Mdacc Cms Poc Final 10-03-19

The University of Texas MD Anderson Cancer Center
Plan of Correction – August 23, 2019 Survey
Provider Name The University of Texas MD Anderson Cancer Provider # 450076 Survey Exit Date – 8/23/2019
Center
Address 1515 Holcombe Blvd., Houston, TX 77030 Survey Type - Tags: A043; A046; A049; A084;
Recertification A094; A115; A117; A131; A143;
A144; A146; A167; A263; A283;
A286; A385; A392; A395; A396;
A405; A489; A491; A494; A536;
A547; A618; A701; A724; A747;
A749; A940; A1005; A1076;
A1077
Preparation and execution of this Plan of Correction does not constitute an admission or agreement by The University of Texas MD Anderson
Cancer Center (Hospital) to the allegations or conclusions set forth in the Form CMS-2567 (Statement of Deficiencies). This Plan of Correction is
prepared and executed solely because provisions of federal law require it. None of the actions by Hospital pursuant to its Plan of Correction
should be considered an admission that a deficiency existed or that additional measures should have been in place at the time of the survey.
Through a collaborative effort of the Hospital, Administration, Nursing Staff, the Medical Staff and the Governing Body, Hospital has taken prompt
and significant corrective action to ensure compliance with the Conditions of Participation over time to ensure safe, quality care for patients.
Accordingly, the Hospital respectfully requests that the Centers for Medicare and Medicaid Services (CMS) accept this Plan of Correction as
credible evidence of current and long-term sustained compliance with the Conditions of Participation.
A000 Initial Comments

Please note that the following Plan of Correction is in response to the August 23, 2019, survey conducted by the CMS and the Texas Health and
Human Services Commission (THHSC).
Page 1 of 141
Tag A 043 (§482.12). There must be an effective governing body that is legally responsible for the conduct of the Hospital. If a hospital
does not have an organized governing body, the persons legally responsible for the conduct of the Hospital must carry out the functions
specified in this part that pertain to the governing body.
Tag A 043. Hospital maintains an effective Governing Body that is legally responsible for the conduct of the Hospital. Alternatively, if
Hospital does not have an organized Governing Body, the persons legally responsible for the conduct of the Hospital carry out the
functions specified in this part that pertain to the Governing Body.
Tag Plan for correcting Procedure for implementing the Follow-up / Monitoring Person
A 043 the deficiency acceptable Plan of Correction Responsible /
Completion Date
A 043 The Chancellor of The Hospital obtained a legal opinion The Hospital will obtain designation from Governing Body
The University of from the Associate Vice Chancellor & the Chancellor, on behalf of the Board of
Texas System, in Deputy General Counsel of The Regents, to confirm the appointment of the Completion Date:
accordance with his University of Texas System regarding Governing Body in the event there is a 10/26/19
statutory authority the appointment of the Governing change in Governing Body.
to act on behalf of Body for the Hospital.
the Board of The Chief Operating Officer or designee will
Regents, confirmed The opinion, obtained on 9/18/19, monitor the minutes of the Governing Body
the appointment of confirms the following: Chancellor meetings so the minutes clearly reflect
Dr. Peter Pisters, James B. Milliken is the chief Governing Body actions consistent with the
M.D., to serve as executive officer of The University of Governing Body’s responsibility for the total
Governing Body of Texas System, a 14-institution system operation of the Hospital. Any deficiencies
the Hospital. of higher education that includes the will be reported to the Governing Body.
Hospital. As Chancellor, Milliken is
The Governing Body authorized to exercise “all the powers
modified its method and authorities of the Board of
for documenting the Regents in the governance of the UT
discharge of its System.” In addition, the Chancellor
responsibilities for has direct line responsibility for all
the total operation aspects of UT System operations.
of the Hospital, to
provide a clear On 8/23/19, the Chancellor confirmed
Page 2 of 141
indication that the appointment of the individual, Dr.

Governing Body is Peter Pisters, as the Governing Body
discharging its of the Hospital, and executed the
responsibilities. Governing Body Charter.
A new format for

the Governing Body
meetings was
developed and
implemented, to
clearly reflect
Governing Body
actions, including
oversight, approvals
and direction for
operation of the
Hospital.
The minutes of
Governing Body
meetings will
include clear
delineation of the
advisory role of the
Executive
Leadership Team
(ELT) and any other
attendees, and the
Governing Body’s
ultimate legal
responsibility for
the conduct of the
Hospital, including
oversight, approval
Page 3 of 141
and direction.
The Governing Body

has taken and
overseen swift and
effective corrective
actions to address
each of the alleged
deficiencies cited
below. Please refer
to Plans of
Correction under
Tags A0046, A0049,
A0084, A0094,
A0144, A0117,
A0131, A0143,
A0146, A0167,
A0283, A0286,
A0392, A0395,
A0396, A0405,
A0491, A0494,
A0618, A0724,
A0749, A0940, and
A1076, each of
which is
incorporated into
this Plan of
Correction.
Page 4 of 141
Tag A 046. The governing body must appoint members of the medical staff after considering the recommendations of the existing members
of the medical staff
Tag A 046. The Governing Body ensures that members of the Medical Staff, including practitioners seeking Temporary Privileges, are
appointed by the Governing Body, after considering the recommendations of existing members of the Medial Staff.
the deficiency acceptable Plan of Correction Responsible /
Completion Date
A 046 The Medical Staff The Chief Medical Officer will The ECMS Chair or designee will monitor the Chief Medical
Bylaws were revised provide education in-person at approval process for temporary privileges Officer
to reflect that all scheduled committee meetings or granted for a 3-month period, to confirm
requests for by written communication to compliance with the process as outlined in the Completion Date:
Temporary Privileges Department Chairs, Division Heads, Medical Staff Bylaws and the policy. The results 10/26/19
are approved by the Credentials Committee of the of the monitoring will be reported monthly to
Governing Body, on Medical Staff (CCMS) members and the ECMS and the Governing Body, if temporary
recommendation of ECMS members, regarding the privileges were approved during the month; and
the Chair of the ECMS process for approving Temporary once at the end of the 3-month monitoring
or designee and a Privileges at the Hospital, including period. After 3 months, the frequency of
peer member of the the Governing Body’s approval of all monitoring will be reassessed by the Chair of
Medical Staff; and Temporary Privileges. ECMS in conjunction with the Governing Body.
that such Privileges Deficiencies will be addressed by the ECMS and
terminate at the the Governing Body.
expiration of the
granting period or the Monitoring activities will begin on or before
resolution of the 10/26/19.
patient need,
whichever is earlier.
The Medical Staff
Bylaws will be
submitted for
approval by a vote of
the Medical Staff on
Page 5 of 141
10/15/19, and
submitted for
approval by the
Governing Body.
A policy on
Temporary Privileges
for Important Patient
Needs will be
submitted for
approval by ECMS
and the Governing
Body on or before
10/22/19.
Page 6 of 141
Tag A 049. The governing body must ensure that the medical staff is accountable to the governing body for the quality of care provided to
patients
Completion Date
A 049 The Medical Staff The HVU monitors patients Emergency blood product releases will be Chair, ECMS
Bylaws were revised receiving blood products in real audited by the Laboratory Medicine Safety and
to reflect that the time through use of data analytics Quality Officer (LM-SQO) to confirm compliance Completion Date:
Medical Staff is tools. Structured data such as vital with the process outlined in the policy. 10/26/19
accountable to the signs and clinician documentation
Governing Body for within the electronic health record The Transfusion and Patient Blood Management
the quality of care contribute to an institution- Committee will perform retrospective reviews of
provided to patients. developed transfusion reaction risk all cases where a patient receives 4 or more units
The Medical Staff number. This number is used to of RBCs in a 24-hour period (exclusive of blood
Bylaws will be prioritize patients for real time products administered in the Operating Rooms)
submitted for records reviews by an RN under the to identify trends in practices relating to RBC
approval by the supervision of a Transfusion transfusions.
Medical Staff on Medicine Advanced Practice
10/15/19 and Provider (TM-APP) or Transfusion The Transfusion and Patient Blood Management
submitted for Medicine physician (TMP), to Committee will perform retrospective reviews of
approval by the complement the monitoring being all serious transfusion reactions to confirm
Governing Body on or provided at the bedside. The risk completion of the transfusion reaction workup
before 10/22/19. number for each patient is updated and identify opportunities for improvement.
in real time, highlighting patients
To demonstrate the exhibiting potential signs of a The results of the review and recommendations
Medical Staff’s reaction. Signs of a reaction prompt for improvement are reported to the ECMS and
accountability for the a formal evaluation by a TM-APP QAPI Council monthly for 3 months. The QAPI
quality of care related supervised by a TMP, who directs a Council will provide a quarterly summation to the
to blood component transfusion reaction workup if Governing Body. After 3 months, the QAPI
administration and appropriate based on clinical Council will determine whether reporting to the
transfusion, the indications. The care team may also QAPI Council and the Governing Body should
following actions will contact the HVU and initiate a continue, and whether the frequency should be
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be taken: transfusion reaction workup based adjusted (up or down) based on performance.
on observed signs and symptoms.
The Blood The TMP determines diagnosis, Any Credentialed Provider deficiencies will be
Component attribution, and severity according addressed through pertinent education and
Administration and to the CDC hemovigilance training, re-education and/or referral for
Transfusion Reaction surveillance protocol, and confidential peer review through the Medical
Policy CLN1115 will documents findings in the electronic Staff, and reported to the Governing Body in
be revised to clarify medical record. accordance with the Medical Staff Bylaws.
the requirement for a
signed order before The incidents cited regarding Monitoring activities will begin on or before
or after emergency patients DG1, DG2, and DG3 were 10/26/19.
release of blood referred to the medical staff for
products, and to limit confidential peer review on
the authority to order 9/19/19. Where deemed
emergency release of appropriate, the involved providers
blood products to were counseled and re-educated.
physicians only. The
policy revisions will
be submitted for
approval by ECMS
and the Governing
Body on or before
10/22/19.
The Hemovigilance
Unit (HVU) will be
fully utilized to
monitor signs and
symptoms of
transfusion reactions,
and reporting
reactions when
suspected.
Page 8 of 141
Quality monitoring
related to rapid
transfusion of
multiple units of RBCs
and workup of
suspected transfusion
reactions will be
implemented with
reporting to ECMS,
Quality Assessment
and Performance
Improvement (QAPI)
Council, and the
Governing Body.
Page 9 of 141
Tag A-084 (§482.12(e)(1)) The governing body must ensure that the services performed under a contract are provided in a safe and effective
manner.
Tag A-084 MD Anderson’s governing body ensures that the services performed under a contract are provided in a safe and effective manner.
Completion Date
A- For deficiencies By 9/20/19, the Chief Nursing On or before 10/26/19, Nursing leadership will Chief Operating
084 related to QAPI Officer completed a review of perform quarterly audits of 100% of contracted Officer
Council activities in contracts for nursing services to (1) nursing personnel files to confirm competency
Nursing or Dialysis, assess competency KPIs and assessments are current. Completion Date:
also refer to A 263, outcomes sufficiency, (2) assess 10/26/19
which addresses vendor’s reporting obligations to Audit deficiencies with the vendor will be
requirements for Hospital, and (3) evaluate needed addressed at the Nursing Operations meeting, so
reporting local and changes to competencies, that nurse competencies are corrected or
institutional documentation and reporting. alternate personnel are provided.
performance
improvement Sourcing and Contract KPI deficiencies and recommendations for
projects, including Management and Legal Services improvements are reported to QAPI Council
the format, content will work with Nursing leadership monthly, with a summation to the Governing Body
and schedule of to amend relevant nursing services quarterly.
reporting, and is contracts as needed to reflect
incorporated into updated KPIs and vendor’s After three months of monitoring ongoing vendor
this Plan of reporting obligations. performance by QAPI Council, the QAPI Council
Correction. will determine whether the duration and
Nursing leadership will review frequency of continued monitoring should be
In September 2019, personnel files for contracted adjusted (up or down) based on performance.
Nursing leadership nurses providing services as of the
identified contracts date of review to confirm staff Monitoring activities will begin on or before
for nursing services competencies are adequate for the 10/26/19.
to confirm services provided.
competency key Nursing Operations will conduct a review, at least
performance Competency review will be annually, of the vendor contract to confirm KPI
Page 10 of 141
indicators (KPIs) and conducted by the Associate and outcomes sufficiency.

