Bethesda Rehabilitation Hospital

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 48051 Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Physical Environment relative to the overall hospital environment being maintained in a manner to ensure the safety and well-being of patients. This deficient practice was evidenced by: 1) Failure to ensure air conditioning and ventilation were maintained in the patient care areas (See Tag A0701); 2) Failure to ensure furnishings at the outpatient clinic were in good repair (See Tag A0701); 3) Failure to ensure the Emergency Power Supply System was routinely inspected and exercised under load (See Tag A0701); 4) Failure to ensure patient supplies and equipment were stored in a climate controlled area (See Tag A0724); 5) Failure to ensure the exterior courtyard was clean and maintained (See Tag A0724); 6) Failure to ensure the facility was free from insects (See Tag A0724); and 7) Failure to ensure the supplies was not expired (See Tag A0724).”

“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: 44495 Based on record review and interview the facility failed to ensure each patient’s right to informed consent. The deficient practice is evidenced by failure of the facility to document the patient was informed of their rights, the risks and benefits of treatment, and the financial policy for 1 (#FF1) of 2 (#FF1, #FF2) records reviewed at the outpatient rehabilitation clinic and 1 (#FF19) of 16 (#FF5-#FF18, #FF20) records reviewed at the inpatient rehabilitation hospital. Findings: Review of the medical record for Patient #FF1 failed to reveal the consent form used by the facility which contained the patient’s rights, the consent to treatment, and the financial policies. In interview on 06/16/2025 at 1:58 PM, SFF21OM verified there was no consent on the record. Review of the medical record for Patient #FF19 failed to reveal the signed consent form used by the facility which contained the patient’s rights, the consent to treatment, and the financial policies. In an interview on 06/23/2025 at 3:35 PM, SFF3MR verified Patient #19 did not sign the consent on the record. 48050”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure each patient had the right to formulate an advance directive and have the hospital staff provide care in compliance with these directives for 1 (#FF8) of 16 (#FF5-#FF2)0 patients reviewed. Findings: Review of Patient #FF8’s medical record revealed Patient #FF8 was admitted on 05/22/2025 for Parkinson’s disease with unsteady gait. Patient #FF8 signed on admission that she had an advance directive. Further review failed to reveal documented evidence of the advance directive in Patient #FF8’s medical record. SFF14MD ordered full resuscitation on 05/23/2025 for Patient #FF8. Further review of Patient #FF8’s medical record showed nursing shift notes documenting Patient #FF8 being a DNR. In an interview on 06/24/2025 at 8:55 AM, SFF2DON confirmed the above mentioned findings. SFF2DON further verified when patients report they have an advance directive, there is no protocol to ensure the advance directive document is obtained and included in the patient’s medical record.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure pharmaceutical services developed policies and procedures that minimized drug errors. This deficient practice was evidenced by the failure of pharmacy to communicate with hospital staff the review of prescribed medications to minimize drug errors such as dosing, high alert drugs, and/or any other adverse drug event. Findings: A review of hospital policy, “482.25 Condition of participation: Pharmaceutical services.” with no policy number, effective date or approval date revealed in part: “(b) Standard: Delivery of services. In order to provide patient safety, drugs and biological must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.-Complete (8) Information relating to drug interactions and information of drug therapy, side effects, toxicology, dosage, indication for use, and routes of administration must be available to the professional staff. Available.” A review of hospital policy “BRH Pharmacy Policy and Procedure (rev 12/21),” with no policy number or approval date did not reveal any information related to drug interactions and information of drug therapy, side effects, toxicology, dosage, indication for use, and routes of administration must be available to the professional staff.” In an interview on 06/17/2025 at 10:40 AM, SFF5LPN indicated medication orders are faxed to the pharmacist, the pharmacist would make contact with the nursing staff if there was an issue with the order and this contact would be via phone call or fax. SFF5LPN further confirmed contact with the pharmacist is rare and there is no communication related to dosing, potential high alert drugs and/or any other adverse drug events related to drug interactions or in-compatibilities with a patient’s prescribed medications.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This deficient practice was evidenced by the failure to ensure documentation of the performance of first dose review by the pharmacist on 16 (#5 - #20) of 20 (#1 - #20) medical records reviewed. Findings: A review of pharmacy policies requested and presented by the hospital included, “482.25 Condition of participation: Pharmaceutical services.” with no policy number, effective date or approval date and “BRH Pharmacy Policy and Procedure (rev 12/21),” with no policy number or approval date. These policies failed to reveal a process for a first dose review by the pharmacy prior to a prescribed medication being administered. A review of 16 (#FF5 - #FF20) of 20 (#FF1 - #FF20) medical records did not reveal any documentation of first dose review by pharmacy prior to the patient being administered a prescribed medication. In an interview on 06/17/2025 at 10:40 AM, SFF5LPN indicated medication orders are faxed to the pharmacist, the pharmacist would make contact with the nursing staff if there was an issue with the order and this contact would be via phone call or fax. SFF5LPN further confirmed there was no documentation as to the pharmacist completing a first dose review. In an interview on 06/24/2025 at 10:45 AM, SFF2DON confirmed the above mentioned findings.”

