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A 023 We respectfully request

that this item be removed from


the Statement of Deficiencies
because it is mistaken in its
statement concerning Missouri
State Law and exceeds the State
Survey Agency’s authority under
Missouri State Law. The
Missouri statute concerning the
employee disqualification list
(Section 660.315, RSMo) states
only that “[n]o person,
corporation, organization, or
association who received the
employee disqualification list
under subdivisions (1) to (5)
of subsection 11 of this
section shall knowingly employ
any person who is on the
employee disqualification
list.” The statute does not
state that the list must be
checked “no less than annually
and periodically on all
employees as long as the
employee is working at the
facility” as stated by the
State Survey Agency. Nor has
the State Survey Agency or
other Missouri state agency
promulgated a rule interpreting
Section 660.315 to establish
such a requirement.
Continued page 2
To the extent that this
statement of the State Survey
Agency reflects its
interpretation of Section
660.315,Missouri State Law
prohibits the State Survey Effective
agency from establishing such 2/15/2011
requirement by interpretation
without going through
established statutory rulemaking
process. See Sections
536.010(6) and 536.021, RSMo.
In any event, University of
Missouri Healthcare is not
subject to the requirements of
Section 660.315 because it is
not one of the types of entities
identified in subdivisions (1)
to (5) of subsection 11 of
Section 660.315.
In an effort to comply with the
surveyor interpretation,Human
Resources Department has
implemented a policy that
requires the department to
periodically check all current
employees against the state EDL.
This will be completed quarterly
by the HR Department. An EDL
audit was completed 1/24/2011.
The audit showed no current
employees were on the EDL. The
Chief Human Resources Officer is
responsible for the
implementation action.
The Plan of Correction for Tag
115, the Condition of Patient
Rights is addressed under the
individual tags related to the
condition.
A0143
A0144
A0154
The hospital respectfully
disagrees with this finding. We
post the Patient Rights and
Responsibilities in public and
conspicuous places throughout
the inpatient and outpatient
facilities to provide this
information to patients and
2/28/11
visitors. In addition, all
inpatients are provided a
personal copy of the Patient
Rights and Responsibilities. In
the outpatient areas, the Rights
and Responsibilities are posted
at each registration desk. To
comply with the surveyor
interpretation, the hospital has
instituted a new process that
requires both inpatients and
outpatients to be provided
education on the Patient Rights
and Responsibilities.
Registration staff will present
and discuss with each patient a
summary of the Patient Rights
and Responsibilities. Each
patient will be offered a full
copy after the discussion.
Patients will then sign the
Conditions of Service Agreement
acknowledging that they were
provided the Patient Rights and
Responsibilities.
cont. page 5
This documentation will then
become a part of the patient
registration record. The
Director of Patient Financial
Services in conjunction with the
Director of Clinical Operations
will be responsible for the
overall implementation of this
process.
Other important actions and
responsible parties include:
- Documenting that patients
received a copy and understood
their Rights and
Responsibilities.
Responsible party: Manager,
Registration; Clinic Managers

Training of Registration staff


will be completed by 2/25/2011.
Responsible parties: Revenue
Cycle Training Department with
overall responsibility by
Director of Financial Services
in conjunction with Director of
Clinical Operations.
University of Missouri Health
Care has signs conspicuously
posted throughout the
facilities that inform patients
and visitors that the 1/25/2011
organization utilizes closed
circuit cameras to monitor for
safety and security. Upon
entering the Emergency Room,
there is a sign in the
Registration area that states
the ER is being monitored by
closed circuit TV. The Sleep
Lab has for many years provided
education to all patients,both
verbally and in written pre-
procedural educational
documents, that the patient
will be video recorded as a
part of the procedure.
To comply with this most recent
interpretation of the
standards, the hospital has
placed signs informing the
patients in the Sleep Lab rooms
and the Trauma Room that these
areas are under surveillance.
Signs are provided for the
portable monitoring equipment
used for epilepsy monitoring of
patients in regular inpatient
rooms.
Continued page 7.
Additional signs were placed
before the completion of the
survey and the surveyors were
made aware of this action before
they exited the hospital on
1/25/2011. In addition to the
additional signage, wording has
been added to the Conditions of
Service informing patients that
UMHC uses closed circuit
monitoring for safety and
security purposes. All patients
will be asked to validate by
their signatures that they are
aware persons entering these
facilities are being monitored
by closed circuit television for
their safety and security.
Responsible party: Manager of
Regulatory Affairs.
A 143
The hospital respectfully
disagrees with this finding
because current policy already 1/26/11
does not allow patients to
change clothes in their rooms.
We would also like the record to
reflect that the bedroom door
windows were initially installed
as a result of a past DHSS
survey that cited the facility
for not being able to observe
the patients while the patients
were in their rooms. In order to
comply with the most recent
standard interpretation,
curtains have been placed over
the windows of the doors in the
behavioral health pediatric unit.
Responsible party: MU Psychiatric
Center Director of Clinical
Operations

See Page 11 for Tag A 144.