make necessary Director of the Nurse Staffing
changes in order to Office or designee upon on-
confirm that services boarding for contracted nursing
performed under the staff. The Associate Director of the
contracts are Nurse Staffing Office or designee
provided in a safe will confirm contracted nurse staff
and effective who are on-site for longer than a
manner. year undergo annual competency
validation. Associate Director of
the Nurse Staffing Office or
Nursing leadership designee will also confirm
will revise Hospital’s competency validation for
process for contracted nursing staff who are
assessment and engaged during institutional
monitoring of implementation of new
contracted nurse competencies.
competencies.
Nursing leadership will address
competency deficiencies with the
nurse staffing vendors as necessary
to confirm nurse competencies are
corrected or alternate personnel
are provided.
During the week of Sourcing and Contract Compliance with requirements to deliver clean
August 12, 2019, the Management and Legal Services linens in a clean vehicle is monitored by the
Associate Vice will work with the Materials Materials Management Director or designee
President, Supply Management Director or designee through the use of a checklist which is completed
Chain Management to amend the laundry services at the time of delivery.
reviewed the contract to include the following
contract for laundry KPIs: The Materials Management Director or designee
services to review 1. a requirement that will perform a sample inspection of each shipment
Page 11 of 141
KPI and outcomes delivered linens be delivered by Texas Medical Center (TMC) by the
sufficiency. protected from following method:
environmental - One cart/bin will be pulled and 10 items
On August 15, 2019, contaminants through will be reviewed for stains.
the Materials appropriate wrapping and
Management vehicle cleanliness, - In addition, monthly inspections of the
Director, Chief 2. a requirement that sterile TMC laundry will be performed by the
Operating Officer, a linens/gowns are kept Materials Management Director or
representative from sterile during transport designee to assess the soiled sort area,
Hospital Infection from the laundry facility to cart wash area, folding area, prep (load
Control and the the Hospital operating and wrap) area, and the sterile pack room.
vendor met to rooms through appropriate Concerns will be shared promptly with the
discuss laundry wrapping, and laundry general manager.
quality. 3. maintenance and reporting
of sterilization logs for - Results of compliance monitoring will be
The contract for deliveries to Hospital. shared with the TMC laundry during
laundry services will quarterly meetings and will be reported
be amended to Beginning in September 2019, monthly to the Infection Control
include appropriate meetings will occur at least Committee.
KPIs related to quarterly to review performance
environmental metrics and outcomes data with The results of the review and recommendations
contaminants and vendor and Hospital for improvement are reported to the QAPI Council
maintaining sterile representatives from some or all of monthly. The QAPI Council will provide a
linens/gowns during the following departments: quarterly summation to the Governing Body.
transport. Sourcing and Contract After 3 months, the QAPI Council will determine
Management, Infection Control, whether reporting to the QAPI Council and the
Nursing, Ambulatory Services, Governing Body should continue, and whether the
Inpatient Services. frequency should be adjusted (up or down) based
on performance.
Supply Chain Management will conduct a review

of the vendor contract, at least annually, to
confirm KPI and outcomes sufficiency.
Page 12 of 141
Monitoring will begin on or before 10/26/19.
On 9/19/19 the On 9/19/19 the Director of

Director of Perioperative Services confirmed
Perioperative that a Brainlab engineer is on-site
Services confirmed during scheduled cases. The
the presence of a Director of Perioperative Services
Brainlab engineer on- confirmed that the Brainlab
site and the vendor engineer does not direct Magnetic
contract with Resonance Imaging and radiology
Brainlab will be staff in performing necessary scans
amended to prior to surgery. The engineer’s
accurately reflect the scope of services is limited to
Brainlab engineer’s technical support of imaging
obligations. integration between Brainlab and
imaging equipment.
Sourcing and Contract

Management will work with the
Director of Perioperative Services
to amend the Brainlab contract’s
Statement of Work to accurately
reflect the Brainlab engineer’s
scope of services.
A process for As of 9/4/19, a Contracted Services KPI deficiencies and recommendations for
developing and Metrics Team consisting of improvements are reported to QAPI Council
monitoring key individuals from Sourcing and monthly, with a summation to the Governing Body
performance Contract Management, Legal quarterly.
indicators for Services, Office of Performance
Page 13 of 141
contracted services Improvement and Office of Chief After three months of monitoring ongoing vendor
will be implemented Quality Officer began regular performance by QAPI Council, the QAPI Council
so that the meetings to: will determine whether the duration and
Governing Body can - Identify relevant Hospital frequency of continued monitoring should be
ensure that contracts for services adjusted (up or down) based on performance.
contracted services - Assign administrative and
are performed in a clinical stakeholders for each On a monthly basis, Chief Quality Officer and Chief
safe and effective contract Operating Officer or designees will review a
manner. - Facilitate review of KPI random sample of 10 service contracts to jointly
sufficiency monitor the contracted services process to
- Facilitate review of outcomes ensure:
KPIs will be data for KPIs tracked by - Contracts underwent KPI sufficiency review
developed as contract stakeholders - KPIs are tracked by contract stakeholders
necessary for the - Modify contracts based on KPI - Contracts with outcomes deficiencies are
Leica Bond RX and outcomes review as presented to QAPI Council and further
contract, the Abbott necessary reported to the Governing Body
capital equipment - Implement a process for - QAPI Council recommendations are
service agreement, escalating contracts with implemented and monitored pursuant to the
the Belimed OR outcomes deficiencies to QAPI QAPI Plan
Single Sterilizer Full Council which are then further
Service Agreement, reported to the Governing Chief Quality Officer and Chief Operating Officer
the Gulf Coast Body or designees will address audit deficiencies in
Testing Agreement, - Develop a contract consultation with QAPI Council and Governing
the National management tool to identify Body.
Children’s Laboratory clinical contracts for services
Services Contract, and facilitate KPI monitoring Monitoring will begin on or before 10/26/19.
the Viracor – IBT /
Eurofins Contract, As of 9/4/19, the Contracted
Castle Bioscience- Services Metrics Team established
Molecular Genetics a regular cadence of meetings
Test Contract, and during which minutes, agendas,
Carefusion. and attendance logs are
maintained.
As of 9/27/19,
Page 14 of 141
clinical review of KPIs On or before 10/22/19, ADM0128

developed for the Supply Chain Management Policy
Best Care EMS and will be revised to reflect procedural
Cross Country requirements for contracted
Staffing contracts is services agreements. The policy
complete. will include procedures related to
KPI development and
monitoring,and QAPI Council and
Governing Body review.
An institution-wide communication
will be circulated educating
affected workforce members on
their responsibilities to ensure
contracts for services have
appropriate KPIs and that
outcomes data are being
monitored in accordance with
contract terms and the QAPI Plan.
Sourcing and Contract

Management and Legal Services
will amend, renew, or enter into
new agreements, as appropriate,
to ensure services are not provided
under expired contracts and to
reflect changes recommended by
QAPI Council.
Contract stakeholders will review

contracts to confirm KPI and
outcomes sufficiency at least
annually.
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Tag A-094 (§482.12(f)(3)) If emergency services are provided at the Hospital but are not provided at one or more off-campus departments of
the Hospital, the governing body of the Hospital must assure that the medical staff has written policies and procedures in effect with respect
to the off-campus department(s) for appraisal of emergencies and referral when appropriate.
Tag A-094 The Governing Body ensures that the medical staff has written policies and procedures in effect with respect to the off-campus
department(s) for appraisal of emergencies and referral when appropriate.
Completion Date
A- On 9/20/19, Code Based on the completed At least annually, Code Blue Operations leadership Emergency
094 Blue Operations assessment, ACLS response and will round on each off-campus location to assess Readiness Officer
leadership, senior crash carts will remain in place at employee training needs, placement of crash carts
Ambulatory the following outpatient off- and emergency supplies, and review of response Completion Date:
leadership, and campus locations: algorithms. 10/26/19
Medical Staff leaders
developed criteria to • Proton Therapy Center Ambulatory medical and administrative leadership
determine the level • West Houston Houston and Code Blue Operations leadership will review
of life support Area Location (HAL) emergency 9-1-1 activations at each off campus
response needed, at • The Woodlands HAL outpatient service location that utilizes BLS
each off campus response. The review will be performed monthly
outpatient service Based on the assessment, the level for 3 months in order to evaluate need for further
location, prior to the of response required for the resources or training. The Medical Director of
arrival of 9-1-1 Mohs/Dermasurgery Center was Code Blue Operations and the Emergency
personnel. changed from ACLS response to Readiness Officer will communicate with Medical
BLS response. and Administrative Directors of each location to
Utilizing these address any deficiencies with the staff training or
criteria, an Educational information will be emergency responses in the off-campus locations.
assessment was provided for current clinical staff at
completed and the off-campus outpatient service Monitoring activities will begin on or before
level of response locations on the revisions to the 10/26/19.
needed at each off Cardiopulmonary Resuscitation
Page 16 of 141
campus outpatient (CPR) Services & Emergency The results of the review and recommendations
service location was Medical Response (Code Blue) for improvement are reported to ECMS and QAPI
determined. Policy (CLN0506), including the Council monthly. The QAPI Council will provide a
Based on the level of level of life support service quarterly summation to the Governing Body.
response needed provided at each location. After 3 months, the QAPI Council will determine
(basic vs. advanced), The following information will be whether reporting to the QAPI Council and the
the necessary provided in writing and in face-to- Governing Body should continue, and whether the
supplies, including face huddles to affected staff frequency should be adjusted (up or down) based
crash carts, staff members: on performance.
training, pagers and
paging systems and Advanced life support locations:
maintenance of
training was • Medical emergency
determined. Facilities response algorithm to
with advanced life include ACLS response with
support response activation of 9-1-1
have a Code Blue • Review of crash cart
Team, a defibrillator contents
and crash cart with • Plan for mock code drills
ACLS medications for ACLS
and supplies. • Method of activating a
Facilities with basic Code Blue response call
life support response • Method of reporting 9-1-1
have staff trained in calls and entering Safety
BLS, an AED and Intelligence events
basic emergency
medical supplies. Basic life support locations:
In addition, the • Medical emergency

Cardiopulmonary response algorithm to
Resuscitation (CPR) include BLS response with
Services activation of 911
& Emergency • Review of emergency
Medical Response
Page 17 of 141
(Code Blue) medical supplies

Policy (CLN0506) was • Plan for mock code drills
updated to include for BLS
criteria for advanced • Method of reporting 9-1-1
life support response calls and entering Safety
(Code Blue Teams) at Intelligence events
locations within the
institution, staff
qualifications and
supplies for each
level of support, and
ongoing monitoring
of the level of
support needed at
locations.
Updates to policy
CLN0506 will be
submitted for
approval by ECMS
and the Governing
Body on or before
10/22/19.
In addition, the
Medical Emergencies
section of the
Emergency
Operations Plan for
each off campus
outpatient service
location was
removed as the
information is
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covered in CLN0506
where location-
specific response is
outlined.
Page 19 of 141
Tag A-115 (§482.13) The Hospital must protect and promote each patient’s rights.
Tag A-115 The Hospital protects and promotes each patient’s rights.
Tag Plan for correcting Procedure for implementing the Follow-up / Monitoring Person Responsible
the deficiency acceptable Plan of Correction / Completion Date
A- Please refer to the Associate VP,

115 plans of correction Patient Experience
for A117, A131,
A143, A144, A146 Completion Date:
and A167, each of 10/26/19
which is
incorporated into
this Plan of
Correction.
Page 20 of 141
Tag A-117 (§482.13(a)(1)) Patient Rights: Notice of Rights