“STOP-ORDERS FOR DRUGS CFR(s): 482.25(b)(5) §482.25(b)(5) - Drugs and biologicals not specifically prescribed as to time or number of doses must automatically be stopped after a reasonable time that is predetermined by the medical staff. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure drugs and biological not specifically prescribed as to time or number of doses must automatically be stopped after a reasonable time that is predetermined by the medical staff. This deficient practiced was evidenced by the failure to include a prescribed time or number of doses and/or automatic stop dates on all prescribed medications in 16 (#5 - #20) of 20 (#1 - #20) medical records reviewed. Findings: A review of hospital policy, “482.25 Condition of participation: Pharmaceutical services.” with no policy number, effective date or approval date revealed in part: “(b) Standard: Delivery of services. In order to provide patient safety, drugs and biological must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.-Complete (5) Drugs and biological not specifically prescribed as to time or number of doses must automatically be stopped after a reasonable time that is predetermined by the medical staff. STOP orders have been determined by the Medical Staff.” A review of 16 (#FF5 - #FF20) of 20 (#FF1 - #FF20) medical records failed to reveal prescribed time or number of doses and/or automatic stop dates on all prescribed medications. In an interview on 06/24/2025 at 10:45 AM, SFF2DON confirmed the above mentioned findings”

“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: 44495 Based on record review and interview, the hospital failed to document surveillance of the infection control program. The deficient practice is evidenced by: 1) failure to document routine hand hygiene surveillance; 2) failure to provide hand sanitizer for staff/patient use; and 3) failure to ensure the hospital maintained a sanitary environment to prevent infections. Findings: 1) failure to document routine hand hygiene surveilance Review of the 2025 Infection Control Plan revealed in part, “Compliance with hand hygiene surveillance will be continuously assessed,” and “Must do more hand hygiene surveillance (at least 5 per month) and share with staff.” Documentation of the hand hygiene observations were requested on 06/23/2025 at 11:20 AM, 1:00 PM, and 3:00 PM. In interview on 06/24/2025 at 10:55 AM, SFF2DON verified she does not keep a formal log of hand hygiene performance checks. 2) failure to provide hand sanitizier for staff/patient use Observations during a tour of the facility on 06/17/2025 between 9:30 AM to 11:30 AM revealed no hand sanitizer/soap dispenser for staff/patient use in the Room FFs bathroom Further observation revealed a used bar of soap sitting on the sink edge in Room FFs bathroom for staff/patient use. In an interview on 06/17/2025 and present for the hospital walk-through SFF1CEO confirmed the above mentioned findings. 3) failure to ensure the hospital maintained a sanitary environment to prevent infections Observations during a tour of the facility on 06/17/2025 between 9:30 AM to 11:30 AM revealed there wasn’t a toilet paper dispenser in the Room FFs bathroom Further observation revealed toilet paper roll laying on top of the paper towel holder behind the commode in Room FFs bathroom. In an interview on 06/17/2025 and present for the hospital walk-through SFF1CEO confirmed the above mentioned findings. 48050”

“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: 44495 Based on record review and interview, the facility failed to ensure compliance with antibiotic stewardship. The deficient practice is evidenced by failure to ensure coordination around all components of the hospital. Findings: Review of the provided “Infection Control Antibiotic Stewardship Q1 Meeting Minutes,” dated 05/12/2025, revealed, in part, “Upon review, patients received appropriate antibiotics according to culture sensitivity reports and opportunities where patients could be switched to oral treatment were utilized.” Review of the “ 2025 PI [Performance Improvement] Dashboard,” provided as the Infection Control Quality Improvement and Performance Improvement (QAPI) measures, failed to reveal any measures associated with antibiotic stewardship. Review of the provided documentation for the antibiotic stewardship program included a monthly “Infection Control Log” which documented room number, admit date, culture date, culture source, diagnosis, organism, site, antibiotic ordered, isolation initiated, f the infection was hospital acquired and days of antibiotic treatment. Further review of the “Infection Control Log” revealed on the log for January, there were dash marks under the columns for isolation and hospital acquired instead of a “Y” or “N” answer. The culture date for one of the patients was also not documented. Review of the February data revealed a patient admitted with Methicillin Resistant Staphylococcus aureus (MRSA) infection of a wound cultured prior to admit and the patient was on Bactrim BID for 10 days, but it was not hospital acquired and the patient was not on isolation. Review of the March data revealed a patient had a pulmonary infection of the right upper lobe diagnosed by chest x-ray 11 days after admission. There was no documentation of sputum cultures and the patient was placed on levofloxicin for 7 days. The infection was documented as not hospital aquired. Review of the April data revealed a urine culture 3 days after admission on Patient #FF20 and diagnosed with urinary tract infection, was placed on ciprofloxacin 500 milligrams for 7 days, and the infection was also documented as not hospital acquired. In interview on 06/23/2025 at 2:00 PM, SFF2DON reviewed verified there were no measures for antibiotic stewardship in the QAPI plan. SFF2DON also verified that the infection control officer was in charge of the antibiotic stewardship program and she was not aware if the pharmacists were involved through communication with the infection control officer. At that time, SFF2DON was asked to provide documentation of the antibiotic stewardship education as referenced in the infection control plan and to provide all data she could get on the antibiotic stewardship program. SFF2DON verified she had no documentation related to reviews performed by the infection control officer, but would inquire about it. SFF2DON was also asked to provide more information about the MRSA infection documented in February and the urinary tract infections in April for Patient #FF12 and #FF20. In interview on 06/23/2025 at 2:50 PM, SFF2DON verified that the antibiotic stewardship data in the Infection Control Log was not correct. SFF2DON verified the information about Patient #FF20 being placed on ciprofloxacin was not correct and the patient was actually discharged to the nursing home the day after the urine was collected for culture. SFF2DON stated she was still trying to locate the information about the patient with MRSA infection. At this time SFF2DON was asked to provide documentation the nursing home was notified of Patient #FF20’s infection. On 06/23/2025 at 3:00 PM, SFF2DON was asked again for documentation of antibiotic stewardship education of the staff. In interview on 06/24/2025 at 10:55 AM, SFF2DON verified she did not have any documentation the nursing home was notified of the urinary infection for Patient #FF20. SFF2DON also verified the last positive MRSA culture received by the facility was in September of 2024, and she was not sure why she documented the facility had a patient with MRSA in February. SFF2DON did not provide any additional documentation related to the infection control program and antibiotic stewardship prior to the exit conference.”