The hospital would like the
record to reflect that these
observations were never cited by
DHSS surveyors in the past when
the facility was operated by the
state. UMHC took ownership of
this facility on July 1, 2009
from the Missouri State
Department of Mental Health. At
that time, UMHC informed all
state parties involved in the
transfer of ownership, including
the state legislature, that the
facility was in need of
significant renovation and
repair. The Missouri Legislature1/25/2011
approved the transfer and
provided funding to accomplish
the renovations. UMHC prepared
a work plan that outlines the
time line and the funding for
each repair. As an example, the
second floor unit is being
completely rebuilt and relocated
with the expected opening of the
new unit to take place in April
2011. The new unit will be a
state-of-the-art psychiatric
unit.
Cont. page 12
While we are in process of these
renovations,the psychiatric
staff has an existing process
for screening each patient for
potential suicide risk and
providing the appropriate level
of monitoring. If a patient is
determined to be at risk for
suicide or destructive behavior,
the patient may be assigned an
escort and is monitored closely
at all times. As shared at the
time of survey, UMHC believes
our screening and monitoring
process has been effective at
preventing suicides, as
evidenced by a lack of suicide
attempts in the restrooms over
the past 15 years.
Since not all patients are at
risk for suicide or destructive
behavior, the hospital is
concerned that restricting
bathroom access and providing
constant visualization of all
patients utilizing the bathrooms
does not respect the patients’
rights to dignity and privacy.
However, we complied with the
surveyors' request to
immediately lock the bathrooms
and monitor patients while in
the bathroom until renovations
can be completed.
We initiated renovation of these
restrooms as follows:
Adult Unit #1, 3South
Women’s Restroom: The remodel as
requested by the surveyors'
interpretation was completed
1/25/11.
Men’s Restroom: The remodel is
completed pending a safety
retrofit of plumbing fixtures.
Restroom is locked until a
patient makes a request and then
patient’s usage is restricted by
constant staff monitoring.
Expected completion date is
2/26/11.
Adult Inpatient Unit #2, 2
South
Women’s and Men’s Restrooms:
These restrooms are locked
until a patient requests to use
the restroom. Then the patient
is monitored by the staff. New
anti-ligature shower heads and
bathroom fixtures are being
installed. Once the
installation of the new
bathroom fixtures has taken
place, the restroom will be
open to patients.
Continued on page 14
This unit is scheduled to be
relocated to a newly remodeled,
state-of-the-art unit in April
2011. Responsible party: MU
Psychiatric Center Director of
Clinical Operations.

2. The hospital respectfully


disagrees with these
observations. The nurse
assigned to these patients
states that she could see the
access ports of two of the
patients in question. One
patient had the access port in
the groin area and that patient
was allowed to cover himself
enough to ensure his privacy but
the nurse could see the access
port from her vantage point.
The second patient's access port
was also visible to the nurse
from her vantage point.
The third patient was cold and
had just pulled his blanket up
above his access port.
Cont. page 15
The surveyor made the
observations from the doorway of
the unit and was not in the same
position as the nurse to
visualize the access ports in
question. 2/24/11
In order to comply with the
finding, however, the hospital
has implemented the following
plan.
The policy and procedure for
initiation of dialysis has been
amended to reflect the current
practice of ensuring visibility
of access ports at all times
during hemodialysis treatment.
The need to have hemodialysis
access sites visible to staff at
all times has been reinforced at
staff meetings.
Patients will be instructed at
initiation of treatment that
sites must be visible to staff
at all times for patient safety.
Monitoring and audits will be
performed in the hemodialysis
unit to verify compliance with
visibility of sites.