Tag A-117 The Hospital informs each patient, or when appropriate, the patient’s representative of the patient’s rights in advance of furnishing
or discontinuing patient care whenever possible.
A- Between 9/6/19 and Outpatients: Outpatients: Assoc. VP, Patient

117 9/19/19, an Experience
interdisciplinary Registration staff members were A monthly compliance report for patient rights
team consisting of given educational information will be reviewed, analyzed, and opportunities for Completion Date:
Inpatient Operations, regarding their obligations to offer improvement identified by the VP, Ambulatory 10/26/19
Ambulatory and to document the offer of the Services or designee.
Operations, Patient patients’ rights information by
Experience, 8/22/19. Monitoring activities will begin on or before
Information 10/26/19.
Technology and Reminder communication regarding
Diagnostic Imaging patient rights information will be Deficiencies will be addressed through staff re-
met to identify sent to current registration staff. education and/or progressive disciplinary action,
opportunities for as appropriate.
improvement in our Educational information on the
existing processes of provision of the patients’ rights The results of the review and recommendations
providing patient’s document has been incorporated in for improvement are reported to the QAPI
rights’ information. the on-boarding process for new Council monthly. The QAPI Council will provide a
registration staff. quarterly summation to the Governing Body.
After 3 months, the QAPI Council will determine
Inpatients: whether reporting to the QAPI Council and the
Governing Body should continue, and whether
A daily report was created to the frequency should be adjusted (up or down)
monitor compliance with delivery of based on performance. .
the patient rights document to
inpatients. This report is monitored
by the Admissions department and
patient rights information is Inpatients:
delivered to inpatients who have
Page 21 of 141
not yet received their patient rights. A monthly compliance report for patient rights
will be reviewed, analyzed, and opportunities for
Reminder communication regarding improvement identified by the VP, Inpatient
patient rights information will be Services or designee.
sent to current registration staff.
Monitoring activities will begin on or before
Education and training on the 10/26/19.
provision of the patients’ rights
document has been incorporated in Deficiencies will be addressed through staff re-
the on-boarding process for new education and/or progressive disciplinary action,
registration staff. as appropriate.
The results of the review and recommendations

for improvement are reported to the QAPI
Council monthly. The QAPI Council will provide a
quarterly summation to the Governing Body.
whether reporting to the QAPI Council and the
the frequency should be adjusted (up or down)
based on performance.
Page 22 of 141
Tag A-131 (§482.13(b)(2)) Patient Rights: Informed Consent

Tag A-131 The Hospital ensures each patient’s right to informed consent
A- On 8/22/19 an Modifications to the EHR are being The Associate Director of the Division of Chair of Anesthesia
131 interdisciplinary made to support the informed Anesthesiology, Critical Care, and Pain Medicine and Perioperative
team consisting of consent for anesthesia during or designee will review a minimum of 30 patients Medicine
representatives from proton therapy as follows: under treatment each month (or, if there are
Anesthesia and fewer than 30 patients in a month, the audit will Completion Date:
Perioperative • On 9/19/19, added a dropdown be 100% of patients under treatment) to confirm 10/26/19
Medicine, to the electronic anesthesia that consents have the appropriate language for
Information consent to indicate if a repeated anesthetics related to a series of
Technology, Legal treatment is for a series, in treatments.
Services and the which case the provider
Office of specifies the duration of the Monitoring activities will begin on or before
Performance treatment on the anesthesia 10/26/19.
Improvement met to consent.
identify • On 9/19/19, added the Deficiencies with consents will be addressed by
opportunities for following language to the the Chair of Anesthesia and Perioperative
improvement in anesthesia consent to clarify Medicine or designee through pertinent
Hospital’s processes (re)education and training, and/or confidential
who will be providing
of obtaining peer review as appropriate.
anesthesia services to the
informed consent for
patient: “I (we) voluntarily The results of the review and recommendations
anesthesia during
request that anesthesia and/or for improvement are reported to the QAPI
proton therapy
treatment. perioperative pain management Council monthly. The QAPI Council will provide a
care (analgesia) as indicated quarterly summation to the Governing Body.
below be administered to me After 3 months, the QAPI Council will determine
(the patient). I (we) understand whether reporting to the QAPI Council and the
it will be administered by MDA Governing Body should continue, and whether
Provider Obtaining Consent| the frequency should be adjusted (up or down)
<<Physician Name>> and/or based on performance.
such associates, technical
Page 23 of 141
assistants and other health care

providers as necessary.
Perioperative means the period
shortly before, during and
shortly after the procedure.”
• A checkbox will be added to the
pre-anesthesia note to clarify
that the patient reaffirms their
consent to receive anesthesia
for proton therapy treatment.
On 9/17/19, Anesthesia Providers

received educational information at
a faculty meeting regarding the
changes to the anesthesia informed
consent process.
On 9/19/19, the Division on
Anesthesiology, Critical Care, and
Pain Medicine sent an email
communication to Anesthesia
Providers reinforcing the changes to
the anesthesia informed consent
process.
Anesthesia Providers who provide
anesthesia care to pediatric patients
in Proton Therapy and Radiation
Oncology will receive educational
information at a faculty meeting
regarding the changes to the pre-
anesthesia note.
Page 24 of 141
The Department of Anesthesiology

will send an email communication
to Anesthesia Providers who
provide anesthesia care to pediatric
patients in Proton Therapy and
Radiation Oncology regarding the
changes to the pre-anesthesia note.
Anesthesia Providers who provide
anesthesia care to pediatric patients
in Proton Therapy and Radiation
Oncology and are on leave must
receive one-on-one education
before return to duty.
Page 25 of 141
Tag A-143 (§482.13(c)(1) Patient Rights: Personal Privacy

Tag A-143 The Hospital ensures each patient’s right to personal privacy
A- On 9/19/19, an On 8/28/19, providers who are The Associate Vice President for Perioperative The Associate Vice
143 interdisciplinary responsible for obtaining surgical Services or designee will audit a sample of at President for
team consisting of informed consent received least 70 procedures per month to confirm Perioperative
representatives from educational information through consents contain appropriate language regarding Services
the Division of email communications. video monitoring and recording.
Surgery, Patient Completion Date:
Experience, On 9/19/19, providers who are Monitoring activities will begin on or before 10/26/19
Perioperative responsible for obtaining anesthesia 10/26/19.
Services, and informed consent received
Deficiencies with consents will be addressed by
Information educational information through
Technology, met to the Associate Vice President for Perioperative
email communications.
identify Services or designee through pertinent
improvements in Educational Information will be (re)education and training, and/or confidential
informed consent to reinforced to providers who are peer review as appropriate.
include consent for responsible for obtaining surgical or
video monitoring and anesthesia informed consent at
recording during Perioperative, Division of Surgery
procedures. and Department of Anesthesia
meetings.
On 8/29/19, the After 3 months, the QAPI Council will determine
following verbiage whether reporting to the QAPI Council and the
was added to Governing Body should continue, and whether
“Disclosure and
Consent Medical and based on performance.
Surgical Procedure”
and on 9/19/19 to
the “Disclosure and
Consent Anesthesia
Page 26 of 141
and/or
Perioperative/Peri-
procedure Pain
Management
(Analgesia)” form:
“I consent to this
procedure being
photographed
and/or video
recorded. These
images may be used
for quality, safety,
and educational
purposes.”
Page 27 of 141
Tag A-144 (§482.13(c)(2)) Patient Rights: Care in a safe setting

Tag A- The Hospital ensures each patient’s right to care in a safe setting.
A– On 8/22/19, the On 8/20/19, Pain Director of Perioperative Nursing or designee will Executive Director,
144 A- Anesthesia Pain Management/Anesthesia Faculty audit 100% of the charts of patients receiving low Professional
F Management and Pain Management Center staff dose ketamine for pain management for nursing Practice, Strategy
physicians ceased were notified by the Department monitoring and documentation, weekly for 4 and Execution
use of low dose Chair and Ad-interim Nurse weeks and then monthly for 2 months. The
ketamine in the Pain Manager that low dose ketamine results of the monitoring will be reported to Completion Date:
Management Center. infusion, with or without low dose Nursing Operations monthly. 10/26/2019
midazolam, will not be performed in
Procedures involving the Pain Management Center until Monitoring activities will begin on or before
low dose ketamine, further notice. 10/26/19.
with or without low
dose midazolam, The Department Chair for Pain The Unit Leaders or designees will address
scheduled after this Management or designee will deficiencies with the nursing staff member
date are being provide educational information to through pertinent education and training, re-
performed in the current physicians who order low education, and/or disciplinary action, as
Non-OR dose ketamine regarding the appropriate.
Procedure/PACU Attachment to the “Pain
location, where Management Policy” for Low Dose Individual physician deficiencies will be
either the Anesthesia Ketamine. This information will addressed through pertinent education and
Pain Management include the setting of training, re-education, and/or referral for
physician or a nurse administration, dosage and route of confidential peer review trough the Medical
with applicable administration, monitoring during Staff, if appropriate.
competencies for and after administration, and
low dose ketamine discharge processes. The results of the review and recommendations
monitors the patient. for improvement are reported to the QAPI
Physicians who order low dose Council monthly. The QAPI Council will provide a
A multidisciplinary ketamine who did not receive the quarterly summation to the Governing Body.
team of Pain educational information will receive After 3 months, the QAPI Council will determine
Management one-on-one education from the whether reporting to the QAPI Council and the
Page 28 of 141
Faculty, Nursing, and Department Chair for Pain Governing Body should continue, and whether
Pharmacy reviewed Management or designee before the frequency should be adjusted (up or down)
Texas Board of return to duty. based on performance.
Nursing, ASPAN
(American Society of The Attachment to the “Pain
Peri-Anesthesia Management Policy” for Low Dose
Nurses) guidelines, Ketamine will be communicated to
and SOPs from current nursing staff who care for
external outpatient patients who receive low dose
pain management ketamine through one-on-one
centers. education by the Nurse Educator or
designee. In addition, nursing
A multidisciplinary competencies for Low Dose
team of Pain Ketamine will be assessed by
Management 10/26/19 and annually thereafter.
Faculty, Nursing, and
Pharmacy reviewed Nursing staff who care for patients
the minimal who receive low dose ketamine but
Anxiolysis (Minimal are on leave must receive this
Sedation) for education before return to duty.
Procedure Policy
(CLN0502), and New nursing staff who will care for
standard of care patients who receive low dose
literature on Low ketamine will receive this education
Dose Ketamine as part of on-boarding.
intravenous
administration. Pain
medicine physicians
administer low dose
IV midazolam, if
needed, as a
premedication to
prevent ketamine
side effects.
Page 29 of 141
In phone
consultation with
CMS on 10/1/19,
CMS agreed that the
infusion of low dose
ketamine (not to
exceed 1 mg/kg),
with or without
midazolam (not to
exceed 2 mg), does
not meet the criteria
for conscious
sedation.
In phone
consultation with
CMS on 10/1/19, the
Hospital confirmed
that conscious
sedation is limited to
areas where staff
have appropriate
competencies for
monitoring conscious
sedation.
On 10/1/19, the
Pharmacy &
Therapeutics
committee ratified
the off-label use of
low dose ketamine,
with or without
Page 30 of 141
midazolam, for pain

management and
affirmed the opinion
of CMS that the
infusion of low dose
ketamine (not to
exceed 1 mg/kg),
with or without
midazolam (not to
exceed 2 mg), does
not meet the criteria
for conscious
sedation.
An Attachment to
the “Pain
Management Policy”
CLN0540 policy was
developed for Low
Dose Ketamine
Intravenous
Administration for
Pain Management.
The Policy will be
submitted for
approval to ECMS
and to the Governing
Body, on or before
10/22/19.
Hospital developed
an audit tool to
monitor and assess
nursing
Page 31 of 141
documentation in
patient charts
regarding Low Dose
Ketamine
Intravenous
Administration, with
or without low dose
midazolam,
including, but not
limited to, the
patient’s RASS score,
vital sign
assessments, pain
scores, and discharge
time.
A– Beginning 8/15/2019 Educational information on dialysis The Hospital Nurse Manager of Hemodialysis or
144 G an interdisciplinary machine programming and designee will conduct a review of 30 physician
team consisting of concentration levels was furnished orders each month (or, if there are fewer than 30
the Nursing Director to Dialysis Nurses on 8/21/2019. physician orders in any month, the review will be
of Specialty Services, 100% of physician orders) to confirm the
Nephrology Medical Reinforcement of the educational machine concentration selections match the
Staff representatives information on the new procedure physician orders.
and representatives will be provided to nurses who
from a contracted perform dialysis on or before Monitoring activities will begin on or before
renal service met 10/21/2019. 10/26/19.
several times to
review the dialysis The results of the review and recommendations
prescription process for improvements will be reported to the Dialysis
and identify QAPI Council.
opportunities for
improvement. The Dialysis QAPI Council will provide a
summation to the QAPI Council quarterly.
The interdisciplinary
team recognized the The QAPI Council will provide a quarterly
Page 32 of 141
limitation of the summation to the Governing Body. After 3