“ANTIBIOTIC STEWARDSHIP IMPROVEMENTS CFR(s): [The hospital-wide antibiotic stewardship program:] (iii) Documents improvements, including sustained improvements, in proper antibiotic use, such as through reductions in CDI and antibiotic resistance in all departments and services of the hospital; This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to provide documentation demonstrating an active antibiotic stewardship program. The deficient practice is evidenced by failure of the facility to provide documentation of improvements, including sustained improvements, in proper antibiotic use, such as through reductions in CDI and antibiotic resistance in all departments and services of the hospital. Findings: Review of the 2025 Infection Control Plan revealed the 2024 status for the Antibiotic Stewardship program documented “Antibiotic Stewardship program started with listings of patients and antibiotics. Monitoring for duration and indication. Few antibiotics ordered at Bethesda. No MRDO’s [multi-drug resistant organisms] of C-diff in 2023.” Review of the 2025 Plan revealed, “Continue with antibiotic stewardship program for optimum patient results. Will need continued education of the staff and medical staff to include duration and reason for antibiotic in order, need to develop teaching tool for patient’s discharged on antibiotic, nurses need to promptly notify physician if culture sensitivity and resistance do not concur with current antibiotic. Close observation of the patient’s on antibiotic for MDRO, C-diff and appropriate isolation if needed.” Review of the “Infection Control Antibiotic Stewardship Q1 Meeting Minutes,” dated 05/12/2025 revealed in part: · Documentation of antibiotic stop dates with diagnosis: This area has improved significantly, and we will strive to have an indication and a stop date on the chart when prescribing an antibiotic. · Notification of culture and sensitivity reports: the pharmacist, physician and IC nurse all need to be notified of any repeat cultures to continue tracking patient’s treatment and appropriate use of antibiotics. · Upon review, patients received appropriate antibiotic according to culture sensitivity reports and opportunities where patient could be switched to oral treatment were utilized. · C-Diff Cases: No cases reported or suspected · HAI Cases: No cases reported · CLABSI: No cases reported · CATI: No cases reported · Hand Hygiene: Improvement continues in this area. Ongoing education/check-off continue for staff and annually. · Appropriate Isolation Precautions: Improvement noted in that the isolation caddies all had adequate supplies and signage. Will continue to monitor to ensure this trend continues. Review of the “2024 Infection Control Review and 2025 Infection Control Plan” revealed the 2025 plan for antibiotic stewardship included , in part, “ Continue antibiotic stewardship program for optimum patient results. Will need continued education of the staff to include duration and reason for antibiotic in order . . “ Review of medical records selected revealed one patient (#FF5) of four total patients reviewed on antibitiocs with no stop order. Patient #FF5 has an order for ciprofloxicin 250 milligrams twice a day. Further review of the “Infection Control Log” revealed on the log for January, there were dash marks under the columns for isolation and hospital acquired instead of a “Y” or “N” answer. The culture date for one of the patients was also not documented. Review of the February data revealed a patient admitted with Methicillin Resistant Staphylococcus aureus (MRSA) infection of a wound cultured prior to admit and the patient was on Bactrim BID for 10 days, but it was not hospital acquired and the patient was not on isolation. Review of the March data revealed a patient had a pulmonary infection of the right upper lobe diagnosed by chest x-ray 11 days after admission. There was no documentation of sputum cultures and the patient was placed on levofloxicin for 7 days. The infection was documented as not hospital aquired. Review of the April revealed doumentation of a urine culture 3 days after admission on Patient #FF20 resulted in a diagnosis of urinary tract infection. Patient #FF20 was placed on ciprofloxacin 500 milligrams for 7 days, and the infection was also documented as not hospital acquired. On 06/23/2025 at 11:20 AM SFF5LPN was given a copy of the 2025 Infection Control Plan with the antibiotic stewardship education highlighted, and asked to provide documentation related to the education.SFF5LPN was asked to provide all documentation related to the antibiotic stewardship program for review. In interview on 06/23/2025 at 2:00 PM, SFF2DON also verified that the infection control officer was in charge of the antibiotic stewardship program and she was not aware if the pharmacists were involved through communication with the infection control officer. At that time, SFF2DON was again asked to provide documentation of the antibiotic stewardship education as referenced in the infection control plan and to provide all data she could get on the antibiotic stewardship program. SFF2DON verified she had no documentation related to antibiotic reviews performed by the infection control officer, but would inquire about it. SFF2DON was also asked to provide more information about the MRSA infection documented in February and the urinary tract infections in April for Patient #FF12 and #FF20. In interview on 06/23/2025 at 2:50 PM, SFF2DON verified that the antibiotic stewardship data in the Infection Control Log was not correct. SFF2DON verified the information about Patient #FF20 being placed on ciprofloxacin was not correct and the patient was actually discharged to the nursing home the day after the urine was collected for culture. SFF2DON states she was still trying to locate the information about the patient with MRSA infection. At this time SFF2DON was asked to provide documentation the nursing home was notified of Patient #FF20’s infection. On 06/23/2025 at 3:00 PM, SFF2DON was asked again for documentation of antibiotic stewardship education of the staff. In interview on 06/24/2025 at 10:55 AM, SFF2DON verified she did not have any documentation the nursing home was notified of the urinary infection for Patient #FF20. SFF2DON also verified the last positive MRSA culture received by the facility was in September of 2024, and she was not sure why she documented the facility had a patient with MRSA in February. SFF2DON did not provide any additional documentation related to the infection control program and antibiotic stewardship prior to the exit conference.”

“ABX STEWARDSHIP LEADERSHIP TRAINING CFR(s): [The leader(s) of the antibiotic stewardship program is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure all staff received competency-based training and education on antibiotic stewardship. Findings: Review of the “2024 Infection Control Review and 2025 Infection Control Plan” revealed the 2025 plan for antibiotic stewardship included , in part, “ Continue antibiotic stewardship program for optimum patient results. Will need continued education of the staff to include duration and reason for antibiotic in order . . “ Review of the plan for infection control education revealed form October 2024 forward, the education was to be provided by the director of nursing. On 06/23/2025 at 11:20 AM SFF5LPN was given a copy of the 2025 Infection Control Plan with the antibiotic stewardship education highlighted, and asked to provide documentation related to the education. SFF5LPN was asked to provide all documentation related to the antibiotic stewardship program for review. On 06/23/2025 at 2:00 PM and 3:00 PM SFF2DON was asked to provide the antibiotic stewardship education. On 06/24/2025 the SFF2DON provided a copy of the “2025 Virtual Skills/ Competency Fair” provided to the staff as the yearly education. Review of the presentation failed to reveal education related to antibiotic stewardship. There was no additional education or documentation related to the infection control program and antibiotic stewardship prior to the exit conference.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) Failure to ensure the nurse call system was properly functioning (see Tag A0144); 2) Failure to ensure the current glucometer was indicated for multi-patient use (see Tag A0144); 3) Failure to ensure the current glucometer control solutions and blood glucose test strips were within the vial’s first opened date range (see Tag A0144); 4) Failure to ensure the emergency code cart was secured (see Tag A0144).”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 48051 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Pharmaceutical Services. The hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use as evidenced by: 1) Failure to ensure glucometer control solutions and blood glucose test strips were within the vial’s first opened date range (see Tag A0505); 2) Failure to ensure emergency medications were not outdated (see Tag A0505); 3) Failure to ensure medications were removed and returned to the pharmacy or properly destroyed upon a patients discharge (see Tag A0505); and 4) Failure to ensure medications available for patient use were properly labeled (see Tag A0505).”