The Dialysis Manager will be


responsible for enforcing and
monitoring these practices.
University of Missouri Health
Care’s existing emergency plan
for horizontal and vertical
evacuation has been augmented
with the development of a unit-
specific plan for the NICU at 2/24/11
Women’s and Children’s Hospital.
NICU staff assembled a
multidisciplinary team,
including clinical staff,
administration and Emergency
Management leadership, to
develop and document the
emergency evacuation process.
The plan clarifies staff
responsibilities, details the
necessary equipment and
supplies. The plan calls for
all babies to be evacuated in
keeping with national standards
that triage the evacuation order
based on immediate danger,
patient stability and level of
acuity. NICU staff will be
educated regarding the plan on
Feb. 22-24. The manager of the
NICU in conjunction with the
interim director of Support
Services are responsible for
implementing the plan. See
Attachment A.
The hospital policy has been
revised so that handcuffs will
not be used on a patient unless
the patient’s behavior is
considered a criminal action 2/9/2011
and the incident will be
reported to the appropriate law
enforcement agency. Non-metal
escort devices will be used in
areas where other types of
restraints cannot be used.
These escort devices will only
be used in accordance with a
physician's order. All
hospital security officers have
been educated to the
requirements of the new policy.
The Manager of Hospital
Security will be responsible
for the implementation and
monitoring of these actions.
See page 21 for A 168.
The hospital has amended the
restraint policy to reflect that
when manual holds are initiated
by a staff member a physician
order is to be obtained. The
revised policy now states the
following;
10. If a patient is placed in a
manual hold, an order for this
3/10/11
type of restraint is required.
These changes were approved by
the Executive Committee of the
Medical Staff on 2/21/11 and
will be distributed to the
medical staff. Hospital staff
will be informed of these
amendments through internal
communications.
The Coordinator of Professional
Nursing, the Chief of Staff and
Chief Medical Officer will be
responsible for implementing
these changes.
A176 UMHC has amended the
restraint policies to reflect
the following changes to
physician education on the use
of restraints.
14. Resident physicians will
receive education on the use
and application of restraints
and seclusion as part of the
resident physicians new hire
orientation.
15. Credentialed physicians
will complete education related
to restraint and seclusion upon
initial credentialing and
recredentialing.
All currently credentialed 3/10/11
medical staff members will
receive individual copies of
the restraint policies and a
educational summary of their
responsibilities in the use of
restraints.

The Chief of Staff and Chief


Medical Officer will be
responsible for implementation
of this action.
3/11/11

A267
Language Services is responsible
for the ongoing process of
monitoring, evaluating and
improving quality of care and 3/11/11
patient safety for the patients
we serve. Our two focus areas
for improving our services are
1) determine the specific
language needs of our patient
population and 2) educate staff
how to identify Limited English
Proficiency (LEP) and Deaf/Hard
of Hearing (DHH) patients and
how to access services to meet
patient needs. We will report
to the MUHC Quality and Patient
Safety Committee twice yearly
with performance data based on
manager evaluations in clinical
areas utilizing Language
Services.
Cont. page 26
Manager evaluations will assess
whether Language Services 1)
provides timely/efficient/
accurate services and 2)
responds to concerns in an
effective and timely manner.
Based on these results,
additional expectations for
performance improvement and
reporting will be defined.
The Director of Patient Family
Centered Care will be
responsible for the
implementation of this action.

The damaged doors were repaired


or replaced by maintenance
1/25/11
staff on 1/25/11.
The Associate Director of
Facilities and Building
Operations is responsible for
implementing and monitoring of
this project.
A 749
The hospital will respond to
this finding by increased
education, monitoring and
accountability for failure to
enforce or comply with hand
hygiene standards. 3/10/11
1.Infection Control has
developed and deployed new
screen savers on patient care
computers that emphasize hand
hygiene between glove changes.
IC staff members have provided
education to staff in the MU
Psychiatric Center in regard to
medication passes. IC will
provide additional education to
the Food Service staff on proper
hand hygiene during food
handling. This also includes
proper utilization of hair and
beard coverings.
IC will also train managers and
supervisors in observation
techniques.
Cont. page 28
2. In addition to monitoring in
the ICUs and ED, the hospital
will increase monitoring to
include all departments with
patient contact. Managers and
Supervisors will round in their
areas daily.
• A Hand Hygiene Monitoring
Tool has been developed to
record hand hygiene
observations. Immediate
feedback will be given to staff
at the time of observation.
• Observations of other staff
will be sent to the appropriate
manager.
Completed forms will be sent to
Infection Control. Infection
Control will review the data
and send collated information
back to all departments.
Outcomes will be shared with
senior leadership and medical
staff and posted in each area
for staff to review.
3.Any employee with multiple
infractions will be counseled
by his/her manager and failure
to improve will result in
progressive discipline.
Responsible party: Chief
Operating Officer in
conjunction with Manager of
Infection Control.

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