2008K hemodialysis months, the QAPI Council will determine whether
machine to 10 reporting to the QAPI Council and the Governing
available potassium Body should continue, and whether the
bath concentration frequency should be adjusted (up or down) based
levels. The on performance.
Nephrology Medical
staff selected their The Hospital Nurse Manager of Hemodialysis or
top 10 concentration designee will address deficiencies with the
options and these individual nursing staff member through
were programmed pertinent education and training, re-education
into the machines. and/or disciplinary action, as appropriate.
A Standard
Operating Procedure
will be created to
permit a biomedical
technician to
reprogram the
machine to address
orders outside of the
10 identified
potassium bath
concentrations.
When a machine is
reprogrammed to
accommodate an
order outside the 10
identified potassium
bath concentrations,
the machine will be
removed from
service until it can be
programmed back to
Page 33 of 141
the 10 standard
potassium bath
concentrations.
The Contract Nurse

noted in the
Statement of
Deficiencies was
referred to the
contracted renal
service for follow up.
A– On 8/14/19, during On 8/14/2019, the dialysis nurse Please refer to monitoring in Tag A–0144(I),
144 H the survey, the who did not alert the Clinical Unit which is incorporated into this Plan of Correction.
Nursing Director of Nurse to the empty enteral feeding
Specialty Services bag was promptly reeducated by
investigated the the Nurse Manager of Hemodialysis.
incident regarding
the enteral feeding The Clinical Unit Nurse who did not
and implemented follow physician orders for enteral
immediate corrective feeding will be reeducated.
action.
Educational information for the
On 8/14/2019, dialysis nurses on the practice of
during the survey an notifying the Clinical Unit Nurse of
interdisciplinary an empty enteral feeding bag will be
team consisting of reviewed at a staff meeting with
the Nursing Director dialysis nurses. Dialysis nurses on
of Specialty Services, leave must receive educational
Nursing Leadership information regarding reporting for
representatives and enteral feeding bags before return
representatives from to duty.
the contracted renal
service met to review Current dialysis nurses will receive
Page 34 of 141
the process for in-person training on following

administering enteral physician orders.
feeding and post
feed flushes and to Dialysis nurses who are on leave
identify must complete training before
opportunities for return to duty.
improvement.
Education and training is
incorporated in the on-boarding
process for new Dialysis Nurses.
A– The Executive Dialysis Nurses will receive in- Unit Leaders or designees will round with dialysis
144 I Director of Quality person training on following nurses weekly for one month to review physician
Safety and Research physician orders, including orders, including pulmonary function tests, VRE
developed a tracking pulmonary function tests, VRE cultures, enteral tube feeding, and daily weights,
tool for compliance cultures, enteral tube feeding, and were followed.
with physician orders daily weights.
for pulmonary Unit Leadership or designee will audit a sample of
function tests, VRE Unit leadership received training 35 charts per month to confirm that physician
cultures, enteral and review of chart review process orders were followed. In addition, the Hospital
tube feeding, and from the Clinical Informatics team. Nurse Manager of Hemodialysis will review 100%
daily weights. of charts of patient who receive dialysis on a
Dialysis Nurses who are on leave weekly basis for 3 months to assess
must complete training before documentation of pre and post weight for
Documentation of return to duty. peritoneal dialysis and hemodialysis.
pre-dialysis and post-
dialysis weight for all Education and training is The results of the review and recommendations
types of dialysis were incorporated in the on-boarding for improvement are reported to the Dialysis
added to the Dialysis process for new Dialysis Nurses. QAPI Council and Nursing Operations monthly for
QAPI plan as at least three months. After 3 months, Nursing
additional quality Operations will determine whether reporting to
indicators to be the Dialysis QAPI Council and Nursing Operations
Page 35 of 141
tracked and should continue and whether the frequency

monitored. should be adjusted (up or down) based on
performance. Reporting to QAPI Council will be
in accordance with the IRG reporting schedule
and standards.

10/26/19.
The Unit Leaders or designees will address

deficiencies with the individual dialysis nurse
through pertinent education and training, re-
education and/or disciplinary action, as
appropriate.
A– 8/23/19, during the Additional inventory of the screw Please refer to monitoring in Tag A–0144(I)
144 J survey, the Nursing top wands was ordered and regarding daily weight monitoring, which is
Director of Specialty received on 9/20/19. incorporated into this Plan of Correction.
Services investigated
the incident of All non-screw top wands were
improper wand use discarded and will not be re-
and identified the ordered.
cause as being a lack
of a sufficient Educational information will be
number of screw-top provided to nurses who perform
wands. dialysis to inform them of the
additional inventory and
A storage drying expectations for use.
cabinet will be
installed that allows The Dialysis QAPI Council selected
Page 36 of 141
all wands to be pre and post weights for

stored appropriately Intermediate Hemodialysis and
before placing into Peritoneal Dialysis Patients as a new
self-seal packet quality indicator and began auditing
ready for usage. dialysis orders.
On 8/15/19, during Educational information on the

the survey, an practice of performing and
interdisciplinary documenting pre and post weights
team consisting of will be reviewed at a staff meeting
the Nursing Director with dialysis nurses. Dialysis nurses
of Specialty Services, on leave will receive educational
Nephrology Medical information before return to duty.
Staff representatives
and representatives Education and training on obtaining
from the contracted and documenting pre-and-post
renal service met to dialysis weights has been
review the practice incorporated in the on-boarding
of performing and process for new dialysis nurses.
documenting pre and
post weights for
Intermediate
Hemodialysis and
Peritoneal Dialysis
Patients.
The Contract Dialysis

Nurse noted in the
Statement of
Deficiencies was
referred to the
contracted renal
service for follow up.
Page 37 of 141
A– On 8/19/19, an Nursing Unit Leadership provided The Chief Nursing Officer or designee will review
144 K interdisciplinary one-on-one education to the nurse and investigate reports of chemotherapy spills
team consisting of identified for not reacting to the monthly to confirm adherence to ADM0171
representatives from concern of the patient and caregiver “Chemotherapy Spills and Surface Contamination
Nursing, Patient and not initiating cleaning of a Policy” by Nursing Staff.
Advocacy, met to chemotherapy spill in a timely
review the practice manner. Monitoring activities will begin on or before
of cleaning 10/26/19.
chemotherapy spills Educational information will be
and identified provided through Unit Huddles The Chief Nursing Officer or designee will address
opportunities for deficiencies with the individual staff members
conducted by Unit leaders for
improvement. with (re)education and training, or disciplinary
nurses who administer
action, as appropriate.
chemotherapy on ADM0171
“Chemotherapy Spills and Surface The results of the review and recommendations
Contamination Policy,” with for improvement are reported to Nursing
emphasis on treating reported Operations monthly for at least three months.
chemotherapy spills as actual After 3 months, Nursing Operations will
chemotherapy spills and initiating determine whether reporting to Nursing
timely clean up. Operations should continue and whether the
frequency should be adjusted (up or down) based
Nurses who administer on performance. Reporting to QAPI Council will
chemotherapy and on leave must be in accordance with the IRG reporting schedule
receive educational information and standards.
before their return.
Educational information on
chemotherapy spills has been
incorporated in the on-boarding
process for new nurses who
administer chemotherapy.
Page 38 of 141
Tag A-146 (§482.13(d)) The Hospital must ensure the confidentiality of patient records requirements are met.
Tag A-146 The Hospital ensures confidentiality of patient records.
A- On 9/19/19, a multi- Workforce members in clinical areas Leadership from Institutional Compliance, Clinical VP, Chief
146 disciplinary team with access to paper and electronic Operations, Nursing and Medical Practice or their Compliance and
consisting of PHI will receive educational designees will conduct safeguard reviews of a Ethics Officer
Inpatient Operations, information that will include: rotating sample of clinical areas utilizing the PHI
Ambulatory confidentiality tool to identify opportunities for Completion Date:
Operations, Nursing, • reinforcing their role and improvement. Individualized (re)education with 10/26/19
Patient Experience personal accountability for the involved workforce members will be provided
and Information protecting the as necessary. Potential unauthorized disclosures
Technology, met to confidentiality paper and of PHI will be referred to Institutional Compliance
review policies electronic PHI for further investigation. Safeguard reviews will
related to • tools to assist with occur weekly for four weeks and then monthly
confidentiality of maintaining confidentiality for two months.
patient records of PHI (e.g., tap-in, tap-out,
(referred to as “PHI”) control/alt/delete, secured Monitoring activities will begin on or before
in order to identify disposal bins) 10/26/19.
opportunities for • reporting concerns about
improvements: the confidentiality of PHI in The results of the safeguard reviews and
the Safety Intelligence (SI) recommendations for improvements will be
• ADM1176 Event Reporting System or reported by Institutional Compliance to the QAPI
Patient to Institutional Compliance Council. The QAPI Council will provide a
Privacy: summation to the Governing Body quarterly.
Safeguarding Leadership from Institutional
Paper PHI Compliance, Clinical Operations, After three months of safeguard reviews, the
Policy Nursing and Medical Practice will be QAPI Council will determine whether the
• ADM0335 sent educational information that frequency of reviews and reporting should be
Information will include: adjusted (up or down) based on performance.
Security
Office Policy • evaluating the
for the use confidentiality of PHI as
Page 39 of 141
and part of the safeguard