“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: 48051 Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Infection Prevention Control ABX Stewardship. The hospital failed to employ methods for preventing and controlling the transmission of infections within the hospital as evidenced by: 1) Failure to properly clean the glucometer after patient use (see Tag A0749); and 2) Failure to properly clean equipment after patient use (see Tag A0749).”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use. This deficient practice was evidenced by: 1) Failure to ensure glucometer control solutions and blood glucose test strips were within the vial’s first opened date range; 2) Failure to ensure emergency medications were not outdated; 3) Failure to ensure medications were removed and returned to the pharmacy or properly destroyed upon a patients discharge; and 4) Failure to ensure medications available for patient use were properly labeled. Findings: 1) Failure to ensure glucometer control solutions and blood glucose test strips were within the vial’s first opened date range A review of hospital policy, “Nursing: Point of Care Devices Blood Glucose Monitor,” no policy number, effective date, indication of governing body approval available and presented as the policy related to the glucometer, revealed in part: “All devices will be used according to the manufacturer’s guidelines unless otherwise specified by an authoritative body with the knowledge to override the manufacturer’s specifications for use. The monitor will be calibrated according to the manufacturer’s guidelines. There will be a record of these readings kept with the nurses at the nurses’ station.” A review of the “True Metrix Self Monitoring Blood Glucose System Owner’s Booklet” for the current True Metrix Monitor (RE4TVH09) that was being used, revealed in part: “Expiration Dates (EXP) - Write date first opened on vial label. Discard vial and unused test strips if either the open vial expiration date or the date printed next to EXP on vial label has passed, whichever comes first. See the test strip Instructions for Use for open vial expiration date. Caution! Use of test strips or control solution past the Expiration Dates may give incorrect test results. Expiration Dates (EXP) - Write date first opened on bottle label. Control Solution: Discard bottle if either 3 months after first opening or date printed next to EXP on bottle label has passed, whichever comes first.” A review of the “True Metrix Self Monitoring Blood Glucose Test Strips Instructions for Use” package insert revealed in part: “Blood Glucose Testing: 1. Check opened date and printed date on test strip vial label. Do not use if after either date printed on the test strip vial label or 4 months after date opened, whichever comes first. Discard vial and test with new vial.” Observations during a walk-through of the hospital on 05/12/2025 from 3:15 PM to 4:45 PM revealed True Metrix Blood Glucose Test Strips currently in patient use without a first open date being recorded on the label. Further observations revealed the True Metrix Control Solutions (Level 1 vial, Level 2 vial, Level 3 vial) currently being used to perform quality control testing without a first open date being recorded on the label. The use of out of date and/or expired test strips and/or control solutions had a potential safety risk associated with the patient being treated or not treated for an incorrect capillary blood glucose result. In an interview on 05/12/2025 at 4:15 PM, S5LPN confirmed the above mentioned findings and further confirmed she was not sure when the test strips and control solutions were first open. S5LPN further confirmed the patient safety risk involved with using out of date or expired supplies and/or inaccurate reading not identified during quality control testing. 2) Failure to ensure emergency medications were not outdated A review of hospital policy, “Nursing Crash Cart & Emergency,” no policy number, effective date or indication of governing body approval available and was presented as the policy related to the crash cart, revealed in part: “Licensed professionals will be assigned to check the crash cart lock and defibrillator monitor daily at the beginning of the day shift. Any equipment found to be non-functioning or in questionable operating condition will be reported immediately. Medications dates and integrity will be check to ensure no medications have expired. The pharmacy consult will inspect the crash cart on a monthly basis. Procedure: Crash Cart: Tamper locks are to be inspected daily. Drawers one (1) and two (2) if tamper lock is broken, the drawer will be checked for missing items and the items replaced immediately. A new lock will be installed by pharmacy. The entire contents of the drawers will be checked against the supply checklist on the clipboard located on top of the crash cart.” Observations during a walk-through of the hospital on 05/12/2025 from 3:15 PM to 4:45 PM revealed drawer 1 of the emergency code cart containing Dopamine 400mg/40ml vial, quantity 25, expired 04/2025 and available for patient use. In an interview on 05/12/2025 and present during the hospital walk-through, S4DON confirmed the above mentioned findings. 3) Failure to ensure medications were removed and returned to the pharmacy or properly destroyed upon a patients discharge A review of the document titled, “Bethesda Rehabilitation Hospital Pharmacy Procedure,” and presented as a pharmacy policy related to the return of medications after a patient is discharged, revealed in part: “5. Weekly, staff will go through all medications in use and removed damaged or expired packages out of use. 6. During pharmacy pickup, any expired or out of use medication can be returned to the pharmacy. 7. Upon discharge, all patient medication will be removed from the medication cart. This medication can be sent home with the patient (except narcotics which will require a prescription), or returned to pharmacy. Observations during a hospital walk-though on 05/12/2025 from 03:15 PM to 4:45 PM revealed labeled medications in the medication refrigerator remaining after patient discharge and available for patient use. Patient #R6 was discharged 03/24/2025 and Novolog U100, 100unit/ml vial, 1 vial was found with Patient #R6 on the attached prescribed label. Patient #R7 was discharged on 03/26/2025 and Lantus Solostar U100, 100units/ml injectable 3ml pens, quantity 11 pens was found with Patient #R7 on the attached prescribed label. In an interview on 05/12/2025 at 4:20 PM, S5LPN confirmed the above mentioned findings and further confirmed these medications should have been returned to the pharmacy. 4) Failure to ensure medications available for patient use were properly labeled A review of the document titled, “Bethesda Rehabilitation Hospital Pharmacy Procedure,” and presented as a pharmacy policy related to the return of medications after a patient is discharged, revealed in part: “5. Weekly, staff will go through all medications in use and removed damaged or expired packages out of use. 6. During pharmacy pickup, any expired or out of use medication can be returned to the pharmacy. 