lunch. If there is a restraint, there is no other RN to monitor patients or complete the 1 hour face-to-face Facility-policy titled “General Staffing” effective 07/01/22 stated in part, “Each unit or area where patient care is provided will have a staffing plan to provide a sufficient number of professional nursing staff (RNs, LPNs/LVNs, CNAs) and professional ancillary staff (registered physical therapists, registered respiratory therapists, etc.) to carry out at least the following activities: -Prescription of care, treatment and services care for patients based on: *Assessment data and other relevant information *Identified patient needs/problems *Appropriate healthcare interventions as specified in standards, policies, and procedures, protocols or as determined by professional judgment *The patient’s response to healthcare interventions ...Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness ...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47893 Based on review of medical records interview, and review of facility policy, the facility failed to protect the patient’s right to make informed decisions about their care, as psychoactive medications were given to patients (#s 1 and 2) without first obtaining the appropriate informed consents. This failure placed 2 of 10 patients (#s 1 and 2 ) reviewed for infomed consent at risk for not being involved in care planning and treatment decisions, and not being able to request or refuse treatment. Findings were: Review of medical record for patient #1 reflected admission to the facility on 12/27/23 and discharge on 12/30/23. Review of an electronic medication administration record (eMAR) revealed that patient #1 was administered: - Olanzapine (a medication that can treat mental disorders) on 12/28/23 at 8:50 PM, and - Sertraline (a medication that can treat depression and anxiety) on 12/29/23 at 9:30 AM. No consent was found in patient #1’s medical record for Olanzapine or Sertraline. Interview on 2/14/23 at 10:15 AM with Staff #1, Chief Nursing Officer, confirmed consents for Olanzapine and Sertraline were not found. Review of a census report for 2/14/204 documented patient #2 was admitted to the facility on 2/1/24. Review of an EMR revealed that patient #2 was first administered Donepezil (a medication that can treat Alzheimer’s disease) on 2/1/23 at 9:00 PM. An “Informed Consent for Psychotropic Medications” form for Donezepil documented patient #2 signed the consent on 2/2/23. Interview on 2/14/23 at 10:15 AM with staff #1, confirmed patient #2 received a dose of Donezepil on 2/1/24, before patient signature was obtained. Review of the facility policy, “Consent to Psychotropic Medication” last review date 6/28/22, documented in part: “ ... Procedure ... Prior to the administration of the medication, the Consent to Receive Psychopharmacological Medications Form must be signed by the patient. No nurse may administer the prescribed medication(s) until this form is completed ...””