Protection of reviews
Information • performing immediate
Resources corrective actions, as
needed, to protect the
Policy ADM1176 confidentiality of PHI
Patient Privacy: • conducting immediate
Safeguarding Paper individualized training with
PHI Policy will be the involved employees
revised to include • reporting potential
language that: unauthorized disclosures of
PHI to Institutional
• describes staff Compliance
and
management In addition, the Safety365 Checklist
responsibilities items related to confidentiality of
and PHI will be revised to emphasize the
accountability for educational information distributed
protecting PHI to workforce members, including
• defines methods “Tap In Tap Out,” secure disposal
for securing PHI bins, and reporting concerns about
• defines the confidentiality of PHI in the SI
progressive reporting system.
disciplinary
action associated New workforce members in clinical
with securing PHI areas will receive educational
information on their personal
Policy ADM0335 accountability for securing PHI as
Information Security part of the Institutional New
Office Policy for the Employee Orientation.
Use and Protection
of Information Regarding the specific findings, the
Resources will be following corrective actions will be
revised to include
Page 40 of 141
language that: taken:
• describes staff On G10NW, the specimen collection

and container and log book will be
management moved to a secured location.
responsibilities
and In the Reconstructive Surgery Unit,
accountability for unsecured PHI was removed. A
protecting PHI secured disposal bin will be placed
• defines methods in close proximity.
for securing PHI
In the Gynecologic Oncology Center,
• defines
stored paper PHI was removed from
progressive
the workroom.
disciplinary
action associated
In the Bone Marrow Aspiration
with securing PHI
Clinic, the front desk will be staffed
continuously during business hours.
Institutional
Specimen log sheets were removed
Compliance will
from the Specimen room.
develop a tool to
assess safeguarding In the Head and Neck Center, stored
confidentiality of paper PHI was secured in the
paper and electronic workroom. Audiologists’ office will
PHI. be locked when not in use by staff.
G22 staff will be included in the

educational information regarding
the confidentiality of PHI.
A locking mechanism will be

installed for the Anesthesia
workroom in Pod A and Pod B of the
surgical area to protect
Page 41 of 141
confidentiality of PHI in surgical

suites.
Page 42 of 141
Tag A-167 (§482.13(e)(5)) The use of restraint or seclusion must implemented in accordance with safe and appropriate restraint and seclusion
techniques as determined by hospital policy in accordance with State law.
Tag A-167 The Hospital ensures that all restraints and seclusion are used in accordance with safe and appropriate techniques and in
accordance with hospital policy.
A- On 9/24/19, an Educational information on policy The Patient Safety and Accreditation (PSA) team, Chief Patient Safety
167 interdisciplinary revisions and the updated process with support from the Office of Performance Officer
team consisting of for ordering restraints will be Improvement (OPI), will review at least 50
representatives from distributed by Chief Medical Officer restraint orders monthly for adherence to Completion Date:
Nursing, Pharmacy, or designee to current physicians Restraint Policy CLN0592 requirements for 10/26/19
Information through institutional restraint ordering and patient assessment.
Technology, Patient communication tools. This
Experience and educational information will focus Additionally, PSA and OPI will conduct a monthly
Psychiatry, met to on physicians having a working retrospective review of psychotropic or sedative
review the restraint knowledge of the Restraint Policy medications ordered IV or IM and STAT. Orders
ordering process to including: not associated with an acknowledgment of
identify chemical restraint intention will be reviewed by
opportunities for • Types of restraints the Chair, Psychiatry or designee to determine
improvement. • Order requirements and order whether the medication was ordered as a
Based on this review, authentication chemical restraint.
the following • Physician assessment
improvements will requirements Monitoring activities will begin on or before
be implemented: 10/26/19.
To reinforce physicians’ working
• Revise the knowledge of the restraint policy, a Results will be shared with Nursing Leadership
computerize link to the policy will be interfaced and Medical Staff Leadership.
d order sets into the electronic health record so
to list the the link is available each time a Nursing Leadership will address deficiencies with
most physician orders a restraint. the individual nursing staff member through
commonly pertinent (re)education and training, or
ordered type Providers who order restraints or disciplinary action, as appropriate.
of restraint manage patients in restraints will be
Page 43 of 141
(nonviolent required to complete a formal Medical Staff leadership will address physician
restraints) education module. Thereafter, deficiencies through pertinent (re)education and
first in the formal education will be required training and/or referral for confidential peer
list, to avoid annually. review.
confusion.
Educational information on the Results of restraint and seclusion reviews will be
• Confirm policy revisions and updated reported monthly to the Institutional Patient
physician process will be provided for clinical Safety Committee. Improvement initiatives will
and nursing nurses caring for patients in be implemented as indicated by the results of the
reassessmen restraints to include: review. The Institutional Patient Safety
t and Committee will report the results and
documentati • Requirements for the improvement initiatives monthly for at least
on of patient assessment of patients with three months to the QAPI Council.
response to restraints
the use of • Re-evaluation and The QAPI Council will provide a quarterly
restraints. documentation of the summation to the Governing Body. After 3
effectiveness of restraints. months, the QAPI Council will determine whether
• Develop a reporting to the QAPI Council and the Governing
chemical Clinical nurses who care for patients Body should continue, and whether the
restraint with restraints and are on leave will frequency should be adjusted (up or down) based
ordering receive the educational information on performance.
pathway before return to duty.
triggered by
specific This educational information will be
medications included in new Clinical Nurse on-
and boarding.
indications.
On 8/23/19, Medical Staff
• Revise the leadership provided one-on-one
Restraint education to the physicians
Policy identified as inappropriately
(CLN0592) to ordering violent restraints, when
include non-violent restraints were
specific intended.
Page 44 of 141
requirement
for the use of
chemical
restraint.
Page 45 of 141
Tag A-263 (§482.21) The Hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment
and performance improvement program.
Tag A-263 The Hospital develops, implements and maintains an effective, ongoing, hospital-wide, data-driven quality assessment and
performance improvement program which 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.
A– A process for As of 9/4/19, a Contracted Services KPI deficiencies and recommendations for Chief Operating
263A developing and Metrics Team consisting of improvements are reported to QAPI Council Officer
monitoring key individuals from Sourcing and monthly, with a summation to the Governing
performance Contract Management, Legal Body quarterly. Completion Date:
indicators for Services, Office of Performance 10/26/19
contracted services Improvement and Office of Chief After three months of monitoring ongoing
will be implemented Quality Officer began regular vendor performance by QAPI Council, the QAPI
so that the meetings to: Council will determine whether the duration and
Governing Body can frequency of continued monitoring should be
ensure that - Identify relevant Hospital adjusted (up or down) based on performance.
contracted services contracts for services
are performed in a - Assign administrative and On a monthly basis, Chief Quality Officer and
safe and effective clinical stakeholders for each Chief Operating Officer or designees will review a
manner. contract sample of 10 service contracts to jointly monitor
- Facilitate review of KPI the contracted services process to confirm:
sufficiency
- Facilitate review of outcomes - Contracts underwent KPI sufficiency review
data for KPIs tracked by contract - KPIs are tracked by contract stakeholders
stakeholders - Contracts with outcomes deficiencies are
- Modify contracts based on KPI presented to QAPI Council and further
and outcomes review as reported to the Governing Body
necessary - QAPI Council recommendations are
- Implement a process for implemented and monitored pursuant to the
escalating contracts with QAPI Plan
outcomes deficiencies to QAPI
Page 46 of 141
Council which are then further Monitoring activities will begin on or before
reported to the Governing Body 10/26/19.
- Develop a contract
management tool to identify Chief Quality Officer and Chief Operating Officer
clinical contracts for services or designees will address deficiencies identified
and facilitate KPI monitoring during audits in consultation with QAPI Council
and Governing Body.
As of 9/4/19, the Contracted
Services Metrics Team established a
regular cadence of meetings during
which minutes, agendas, and
attendance logs are maintained.
On or before 10/22/19, ADM0128

Supply Chain Management Policy
will be revised to reflect procedural
requirements for contracted
services agreements. The policy will
include procedures related to KPI
development and monitoring, and
QAPI Council and Governing Body
review.
An institution-wide communication
will be circulated educating affected
workforce members on their
responsibilities to confirm contracts
for services have appropriate KPIs
and that outcomes data are being
monitored in accordance with
contract terms and the QAPI Plan.
Sourcing and Contract Management

and Legal Services will amend,
Page 47 of 141
renew, or enter into new

agreements, as appropriate, so
services are not provided under
expired contracts and to reflect
changes recommended by QAPI
Council.
Contract stakeholders will review

contracts to confirm KPI and
outcomes sufficiency at least
annually.
A- QAPI Council and Institutional Performance and QAPI Council meetings minutes will be reviewed
263B Governing Body will Quality Improvement projects by the Chief Operating Officer or designee to
document and track originating from: validate Critical and Sentinel Event action plans
performance • Critical and Sentinel are reviewed, discussed and tracked by the QAPI
improvement events (as defined in Council to confirm completion of the action plan.
projects that were QAPI Plan) The QAPI Council will take action to address
implemented as a • Other serious safety deficiencies when indicated. When deficiencies
result of incidents events (deviation from are identified and actions are taken, the QAPI
involving harm to standard practice or Council activities will be reported to Governing
patients by error) with harm Body.
enhancing QAPI
• Other serious safety
monitoring of action Monitoring activities will begin on or before
events (deviation from
plans arising from 10/26/19.
standard practice or
review of Critical and
Sentinel Event RCAs, error) without harm
Debriefs, and (e.g. Near miss), but
Investigations. identified as being
related to systems
issues, high-risk, wide
spread/high volume,
and/or problem-prone
areas
Page 48 of 141
will be catalogued by the

Patient Safety and
Accreditation Team and will be
reported during regularly
scheduled meetings to the
IPSC, QAPI Council and
Governing Body with metrics of
improvement, action items,
accountable parties, results
and dates of resolution until
root causes for each are
mitigated and sustained
improvement is achieved.
A- QAPI Council and The QAPI Council will critically Governing Body meetings minutes will be
263C Governing Body will review newly presented Critical and reviewed by the Chief Operating Officer to
measure success and Sentinel Event RCAs, Debriefs and validate safety event action plans are tracked for
track performance to Investigations using a checklist to completion.
confirm that validate action items, responsible
improvements are parties, forward-measured metrics, Monitoring activities will begin on or before
sustained by tracking and a cadence of subsequent QAPI 10/26/19.
of performance reporting are included in the action
improvement plan.
projects that were
implemented as a The QAPI Council will critically
result of incidents review and evaluate of the status of
involving harm to previously reported safety event
patients. outstanding action items and
change implementations, including
a determination of adequacy of
allocated resources, until root
causes for each are mitigated and
sustained improvement is achieved.
Page 49 of 141
The Governing Body will expand the

agenda item for Critical and Sentinel
Event Reporting discussion to
critically review new and previously
reported safety event data including
action items, responsible parties,
forward-measured metrics, and
cadence of subsequent reporting,
until root causes for each are
mitigated and sustained
improvement is achieved.
A- The QAPI Council and The schedule for Institutional Adherence to the schedule for IRG reports and
263D Governing Body will Reporting Groups (IRG) reporting the use of the reporting template will be
confirm local quality will be reviewed to confirm areas monitored by the office of the Chief Quality
improvement are scheduled to report their local Officer or designee and noncompliance will be
initiatives are quality improvement initiatives to addressed with the IRG leader and, when
escalated to the the QAPI Council, and Governing necessary, escalated to the Chief Operating
QAPI Council, Body. Officer or designee.
Executive Leadership
Team and Governing IRG leaders and Safety and Quality Monitoring activities will begin on or before
Body. Officers (SQOs) will be informed on 10/26/19.
the schedule of reporting. The
information will emphasize that
quality improvement initiatives
originating from local observations
and events without harm that do
not involve systems issues, high-risk,
wide spread/high volume, and/or
problem-prone areas will be
catalogued by the Office of
Performance Improvement and
reported to the QAPI Council during
regularly scheduled IRG reports as
Page 50 of 141
defined in Appendix 2 of the

Institutional 2020 QAPI Plan but no
less than annually. The QAPI Council
will report these to regularly
scheduled meetings of the
Governing Body as planned or more
frequently if indicated.
The QAPI Council PowerPoint

reporting template for IRG reports
was amended to include a specific
requirement for information on the
content and status of quality
improvement projects, particularly
those born out of review of local
safety event data. The PowerPoint
template will be shared with IRG
leaders and SQOs.
A- The Sentinel Event Critical and sentinel events are Critical and sentinel events, as well as
263E Policy (ADM1078) reported to the Institutional Patient compliance with escalation processes, will be
will be revised to Safety Committee (IPSC) monthly. reported by the IPSC to the QAPI council monthly
align with the criteria In addition, critical and sentinel with recommendations for improvement. The
for escalation of events will be reviewed monthly by QAPI Council will provide a summation to the
critical and sentinel the IPSC for compliance with Governing Body quarterly.
events to executives escalation processes.
outlined in the QAPI Restraint monitoring results, including the use of
Program as approved Restraint monitoring results, chemical restraints, and recommendations for
by the Governing including the use of chemical improvement, will be reported by the IPSC to the
Body. restraints, will be reported to the QAPI Council quarterly. The QAPI Council will
Institutional Patient Safety provide a summation to the Governing Body
The sentinel event Committee monthly. Data will be quarterly.
policy revisions will analyzed to identify opportunities
be submitted for for improvement. Appropriate Monitoring activities will begin on or before
approval by ECMS action plans will be generated as 10/26/19.
Page 51 of 141
and the Governing indicated.