7. Upon discharge, all patient medication will be removed from the medication cart. This medication can be sent home with the patient (except narcotics which will require a prescription), or returned to pharmacy. Observations during a hospital walk-though on 05/12/2025 from 03:15 PM to 4:45 PM revealed unlabeled medications in the medication refrigerator remaining after patient discharged and available for patient use. The following medications had no prescribing label attached identifying the patient the medications were assigned: Lantus Solostar U100, 100units/ml injectable 3ml pen, quantity 1 pen and Trulicity 0.75mg/0.5ml single dose injection pen, quantity 2 pens. The following medications prescribing label, including the patient’s name, had been partially torn off the packaging: Novolog U100, 100unit/ml vial, quantity 1 and Lantus U100, 100unit/ml vial, quantity 1. In an interview on 05/12/2025 at 4:20 PM, S5LPN confirmed the above mentioned findings and further confirmed these medications should have been returned to the pharmacy.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by the failure to secure the weather strip surrounding the entry door of Room “a.” Observations during a hospital walk-though on 05/12/2025 from 03:15 PM to 4:45 PM revealed approximately 2 inches of weather stripping around Room a’s entry door pulled away from the door frame at the bottom left side. This end of the weather stripping was protruding towards the center of the doorway, which created an unsafe condition and the potential for patient injury if the patient were to make contact with this protruding piece which appeared to have sharp and jagged edges. In an interview on 05/12/2025 and present during the hospital walk-through, S1CEO confirmed the above mentioned findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure facilities, supplies and equipment must be maintained to ensure an acceptable level safety and quality. This deficient practice is evidenced by: 1) Failure to ensure Glucometer quality controls were performed daily; and 2) Failure to ensure Emergency Cart checks were performed daily. Findings: 1) Failure to ensure Glucometer quality controls were performed daily A review of hospital policy, “Nursing: Point of Care Devices Blood Glucose Monitor,” no policy number, effective date, indication of governing body approval available and presented as the policy related to the glucometer, revealed in part: “All devices will be used according to the manufacturer’s guidelines unless otherwise specified by an authoritative body with the knowledge to override the manufacturer’s specifications for use. The monitor will be calibrated according to the manufacturer’s guidelines. There will be a record of these readings kept with the nurses at the nurses’ station.” A review of the “True Metrix Self Monitoring Blood Glucose System Owner’s Booklet” for the current True Metrix Monitor (RE4TVH09) that was being used, revealed in part: “We recommend performing Control Tests for practice before using your meter for the first time to test your blood. Control Tests should be performed: o For practice to ensure your testing technique is good, o Occasionally as you use a vial of test strips, o When opening a new vial of test strips, o If results seem unusually high or low, o If a vial has been left opened or exposed to extreme heat or cold, or humidity, o Whenever a check on performance of the system is needed, o If meter damage is suspected (meter was dropped, crushed, wet, etc.)” A review of the Glucometer Log revealed no documentation of the quality controls being performed on 05/08/2025 and 05/09/2025. This had the potential to affect the outcome of treatment being performed on 2 (#R2, #R3) of 2 (#R2, #R3) patients having capillary blood glucose monitoring being performed with subsequent treatment being administered based on these results. In an interview on 05/12/2025 at 4:15 PM, S4LPN confirmed the above mentioned findings, the quality controls should be performed daily, and during the days mentioned in the above findings Patient #6 and #7 blood glucose was monitored via the glucometer without quality controls being performed. 2) Failure to ensure Emergency Cart checks were performed daily A review of hospital policy, “Nursing Crash Cart & Emergency,” no policy number, effective date or indication of governing body approval available and was presented as the policy related to the crash cart, revealed in part: “Licensed professionals will be assigned to check the crash cart lock and defibrillator monitor daily at the beginning of the day shift. Any equipment found to be non-functioning or in questionable operating condition will be reported immediately. Medications dates and integrity will be check to ensure no medications have expired. The pharmacy consult will inspect the crash cart on a monthly basis. Procedure: Crash Cart: Tamper locks are to be inspected daily. Drawers one (1) and two (2) if tamper lock is broken, the drawer will be checked for missing items and the items replaced immediately. A new lock will be installed by pharmacy. The entire contents of the drawers will be checked against the supply checklist on the clipboard located on top of the crash cart.” Observations during a hospital walk-though on 05/12/2025 from 03:15 PM to 4:45 PM revealed the emergency code cart located on the main hallway in front of the nursing station with no tamper resistant lock securing the medication drawer. A review of the Emergency Cart Checklist revealed no documentation of the emergency cart being checked: 01/01/2025 to 01/09/2025; 01/13/2025 to 01/31/2025; 02/01/2025 to 02/12/2025; 02/15/2025 to 02/28/2025; 03/01/2025 to 03/26/2025; 03/28/2025 to 03/31/2025; 04/01/2025 to 04/09/2025; and 04/11/2025 to 04/30/20/2025. In an interview on 05/12/2025 and present during the hospital walk-through, S4DON confirmed the above mentioned findings.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections within the hospital. This deficient practice was evidenced by: 1) Failure to properly clean the glucometer after patient use; and 2) Failure to properly clean equipment after patient use. Findings: 1) Failure to properly clean the glucometer after patient use A review of hospital policy, “Policy and Procedure: Infection Control” no policy number, effective date or indication of governing body approval available. A date at the bottom of the page was partially blotted out with white out. This policy revealed in part: “The Hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control and investigation of infections and communicable diseases. The facility maintains an infection control program. The facility is monitored for cleanliness routinely. The facility employees housekeeping staff that is trained on infection control practices. There is an infection control manual that is used as a reference to follow. There is an infection control specialist that rounds and makes recommendations as necessary. The Director of Nursing will review with Administration as necessary to make the recommendations as applicable.” Observations during a hospital walk-though on 05/12/2025 from 03:15 PM to 4:45 PM revealed S5LPN cleaning the True Metrix Blood Glucose Monitor with 2 x 2 alcohol pads. In an interview on 05/12/2025 at 4:20 PM, S5LPN confirmed the above mentioned findings and further confirmed Santi-wipe was not used to clean the meter. 2) Failure to properly clean equipment after patient use A review of hospital policy, “Policy and Procedure: Infection Control” no policy number, effective date or indication of governing body approval available. A date at the bottom of the page was partially blotted out with white out. This policy revealed in part: “The Hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control and investigation of infections and communicable diseases. The facility maintains an infection control program. The facility is monitored for cleanliness routinely. The facility employees housekeeping staff that is trained on infection control practices. There is an infection control manual that is used as a reference to follow. There is an infection control specialist that rounds and makes recommendations as necessary. The Director of Nursing will review with Administration as necessary to make the recommendations as applicable.” Observations during a hospital walk-though on 05/12/2025 from 03:15 PM to 4:45 PM revealed the following surfaces containing remnants of substances that do not allow for the proper cleaning of surface to prevent infectious disease from harboring and remaining in these areas: Room “a” had tan/brown crusty substances on the left hand rail and the chair next to the bed had black sticky substance approximately 1 inch by 1 inch on the seat cushion; Room “d” had 2 area on the left side rail containing clear tape wrapped around the top edging; 2 Mindray Vital Sign Monitors on rolling carts. Both monitors had numerous areas of sticky substance resembling the prior placement of stickers on either side of the monitor’s plastic enclosures. Also the associated oxygen saturation finger probe of each of these monitors had tape wrapped around them; Medline No-touch Forehead Thermometer found in the supply basket of one of the vital sign carts had tape holding the battery in place; and Portable SaO2 monitor found in the supply basket of one the vital sign carts had tape holding the battery in place. In an interview on 05/12/2025 and present during the hospital walk-through, S1CEO confirmed the above mentioned findings and further confirmed these surfaces had not been properly cleaned and the surfaces identified with tape and stickiness could not be properly cleaned in their present condition.”

“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: 48051 Based on record reviews and interview, the facility failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by: 1) the facility to failed ensure the QAPI Program specified the method and frequency of data collection for indicators as evidenced by failure to have a documented QAPI Plan or documented evidence of current data on quality indicators (see findings in Tag A-0273); 2) the facility’s governing body failed to ensure the QAPI program reflects the complexity of the hospital’s organization and services, involves all hospital departments and services and maintains and demonstrates evidence of its QAPI program. This deficient practice was evidenced by the failure to provide a QAPI plan or any findings, data or functions of QAPI taking place (see findings in Tag A-0308); and 3) the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the facility’s performance by having insufficient staff designated to conduct the QAPI functions of the facility. This deficient practice is evidenced by assigning this responsibility to S11QA who is not a full time employee and oversees 3 locations for this provider (see findings in Tag A-0315).”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the facility failed to ensure compliance with patient rights as required by the state regulations for Behavioral Health Service providers. The deficient practice was evidenced by: 1) failure to post a copy of patient rights in a conspicuous location in the offsite Behavioral Health clinic; and 2) failure to ensure all patient rights were included in facility policy and communicated to patients. Findings: 1) failure to post a copy of patient rights in a conspicuous location in the offsite Behavioral Health clinic Observations during a facility walk through on 04/01/2025 at 2:43 PM failed to reveal the patients’ rights posted in the facility. In interview on 04/01/2024 at 2:45 PM, S1CEO verified the patients’ rights were not posted in the facility. 2) failure to ensure all patient rights were included in facility policy and communicated to patients A review of facility policy, “Bethesda Outpatient Program, Subject: Client Rights,” Policy #: BOP - 030, with an effective date of 12/02/2022 and last reviewed on 12/28/2023, and the review of information presented to and signed by the patient on admissions, “Patients’ Legal and Human Rights,” failed to reveal the following patient rights set forth in the state regulations for Behavioral Health Service providers: The right to have a family member, chosen representative and/or his or her own physician notified of admission to the BHS provider at the request of the client; The right to receive treatment and medical services without discrimination based on race, age, religion, national origin, gender, sexual orientation, or disability; The right to receive care in a safe setting; The right to receive the services of a translator or interpreter, if applicable, to facilitate communication between the client and the staff; The right to participate or refuse to participate in experimental research when the client gives informed, written consent to such participation, or when a client’s parent or legal guardian provides such consent, when applicable, in accordance with federal and state laws and regulations; The right to be informed, in writing, of the policies and procedures for filing a grievance and their review and resolution; The right to receive treatment in the least restrictive environment that meets the client’s needs; The right to not be restrained or secluded in violation of federal and state laws, rules and regulations; The right to be informed in advance of all estimated charges and any limitations on the length of services at the time of admission or within 72 hours; The right to be informed of the nature and purpose of any services rendered, the title of personnel providing that service, the risks, benefits, and side effects of all proposed treatment and medications the probable health and mental health consequences of refusing treatment, and other available treatments which may be appropriate; and The right to have a copy of these rights, which includes the information to contact HSS during routine business hours. In interview on 04/01/2024 at 4:30 PM, S2SWPD confirmed the above mentioned findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure the patient’s right to received care in a safe setting. This deficient practice was evidenced by: 1) failure to document a provider admission order to designate the outpatient program level of care on 3 (#1 - #3) of 3 (#1 - #3) medical records reviewed; 2) failure to ensure 