Body on or before
10/22/19.
The restraint policy

(CLN0592) will be
revised to include
the specific
requirements for
reporting the use of
restraints, including
the use of chemical
restraints.
The Restraint policy

revisions will be
submitted for
approval by ECMS
and the Governing
Body on or before
10/22/19.
Page 52 of 141
Tag A-283 (482.21(b)(2)(ii), (c)(1), (c)(3)

(b)(2)(ii) The Hospital must use data collected to identify opportunities for improvement and changes that will lead to improvement
(c)(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.
(c)(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.
Tag A-283 The Hospital’s performance improvement program uses data collected to identify opportunities for improvement and changes that
will lead to improvement. The Hospital sets 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. The Hospital takes 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.
A- For deficiencies Chief Operating

283 related to QAPI Officer
Activities in Nursing,
Surgery, Dialysis, Completion Date:
Outpatient Services, 10/26/19
Lab and Infection
Control refer to A
263 A. through A 263
D, which address
requirements for
reporting local and
institutional
performance
improvement
projects, including
the format, content
and schedule of
reporting and
requirements for
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reporting
performance
improvement
projects
implemented in
response to sentinel
events, RCAs and
other harm events in
accordance with the
QAPI Program, and
are incorporated into
this Plan of
Correction.
For deficiencies
related to QAPI
activities for
contracted services,
please refer to A 084
which addresses
processes to confirm
services provided
under contract
include performance
indicators that are
sufficient to evaluate
these services, and is
incorporated into
this Plan of
Correction.
Page 54 of 141
Tag A-286 (482.21(a), (c)(2), and (e)(3))

(a)(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 ... identify and reduce medical errors.
(2) The Hospital must measure, analyze, and track ...adverse patient events
(c)(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement
preventive actions and mechanisms that include feedback and learning throughout the Hospital.
(e)(3) 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 that clear expectations for safety are
established
Tag A-286 The Hospital’s QAPI program includes, but is not limited to, an ongoing program that shows measurable improvement in indicators
for which there is evidence that it will identify and reduce medical errors. The Hospital measures, analyzes, and tracks adverse patient events.
Performance improvement activities track medical errors and adverse patient events, analyze their causes, and implement preventive actions
and mechanisms that include feedback and learning throughout the Hospital. The Hospital's governing body, medical staff, and administrative
officials are responsible and accountable for ensuring that clear expectations for safety are established.
A- Please refer to the Chief Operating

286 Plan of Correction for Officer
A263, Section E,
which is Completion Date:
incorporated into 10/26/19
this Plan of
Correction.
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Tag A-385 (§482.23) The Hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be
furnished or supervised by a registered nurse.
Tag A-385 The Hospital ensures that it provides 24-hours nursing services that are supervised by a registered nurse. The Hospital ensures that
it provides patient care in accordance with facility policy, physician orders, care plans, and evaluates patients’ needs.
A- Please refer to the Chief Nursing

385 plans of correction Officer
for A392, A395,
A396, and A405, Completion Date:
each of which is 10/26/19
incorporated into
this Plan of
Correction.
Page 56 of 141
Tag A-392(§482.23(b)) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses,
and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or
nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.
Tag A-392 The Hospital ensures that it has adequate licensed nurse and other staffing to meet patient needs. The Hospital has supervisory
and staff personnel for each department or nursing unit to ensure the immediate availability of a registered nurse at any patient’s bedside.
The Hospital ensures that all physician orders are carried out, physicians are notified of significant changes, and that patient care plans are
implemented.
A- Adequate Staffing The Division Administrator for Staffing adjustments will be monitored by the Chief Nursing
392 The Division Nursing or designee will provide Unit Leader’s or designee’s review of daily Officer
Administrator for educational information to unit assignment sheets.
Nursing assessed leaders on the revisions to, Nurse Completion Date:
actual staffing Staffing Policy and Plan (CLN1054). The Unit Leader or designee will continue to 10/26/19
against the Hospital’s The unit leaders will provide assess the adequacy of daily staffing based on
planned minimum educational information to front line patient care needs and adjust resources as
inpatient nurse nursing staff on the revisions to needed, per the methodology outlined in the
staffing grid for a Nurse Staffing Policy and Plan nurse staffing policy.
period of 3 months. (CLN1054) and the process to
The results were escalate concerns about staffing Staffing adjustments, up or down, will be
discussed with that may impact delivery of patient recorded along with the reason and will be
Nursing Executive care. tracked by the nursing staffing office.
Leadership and it
was determined A resource document will be Data will be analyzed by nursing executive
actual staffing levels created for clinical leadership to leadership team to identify opportunities for
met or exceeded provide clear instructions for improvement such as process change, additional
planned, minimum assessing compliance with the education or technological resources.
staffing levels. process for escalation of staffing Effectiveness of these strategies will also be
Therefore, further adjustment needs to confirm evaluated by the Chief Nursing Officer or
analysis was patient needs are met and care is designee, including:
undertaken to delivered as ordered. Assessments
identify of compliance are to be performed • Feedback received from front line staff
opportunities for each shift by Unit Leaders. regarding perceptions of adequacy of
Page 57 of 141
improvement in staffing during focus group sessions;

professional nursing The resource document will be
practice and patient shared with clinical nursing leaders. • Feedback received from front line staff
care delivery. and managers communicated during
Clinical nursing leaders on leave nursing leadership rounds;
The Chief Nursing must be educated on the policy
Officer and other revisions before return to duty. • By comparing results of Culture of Safety
nursing leaders Survey conducted in 2018 to 2020 survey
reviewed the Nurse Executive nursing leadership and results.
Staffing Policy and clinical nursing leadership rounds
Plan (CLN1054), and were restructured to focus on Monitoring activities will begin on or before
determined revisions staffing to meet patient needs. The 10/26/19.
were needed to Chief Nursing Officer communicated
provide clear expectations for individual nurse The results of monitoring will be shared during a
expectations for executive team members to include Nursing Operations meeting.
adjusting planned staffing discussions with front line
The results of monitoring and any
staffing for each staff during leadership rounds.
recommendations for improvements are
patient care unit Clinical Directors were instructed to
reported monthly to the QAPI Council monthly,
based patient care include staffing discussions with
with a summation to the Governing Body
needs and for front line staff and to report findings
quarterly.
communicating with at weekly Directors leadership
the clinical huddle.
After three months of monitoring, the QAPI
leadership and the
Council will determine whether the frequency of
nurse staffing office The nurse expert consultant who
review should be adjusted (up or down) based on
(inpatient units) held focus group sessions will share
performance.
when adjustments findings and recommendations with
are necessary. the nurse executive team. The
information will be shared at
To address vacancies Nursing Operations meetings.
and meet patient
care needs nursing To address vacancies, meet patient
operations will care needs and support professional
create a nursing task nursing practice, nursing task force
force to expand will (1) contact local schools of
Page 58 of 141
opportunities to nursing to discuss modifications of

Associate Degree MD Anderson’s recruitment
prepared registered strategies to include onboarding of
nurses and Associate Degree Registered Nurses,
redistribute current (2) reallocate registered nurses
nursing resources. assigned to the nursing resource
pool for extended time based
To further assess assignments on identified inpatient
opportunities for units, (3) explore models to develop
improvement in a personal care teams pilot
meeting patient care program. The nursing task force will
needs, a nursing report progress of the identified
consultant was initiatives to Nursing Operations
engaged on 10/2/19 monthly.
and 10/3/19 to hold
focus groups
with front line nurses
across the hospital to
elicit staff
perceptions of
current patient care
delivery practices
and identify areas for
improvement.
A- Knowledge of Defibrillator operations and testing The Clinical Director or designee will observe a
392 Defibrillator Testing will be reviewed and reinforced with sample of 20 clinical nurse leaders and nurses
The process for applicable nursing staff through in each week for one month, then monthly for at
defibrillator testing person training with return least two months, to assess compliance with
was revised to add demonstration. defibrillator testing requirements.
clinical nursing
leadership to the Training will include: Monitoring activities will begin on or before
rotation schedule to • Operation of defibrillators 10/26/19.
perform defibrillator • Testing defibrillators
testing and record • Frequency of defibrillator Nursing leadership will address deficiencies
Page 59 of 141
the daily testing of testing through pertinent education and training, re-
defibrillator education and/or disciplinary action, as
machines. Applicable nursing staff who are on appropriate.
leave must complete defibrillator
training before return to duty. The Clinical Director or designee will review the
results of the observations and completion of the
Education and training on education with the Chief Nursing Officer or
Defibrillator Operation and Testing designee and make recommendations for
is incorporated in the on-boarding improvements to Defibrillator Operation and
process for new applicable licensed Testing to Nursing Operations meeting.
nursing staff.
for improvement are reported to Nursing
Operations monthly for at least three months.
After 3 months, Nursing Operations will
determine whether reporting to Nursing
Operations should continue and whether the
on performance. Reporting to QAPI Council will
be in accordance with the IRG reporting schedule
and standards.
A– Nursing Care Unit leadership received training Unit Leaders or designees will round with nurses
392 (Purposeful and review of chart review process weekly for one month to review whether
Rounding, from the Clinical Informatics team. provider orders were followed, providers were
Implementing notified of critical labs, if applicable, vital signs
Physician Orders, Current nursing staff on inpatient were assessed and documented as ordered, the
Notifying Physicians units will receive educational alignment of the nursing care plan with medical
of Critical Labs and information, to include diagnoses, and currency of the care plan.
Vital Signs, and documentation regarding following
follow Plan of physician orders, notifying Unit Leaders or designee will audit a sample of 35
Correction) physicians of critical labs and vital patient records retrospectively and report each
Page 60 of 141
signs, and following care plans as month to the Nursing Operations meeting for
The Executive outlined in Inpatient Nursing three months.
Director of Quality Documentation of Patient Care
Safety and Research Policy (CLN0647), and Ambulatory Monitoring activities will begin on or before
developed a tracking Care-Nursing Documentation 10/26/19.
tool for compliance (CLN0487).
with purposeful The Unit Leaders or designees will address
rounding, following Nursing staff who are on leave must deficiencies with the individual nursing staff
physician orders, complete training before return to member through pertinent education and
notifying physicians duty. training, re-education and/or disciplinary action,
of critical labs and as appropriate.
vital signs, and Education and training is
following care plans. incorporated in the on-boarding The results of the review and recommendations
process for new licensed nursing for improvement are reported to Nursing
staff. Operations monthly for at least three months.
After 3 months, Nursing Operations will
and standards.
A- Wound Care Current clinical licensed nursing The Executive Director of Professional Practice,
392 staff will receive educational Strategy and Execution or designee will work in
Nursing leadership information to include: collaboration with Unit Leaders to assess
reviewed the online compliance with wound care practices.
nursing procedure • Update to the procedure for
and education dressing changes and Unit Leaders or designee will round with nurses
resource for content wound care to include weekly for one month to confirm dressings are
and made date/time on dressings dated to reflect the time changed and whether
recommendation for • Documentation Infection Control practices were observed.
the following: • Infection Control practices
Page 61 of 141
• Role of wound care nurse Unit Leaders or designee will perform a