4 (S4PhD, S6RN, S8MHT, S10FNP) of 6 (S2SWPD, S4PhD, S6RN, S7MHT, S8MHT, S10FNP) personnel files revealed documentation of training in de-escalation techniques; 3) failure to ensure 1 (S8MHT) of 2 (S7MHT, S8MHT) unlicensed personnel were screened through the Louisiana Department of Health (LDH) Adverse Actions Website prior to hire; and 4) failure to ensure a patient or non-patient contacting the facility via telephone in a crisis situation is appropriately and timely referred to appropriate care. Findings: 1) failure to document a provider admission order to designate the outpatient program level of care on 3 (#1 - #3) of 3 (#1 - #3) medical records reviewed A review of Patients #1 - #3 medical records failed to reveal a provider order for admission to the BHS provider’s outpatient program and a designation of the level of care to be provided. The proper level of care could not be identified without a provider order. This could create an unsafe setting for a patient with the potential to not be properly monitored. In an interview on 04/01/2025 at 11:35 AM, S3LPN confirmed the above mentioned findings. In an interview on 04/01/2025 at 1:35 PM, S2SWPD confirmed an admission order to a program was not written for the above mentioned patients. 2) failure to ensure 4 (S4PhD, S6RN, S8MHT, S10FNP) of 6 (S2SWPD, S4PhD, S6RN, S7MHT, S8MHT, S10FNP) personnel files revealed documentation of training in de-escalation techniques A review of S4PhD, S6RN, S8MHT, and S10FNP personnel files failed to reveal documentation of de-escalation training. This could potentially create an unsafe setting for a patient(s) who exhibit escalating behaviors. In an interview on 04/01/2025 at 2:41 PM, S2SWPD confirmed the above mentioned findings and further confirmed the above mentioned personnel would be scheduled to complete this training soon. 3) failure to ensure 1 (S8MHT) of 2 (S7MHT, S8MHT) unlicensed personnel were screened through the Louisiana Department of Health (LDH) Adverse Actions Website prior to hire Review of LAC: Title 48, Chapter 92, Direct Service Worker Registry, revealed in part, the following: 9202. C. Licensed and/or certified health care providers shall access the registry to determine if there is a finding that a prospective hire, or currently employed or contracted DSW, has been determined to have committed exploitation, extortion, abuse or neglect of an individual being supported, or misappropriated the individual’s property or funds. If there is such a finding on the registry, the prospective employee shall not be hired as a DSW nor shall a current employee have continued employment as a DSW with the licensed and/or certified health care provider. §9231. Health Care Provider Responsibilities, A. Prior to hiring any DSW or trainee, the licensed and/or certified health care provider shall: 3. access the registry in accordance with the provisions of §9202.C-C.1. Review of the Louisiana State Adverse Actions List Search website revealed in part: Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual’s property or funds. If there is such a finding on the registry, the prospective employee shall not be hired. A review of S8MHT personnel file revealed a date of hire as 02/24/2025 and failed to reveal documentation of the LDH Adverse Actions Website verification prior to hire. This could create an unsafe setting for patient(s) being observed and monitored by an unlicensed staff member that has been placed on this list for an offense. In an interview on 04/01/2025 at 3:00 PM, S9OC confirmed the above mentioned findings 4) failure to ensure a patient or non-patient contacting the facility via telephone in a crisis situation is appropriately and timely referred to appropriate care A review of facility policy, “Bethesda Outpatient Program, Subject: Inquiry/Screening,” Policy #: BOP - 008, with an effective date of 12/02/2021 and last reviewed on 12/22/2022, revealed in part: “Inquiry/Screening: Policy: It is the policy of Bethesda Outpatient Program to provide services for intake assessments and referrals by trained professionals. Staff will be available weekdays between the hours of 8:00am and 4:00pm weekdays. After hours calls will be returned on the following business day. Purpose: To provide a systematic method for monitoring and processing admission inquiries to the outpatient programs while providing accurate and timely assessments.” Observations upon arrival to the off-site location of the facility on 03/31/2025 at 7:55 AM revealed the entry door locked, the interior of the facility appearing dark and a sign on the door revealed, “Bethesda Behavioral Health Programs 756 Colonial Drive Suite B 225-778-5214.” Attempt to contact the facility at the before mentioned number revealed a voice mail. In an interview on 04/01/2025 at 11:57 AM, S1CEO confirmed the telephone were going to voice mail and should be forwarded to staff member’s cell phone. S1CEO confirmed if the message went to an unanswered voice mail, it could potentially have a negative effect on a patient in crisis.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure the patient’s right to be free from all forms of abuse or harassment. This deficient practice was evidenced by the failure to ensure potential allegations and/or suspicion of abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations. Findings: Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or LDH. This statute would include any issue under review for the determination whether the facility failed to take prudent action to prevent, and/or respond to an alleged occurrence such as a potential self-injurious behavior or an elopement. A review facility incident reports revealed Patient #1 left the facility on 03/26/2025. A review of a written statement by S12LMSW dated 03/26/2025 at 11:00 AM revealed in part: “on the above date and approximate time while doing group, [Patient #1] walked out of the room as if he was going to the bathroom. Group started again at 11:00 AM he did not return so I asked staff where was he and if they saw him.” A review of a written statement by S7MHT dated 03/26/2025, no time documented, revealed in part: the patient was thought to be in the restroom, but after a search, it was determined he was not in the restroom or the building. In an interview on 04/01/2025 at 2:33 PM, S3LPN confirmed the facility has not submitted a self-report to HSS regarding the Patient #1 leaving the facility. In an interview on 04/01/2025 from 9:00 AM, S2SWPD confirmed Patient #1 left the facility on 03/26/2025 during the time frame of group session #2 from 10:00 AM to 10:45 AM. Patient #1 asked for restroom break and at some point during this break, Patient #1 exited the facility unattended and the staff were unaware he had left the building. She further confirmed the facility had not reported the incident to HSS.