• Add retrospective audit of a sample of 35 patient
requirement Nursing staff who are on leave will records involving wound care and results will be
for date and receive educational information on reported each month to the Nursing Operations
time on all wound care before return to duty. meeting for three months.
dressings
changes Educational information on wound Monitoring activities will begin on or before
care is incorporated in the on- 10/26/19.
• Reinforce boarding process for new licensed
Infection nursing staff. The Unit Leader or designee will address
Control deficiencies with individual nursing staff
practices members through pertinent education and
training, re-education and/or disciplinary action,
• Clarification as appropriate.
of wound
care nurse The results of the review and recommendations
role and for improvement are reported to Nursing
wound care Operations monthly for at least three months.
orders After 3 months, Nursing Operations will
and standards.
Page 62 of 141
Tag A-395 (§482.23(b)(3)) A registered nurse must supervise and evaluate the nursing care for each patient.
Tag A-395 The Hospital ensures that a registered nurse supervises and evaluates the nursing care for each patient.
A- Nursing and Executive Director of Professional DI nursing staff will obtain data through patient Chief Nursing
395 Diagnostic Imaging Practice, Strategy and Execution or interviews regarding the time of diet status Officer
(DI) leadership designee will provide educational change for inpatients receiving IV and/or oral
reviewed the process information for inpatient nursing contrast for CT. Completion Date:
of communication staff, Diagnostic Imaging and CT 10/26/19
between the RN Technologists through in person Data will be collected by Associate Director of
caring for the patient education to address Diagnostic Imaging and the Associate Director of
and the nursing staff communication regarding hydration Clinical Nursing or designees or designee for
in Diagnostic and diet status for patients with three months.
Imaging. It was scheduled CT procedures.
determined that Monitoring activities will begin on or before
policy revisions and Executive Director of Clinical 10/26/19.
additional education Informatics or designee will perform
for the inpatient staff a crosswalk analysis between online The results of the review and recommendations
were needed CT patient education and the EHR for improvement are reported to Nursing
regarding diet status based education. Operations monthly for at least three months.
prior to Computed After 3 months, Nursing Operations will
Tomography (CT) Current inpatient nurses, DI nurses determine whether reporting to Nursing
scans. and CT technologist will receive Operations should continue and whether the
educational information on frequency should be adjusted (up or down) based
The Adult/Pediatric communication regarding diet on performance. Reporting to QAPI Council will
Oral Contrast status to include: be in accordance with the IRG reporting schedule
Administration on and standards.
Inpatient Units and • Hydration for patients with
the Emergency scheduled procedures The Associate Director of Diagnostic Imaging
Center Policy Nursing or designee will address deficiencies with
• Patient preparation for
(CLN1027) will be procedures and scans with oral the individual staff through pertinent education
reviewed and and training, re-education and/or disciplinary
contrast
updated. Updates action, as appropriate.
Page 63 of 141
will include: Inpatient nurses, DI nurses and CT

Information about technologists who are on leave must
hydration and diet complete training before return to
status. The Policy will duty. Education and training is
be submitted for incorporated in the on-boarding
approval by ECMS on process for new inpatient nurses
or before 10/22/19. and CT Technologists.
The Divisional policy

Administration of
Iodinated Contrast
Material Policy (DI
policy #3.30) will be
reviewed and
updated on or before
10/22/19. Updates
to include
Information about
hydration and diet
status.
Page 64 of 141
Tag A-396 (482.23(b)(4)) The Hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The
nursing care plan may be part of an interdisciplinary care plan.
Tag A-396 The Hospital ensures that the nursing staff develops, and keeps current, a nursing care plan for each patient.
A- The Interdisciplinary Inpatient Nurse Leadership were Nursing Leaders or designees in each inpatient Chief Nursing
396 Inpatient Care Plan educated on a report available in unit will complete at least 20 audits each week to Officer
and Education the EHR (“Active Care Plans assess alignment of nursing care plans and the
Record Policy (Care Currently Admitted Patients”), problem list. Completion Date:
Plan Policy) which allows a comparison of the 10/26/19
(CLN0473) was patient’s problem list with the The inpatient Nurse Leader or designee will
reviewed and revised patient care problems identified by address deficiencies with the individual staff
by Nursing nursing from the assessment. through pertinent education and training, re-
Leadership to include education and/or disciplinary action, as
timely initiation of The inpatient Nurse Leadership or appropriate.
care planning upon designees will use the Active Care
inpatient admission Plans Currently Admitted Patients Monitoring results will be reported to the
and ongoing review report to assess nursing care plans Executive Director of Quality, Safety and
throughout hospital for alignment with the patient Research or designee and to Nursing Operations.
stay. Policy CLN0473 problem list.
was revised and Monitoring activities will begin on or before
became effective on The Informatics Resource Nurses 10/26/19.
9/12/19. (IRN) will (re)educate current
inpatient nursing staff regarding The results of the review and recommendations
Inpatient Nurse documentation of nursing care plans for improvement are reported to the QAPI
Leadership received as per CLN0473. Council monthly. The QAPI Council will provide a
information to quarterly summation to the Governing Body.
reinforce the use of Inpatient Nurse Leadership and After 3 months, the QAPI Council will determine
an EHR report inpatient nursing staff who are on whether reporting to the QAPI Council and the
available that leave must receive education before Governing Body should continue, and whether
highlights the return to duty. the frequency should be adjusted (up or down)
alignment among the based on performance.
patient’s Care plan, Education on the Care Plan Policy is
Page 65 of 141
diagnosis, and incorporated in the on- boarding

hospital problems. process for new inpatient Nurse
Information was Leadership and inpatient nursing
provided in August staff.
2019.
Page 66 of 141
Tag A-405 (482.23(c)(1), (c)(1)(i), (c)(2)) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws,
the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of
practice. Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if
such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules,
and regulations. All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with
Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff
policies and procedures.
Tag A-405 The Hospital ensures that nursing staff administers medications as ordered by the practitioner responsible for the patient’s care and
that nursing staff follow the Hospital’s policies for documentation of treatment and interventions.
A- Medication Medication Administration: The Medication Administration: The Unit Leader for Chief Nursing
405 Administration: A memo for Midodrine ordering Dialysis will monitor patient records for timely Officer
multidisciplinary guidelines was released to Midodrine administration prior to dialysis for a
team met to Nephrology members of the medical three month period. Completion Date:
evaluate the specific staff the week of 9/23/19 and will 10/26/19
events related to be shared with inpatient and dialysis Monitoring activities will begin on or before
ordering and timely nurses. 10/26/19.
medication
administration. The Just in time training for inpatient The results of this monitoring will be reported to
following and dialysis nurses related to the Dialysis QAPI committee and shared during a
recommendations changes in Midodrine ordering and Nursing Operations meeting.
are being timely administration will be
implemented: provided. The results of the review and recommendations
for improvement are reported to Nursing
Nephrology medical To promote coordination of timely Operations monthly for at least three months.
staff reviewed administration of medications and After 3 months, Nursing Operations will
ordering guidelines furnishing of dialysis treatments, the determine whether reporting to Nursing
for Midodrine, met Dialysis staff will communicate the Operations should continue and whether the
with pharmacy and patient list for first shift pickups to frequency should be adjusted (up or down) based
dialysis leadership on the transportation staff; on performance. Reporting to QAPI Council will
9/20/19 and a transportation leaders will prioritize be in accordance with the IRG reporting schedule
released memo for and standards.
Page 67 of 141
Midodrine ordering patients and monitor data weekly.

guidelines to Timely delivery of dialysis patients to the dialysis
nephrology medical unit will be monitored weekly.
staff the week of
9/23/19. Monitoring activities will begin on or before
10/26/19.
The procedure for
transportation to The results of this monitoring are being reviewed
dialysis was reviewed in Dialysis QAPI and shared during a Nursing
with Dialysis and Operations meeting.
Transportation
leadership and a new The results of the review and recommendations
process was for improvement are reported to the QAPI
established. The Council monthly. The QAPI Council will provide a
following will be quarterly summation to the Governing Body.
implemented as SOP: After 3 months, the QAPI Council will determine
Dialysis staff will whether reporting to the QAPI Council and the
communicate to the Governing Body should continue, and whether
transportation staff the frequency should be adjusted (up or down)
the patient list for based on performance.
first shift pickups,
transportation The Hospital will address deficiencies with the
leaders agree to individual staff through pertinent education and
prioritize patients. training, re-education and/or disciplinary action,
as appropriate.
Medication
Assessment and
Reassessment: The Medication Assessment and
Inpatient Nursing Reassessment: The Executive Medication Assessment and Reassessment: PSA
Documentation of Director of Professional Practice, and OPI will conduct a monthly retrospective
Patient Care Policy Strategy, and Execution or designee review of patients who received psychotropic or
(CLN0647) was will provide education for nurses on sedative agents via IM or IV route and STAT. The
reviewed by Nursing assessment and re-assessment review will validate the medication indication
Executive Leadership related to administration of STAT or presence in the provider order and nursing
Page 68 of 141
team and PRN medications and documentation of patient assessment and

determined no documentation of treatment and appropriate reassessment following medication
changes are needed. interventions. administration.
However, re-
education with staff Education will include Monitoring activities will begin on or before
was needed. documentation of medication 10/26/19.
administration, including clinical
indications for administration, The results of the review and recommendations
monitoring the effectiveness of for improvements will be reported to the Nursing
medications and re-assessment. Operations.
Nurses who are on leave must The results of the review and recommendations
complete education before return for improvement are reported to the QAPI
to duty Council monthly. The QAPI Council will provide a
Education on medication After 3 months, the QAPI Council will determine
administration and documentation whether reporting to the QAPI Council and the
is incorporated in the on-boarding Governing Body should continue, and whether
process for all new nurses. the frequency should be adjusted (up or down)
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Tag A-489 (482.25) 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.
Tag A- 489 The Hospital provides pharmaceutical services that meet the needs of the patients. The Hospital has pharmaceutical policies and
procedures that minimize drug errors and ensure that the pharmacy is kept under competent supervision.
A- Please refer to the Vice President of

489 plans of correction Pharmacy
for A491 and A494,
each of which is Completion Date:
incorporated into 10/26/19
this Plan of
Correction.
Page 70 of 141
Tag A-491 (482.25(a)) The pharmacy or drug storage area must be administered in accordance with accepted professional principles.
Tag A-491 The Hospital ensures that the pharmacy and drug storage area is administered in accordance with accepted professional principles.
A- Between 8/19/19 Pharmacy leadership and Director of On or before 10/26/19, and continuing for three Vice President of
491 and 9/20/19, Sourcing and Contract Management months thereafter, Pharmacy Quality Assurance Pharmacy
Pharmacy reviewed will develop transportation of will audit a sample of 30 vendor transports of
existing vendor hazardous pharmaceuticals vendor hazardous pharmaceuticals per month (or 100% Completion Date:
contracts for contracts to include: of transports if fewer than 30) to confirm (1) the 10/26/19
transportation of presence of spill kits with couriers; (2) courier
hazardous - A Statement of Work reflecting understanding of applicable policies and
pharmaceuticals to transportation of chemotherapy procedures; and (3) appropriate labeling of
evaluate key agents requiring specialized chemotherapy containers before transport.
performance training and specialized Deficiencies requiring timely correction identified
indicators (KPIs). equipment for spill containment during Pharmacy auditing will be documented
and cleanup, and communicated to Vice President of
Contract(s) with - KPIs requiring appropriate Pharmacy, Director of Sourcing and Contract
vendor(s) for training on how to contain and Management and, with respect to spill kits and
transportation of clean a chemotherapy spill courier knowledge, vendor representative.
hazardous along with required
pharmaceuticals will documentation evidencing the The results of the review and recommendations
include KPIs related training, which will be provided for improvements will be reported to the
to requirements for to Hospital on a quarterly basis, Institutional Safety Committee.
adherence to and
Hospital Policy - A requirement for adherence to The results of the review and recommendations
ADM0171 Hospital Policy ADM0171 for improvement are reported to the QAPI
Chemotherapy Spills Chemotherapy Spills and Council monthly. The QAPI Council will provide a
and Surface Surface Contamination Policy quarterly summation to the Governing Body.
Contamination before vendor personnel begin After 3 months, the QAPI Council will determine
Policy, and providing services to the whether reporting to the QAPI Council and the
Statement(s) of Work Hospital, and supporting Governing Body should continue, and whether
that include documentation evidencing the frequency should be adjusted (up or down)
transportation of compliance with the policy, based on performance.
Page 71 of 141
chemotherapy which will be provided to