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure the QAPI Program specified the method and frequency of data collection for indicators as evidenced by failure to have a documented QAPI Plan or documented evidence of current data on quality indicators. Findings: A request was initiated with the initial document request upon entry on 03/31/2025 at 9:00 AM with S3LPN. This included: QAPI committee meetings and indicators/outliers from 10/01/2024 to 03/01/2025; QAPI Plan and program with governing body approval. The following policies were received from S1CEO on 03/31/2025 at 1:00 PM: “Bethesda, Subject: Performance Improvement,” policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025 and “Bethesda, Subject: Performance Measurement & Management,” policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025. The information received did not reveal a QAPI data, meeting minutes or QI plan. In an interview on 03/31/2025 at 1:00 PM, S1CEO confirmed these policies and indicated the facility was “working on the QI Plan and on the data.” A request was initiated on 03/31/2025 at 3:30 PM with S2SWPD for the QI Plan and QAPI data. In an interview on 03/31/2025 at 3:30 PM S2SWPD confirmed she would have this information in the morning. A review of meeting minutes identified by S1CEO as Departmental Meeting on 01/15/2025, no time available and Governing Body meeting minutes from 02/25/2025 at 4:30 PM failed to reveal documentation related to QAPI discussion. In an interview on 04/01/2025 at 11:57 AM. S1CEO confirmed the above information and the facility was “working on the QI Plan and gathering the data.” The following policy was received from S1CEO on 04/01/2025 at 3:25 PM: “Bethesda, Subject: Performance Improvement Policy,” policy number not available, an effective date of 06/01/2021, last reviewed on 10/15/2024. The information received did not reveal QAPI data, meeting minutes or QI plan. In an interview on 04/01/2025 at 3:25 PM. S1CEO confirmed all information for QAPI had been presented to the surveyors. He indicated we could contact S11QA for further questions and he initiated a phone call with S11QA for the surveyors to discuss. In a telephone interview on 04/01/2025 at 3:25 PM, S11QA confirmed the before mentioned policies and further confirmed the facility had no QAPI Plan and no other information to present.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility’s governing body failed to ensure the QAPI program reflects the complexity of the facility’s organization and services, involves all facility’s departments and services and maintains and demonstrates evidence of its QAPI program. This deficient practice was evidenced by the failure to provide a QAPI plan or any findings, data or functions of QAPI taking place. Findings: A request was initiated with the initial document request upon entry on 03/31/2025 at 9:00 AM with S3LPN. This included: QAPI committee meetings and indicators/outliers from 10/01/2024 to 03/01/2025; QAPI Plan and program with governing body approval. The following policies were received from S1CEO on 03/31/2025 at 1:00 PM: “Bethesda, Subject: Performance Improvement,” policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025 and “Bethesda, Subject: Performance Measurement & Management,” policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025. The information received did not reveal a QAPI data, meeting minutes or QI plan. In an interview on 03/31/2025 at 1:00 PM, S1CEO confirmed these policies and indicated the facility was “working on the QI Plan and on the data.” A request was initiated on 03/31/2025 at 3:30 PM with S2SWPD for the QI Plan and QAPI data. In an interview on 03/31/2025 at 3:30 PM S2SWPD confirmed she would have this information in the morning. A review of meeting minutes identified by S1CEO as Departmental Meeting on 01/15/2025, no time available and Governing Body meeting minutes from 02/25/2025 at 4:30 PM failed to reveal documentation related to QAPI discussion. In an interview on 04/01/2025 at 11:57 AM. S1CEO confirmed the above information and the facility was “working on the QI Plan and gathering the data.” The following policy was received from S1CEO on 04/01/2025 at 3:25 PM: “Bethesda, Subject: Performance Improvement Policy,” policy number not available, an effective date of 06/01/2021, last reviewed on 10/15/2024. The information received did not reveal QAPI data, meeting minutes or QI plan. In an interview on 04/01/2025 at 3:25 PM. S1CEO confirmed all information for QAPI had been presented to the surveyors. He indicated we could contact S11QA for further questions and he initiated a phone call with S11QA for the surveyors to discuss. In a telephone interview on 04/01/2025 at 3:25 PM, S11QA confirmed the before mentioned policies and further confirmed the facility had no QAPI Plan and no other information to present.”

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 48051 Based on record review and interview, the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the facility’s performance by having insufficient staff designated to conduct the QAPI functions of the facility. This deficient practice is evidenced by assigning this responsibility to S11QA who is not a full time employee and oversees 3 locations for this provider. Findings: A request was initiated with the initial document request upon entry on 03/31/2025 at 9:00 AM with S3LPN. This included: QAPI committee meetings and indicators/outliers from 10/01/2024 to 03/01/2025; QAPI Plan and program with governing body approval. The following policies were received from S1CEO on 03/31/2025 at 1:00 PM: “Bethesda, Subject: Performance Improvement,” policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025 and “Bethesda, Subject: Performance Measurement & Management,” policy number not available, an effective date of 01/20/2022 and last reviewed on 02/16/2025. The information received did not reveal a QAPI data, meeting minutes or QI plan. In an interview on 03/31/2025 at 1:00 PM, S1CEO confirmed these policies and indicated the facility was “working on the QI Plan and on the data.” A request was initiated on 03/31/2025 at 3:30 PM with S2SWPD for the QI Plan and QAPI data. In an interview on 03/31/2025 at 3:30 PM S2SWPD confirmed she would have this information in the morning. A review of meeting minutes identified by S1CEO as Departmental Meeting on 01/15/2025, no time available and Governing Body meeting minutes from 02/25/2025 at 4:30 PM failed to reveal documentation related to QAPI discussion. In an interview on 04/01/2025 at 11:57 AM. S1CEO confirmed the above information and the facility was “working on the QI Plan and gathering the data.” The following policy was received from S1CEO on 04/01/2025 at 3:25 PM: “Bethesda, Subject: Performance Improvement Policy,” policy number not available, an effective date of 06/01/2021, last reviewed on 10/15/2024. The information received did not reveal QAPI data, meeting minutes or QI plan. In an interview on 04/01/2025 at 3:25 PM. S1CEO confirmed all information for QAPI had been presented to the surveyors. He indicated we could contact S11QA for further questions and he initiated a phone call with S11QA for the surveyors to discuss. In a telephone interview on 04/01/2025 at 3:25 PM, S11QA confirmed the before mentioned policies and further confirmed the facility had no QAPI Plan and no other information to present. In an interview on 04/01/2025 at 4:50 PM, S1CEO confirmed S11QA was the personnel assigned to quality assurance for all 3 facilities.”