agents and training Hospital on a quarterly basis. A
and equipment copy of this Policy will be Pharmacy leadership will conduct a review of the
requirements. provided to the vendor(s). vendor contract(s) no less than annually to
confirm KPI and outcomes sufficiency.
Prior to transport, The Vice President of Pharmacy or
containers used to designee will provide educational 20 point of care sites will be audited monthly by
transport information to applicable pharmacy Environmental Health & Safety staff to monitor
chemotherapy will operations personnel regarding staff knowledge of waste disposal processes for
contain markings on labeling chemotherapy containers three months. Just in time education will be
the outside warning as containing hazardous provided by EHS staff as needed.
that hazardous drugs pharmaceuticals prior to transport
are inside. as required by the Shipment of The results of the review and recommendations
Hazardous Materials Policy for improvement are reported to the QAPI
During the week of (ADM0164). The label will state: Council monthly. The QAPI Council will provide a
8/12/19, “Hazardous Drugs – Special quarterly summation to the Governing Body.
Environmental Handling Required.” After 3 months, the QAPI Council will determine
Health & Safety (EHS) whether reporting to the QAPI Council and the
addressed the Staff that handle controlled Governing Body should continue, and whether
finding by installing substances at the Woodlands, the frequency should be adjusted (up or down)
Narcotic Wasting League City and West Houston based on performance.
Systems (Stericycle) locations will be provided
in the Houston Area educational information on how to
Location (West use the Narcotic Wasting Systems
Houston). On 9/9/19, (which meets the DEA and EPA
a Red Huddle definition of non-retrievable
communication was container) and our other processes
sent to nursing in related to waste disposal.
these locations
regarding the proper
use of these systems.
Page 72 of 141
Tag A-494 (482.25(a)(3)) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs.
Tag A-494 The Hospital ensures that it keeps accurate records of the receipt and distribution of all scheduled drugs.
A- Pharmacy leadership On 8/15/19, Vice President of Pharmacy Medication Diversion Prevention team Vice President of
494 and Nursing met on Pharmacy sent an email will review reports on continuous intravenous Pharmacy
8/30/19 to discuss communication to the Executive (IV) infusion of controlled substance medications
lock boxes, port- less Directors of Nursing, and the for waste documentation with tubing changing Completion Date:
tubing, and Directors of Nursing regarding the and compare volume dispensed versus volume 10/26/19
controlled substance use of port-less tubing. administered. The Institutional Medication
medication Diversion Prevention Committee will provide
reconciliation and Pharmacy deployed and oversight of the intravenous (IV) infusion of
education on implemented lock boxes on 9/9/19 controlled substance medication reconciliation.
aforementioned in the appropriate patient care A sample of 50 identified orders will be
items. areas. reconciled on an ongoing basis.
Pharmacy Leadership Nursing educational information Pharmacy Quality Assurance will review active
developed and was communicated to nurses in orders report to identify patients receiving
analyzed a historical affected areas via a Red Huddle by continuous intravenous (IV) infusion of controlled
medication orders the Director of Professional substance medications. Staff will audit 50
report to identify Development in Nursing Education patients per month to confirm the presence of
which patient care on 9/4/19. lock boxes and port-less tubing.
areas use continuous
intravenous (IV) Monitoring activities will begin on or before
infusion of controlled 10/26/19.
substance
medications. The results of the review and recommendations
Page 73 of 141

Page 74 of 141
Tag A-536 (482.26(b)(1)) Proper safety precautions must be maintained against radiation hazards. This includes adequate shielding for
patients, personnel, and facilities, as well as appropriate storage, use and disposal of radioactive materials.
Tag A-536 The Hospital ensures that proper safety precautions are maintained against radiation hazards including adequate shielding for
patients, personnel, and facilities, as well as appropriate storage, use, and disposal of radioactive materials.
A- The Radiation Safety The Radiation Safety Office will The Radiation Safety Office and designees will Divisional Patient
536 Office will review identify and remove radioprotective review a sample of 5 areas per month to confirm Safety and Quality
and revise the apparel that has been procured the use of the appropriate cleaning agent. Officer, Diagnostic
Radioprotective from manufacturers not on the Imaging
Apparel Policy approved manufacturer list. The Monitoring activities will begin on or before
(ADM3264) to apparel will be disposed of per the 10/26/19. Completion Date:
include step-by-step guidelines of the institutional policy 10/26/19
processes for the (ADM0166, Disposal of Hazardous Results will be reviewed by the Radiation Safety
cleaning of and Special Waste Materials Policy). Office monthly and will be presented to
radioprotective leadership in the Division of Diagnostic Imaging
apparel on or before The Radiation Safety Office will monthly at safety meetings.
10/22/19. provide educational information for
current users of radioprotective The results of the review and recommendations
The Radiation Safety apparel of the manufacturer for improvement are reported to the QAPI
Office selected one selection and the revised process for Council monthly. The QAPI Council will provide a
agent for use in cleaning and disinfection of quarterly summation to the Governing Body.
cleaning and garments. After 3 months, the QAPI Council will determine
disinfection of whether reporting to the QAPI Council and the
radioprotective Current users of radioprotective Governing Body should continue, and whether
apparel that aligns apparel who are on leave must the frequency should be adjusted (up or down)
with the receive educational information based on performance.
manufacturer’s before return to duty. New users of
instructions for use radioprotective apparel will receive
and the Instrument the educational information as part
and Equipment: of on-boarding.
Cleaning,
Disinfection and
Page 75 of 141
Sterilization Policy
(CLN0439) on
9/18/19.
Procurement of
radioprotective
apparel will be
limited to those
manufacturers on
the approved
manufacturer list
who identify the
singular agent as
appropriate for their
garments.
Page 76 of 141
Tag A-547 (§482.26(c)(2)) Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer
procedures.
Tag A-547 The Hospital ensures that only qualified staff, designated by the medical staff, may use the radiologic equipment and perform
procedures.
A- Radiation Safety Radiation Safety Training Radiation Safety Training Divisional Patient
547 Training Safety and Quality
Educational information will be Leadership in the Division of Diagnostic Imaging Officer, Diagnostic
Leadership in the provided by leadership in the will audit appropriate personnel records for Imaging
Division of Diagnostic Division of Diagnostic Imaging for completion of radiation safety training.
Imaging will develop current Diagnostic Imaging Completion Date:
a standardized radiologic technologists and Monitoring activities will begin on or before 10/26/19
process that specifies supervisors/managers regarding the 10/26/19.
expectations for newly developed and implemented
completion of annual process. Radiation safety training compliance results will
radiation safety be reviewed for all radiologic technologists
training. Current Diagnostic Imaging quarterly at staff meetings and reported
radiologic technologists and quarterly at safety meetings led by the Division of
Leadership in the supervisors/managers on leave Diagnostic Imaging for the first year,
Division of Diagnostic must receive educational semiannually the second year, and annually
Imaging will create information before return to duty. thereafter.
radiation safety
training compliance New Diagnostic Imaging radiologic The results of the review and recommendations
reports that will be technologists and for improvement are reported to the QAPI
reviewed by supervisors/managers will receive Council monthly. The QAPI Council will provide a
departmental this educational information as part quarterly summation to the Governing Body.
leadership and of on-boarding. After 3 months, the QAPI Council will determine
reported quarterly at whether reporting to the QAPI Council and the
safety meetings, and Governing Body should continue, and whether
will review these the frequency should be adjusted (up or down)
reports during based on performance.
annual employee
Page 77 of 141
evaluations.
Gamma Knife Privileges
Gamma Knife Gamma Knife Privileges
Privileges At the time of periodic reappointment to the
The Radiation Oncology Department Medical Staff for providers in the Department,
Gamma Knife Chair or designee will confirm that the Radiation Oncology Department Chair will
Authorized User (AU) current Gamma Knife AUs have review the Authorized User status, vendor
status will be been trained by the vendor. AUs training, and current clinical competence of
restricted to who have not been trained will be providers privileged for or requesting privileges
credentialed removed from the institution’s for Gamma Knife procedures.
providers who have license and will request withdrawal
completed vendor of privileges.
training.
The Radiation Oncology Department
Only Authorized Chair will submit recommendations
Users may obtain for criteria for Gamma Knife
privileges for Gamma privileges to the Credentialing
Knife procedures. Committee of the Medical Staff
(CCMS) for approval.
The Medical Staff
process for initial Current Gamma Knife Authorized
credentialing and Users with privileges for the
privileging, as well as procedure will provide evidence of
re-credentialing and the compliance with the approved
re-privileging will be privileging requirements to the
followed for Gamma Radiation Oncology Department
Knife Authorized Chair. The Radiation Oncology
Users. Department Chair will notify the
CCMS of providers who do not meet
these requirements and request
either proctored privileging or
withdrawal of privileges.
The CCMS submits all privilege
Page 78 of 141
recommendations to ECMS, which

submits the recommendations to
the Governing Body for approval.
Page 79 of 141
Tag A-618 (482.28) The Hospital must have organized dietary services that are directed and staffed by adequate qualified personnel.
However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if
the company has a dietitian who serves the Hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the
minimum standards specified in this section and provides for constant liaison with the Hospital medical staff for recommendations.
Tag A-618 The Hospital has organized dietary services that are directed and staffed by adequate qualified personnel.
A- On 8/30/19, the Rounding with Infection Control and Weekly monitoring by Infection Control and daily VP, Clinical Support
618(A) Director of Food & Food and Nutrition Services began monitoring by Food and Nutrition Services and Services
Nutrition Services, 9/10/19 to evaluate effectiveness of Materials Management using the Dock Audit
Infection Control, barricades and/or demarcated lines tool. Completion Date:
and Facilities and at designated bays to confirm clear 10/26/19
Materials separation of clean and dirty Monitoring activities will begin on or before
Management met to activities to prevent cross- 10/26/19.
review the CMS contamination of food products.
expectations for Executive Chef will report the Dock Audit Tool
ensuring that The Director of Food & Nutrition results monthly at the Food & Nutrition Services
construction and Services and the Executive Chefs will Safety Committee (FNSSC) meetings.
contaminated linen create an Equipment and Surface
were being off Cleaning Operations Manual. Director of Food and Nutrition Services will
loaded and on report the Dock Audit results monthly to the
loaded as outlined in On 9/30/19, Executive Chefs and Infection Control Committee.
Isolation Policy team completed full deep cleaning
CLN0432 to prevent of floors, walls, doors, and ceilings Chef Manager will complete Cooler/Freezer Daily
cross-contamination of cooler/freezer trailers. Checklist to audit cleaning and temperature
of food products. monitoring of trailers. Audit results will be
(Re)training for food and nutrition reported monthly to the Director of Food and
On 9/18/19, the staff will be provided as needed. Nutrition Services and any corrective actions will
Director of Food & Interior of trailers will be cleaned be taken as necessary.
Nutrition Services weekly and as needed based on
met with the audit results. The results of the review and recommendations
Associate Directors for improvement are reported to the QAPI
and Executive Chefs On 8/30/19, Materials Council monthly. The QAPI Council will provide a
Page 80 of 141
to review the CMS Management, Facilities, quarterly summation to the Governing Body.
expectations for Environmental Services, Infection After 3 months, the QAPI Council will determine
ensuring that the Control, and Food and Nutrition met whether reporting to the QAPI Council and the
procedures for to begin strategically planning dock Governing Body should continue, and whether
cleaning and workflow and discuss construction the frequency should be adjusted (up or down)
sanitizing of projects. Processes to be based on performance.
equipment to include implemented:
freezer/cooler • Designated bays for Food
storage trailers on and Nutrition Services
the dock are cooler/freezer and delivery
completed as trailers.
outlined in policy #7- • Designated bays for
08 Cleaning &
construction and dirty linen
Sanitizing as well as
off loading and on loading.
policy #602 Master
Cleaning Procedures • All linen will be fully covered
and Schedule. while being on loaded and
off loaded.
The Director of Food • All construction debris will
& Nutrition Services be covered.
and Infection Control • Install trash receptacles on
will review the Food dock.
and Nutrition
Department’s Food and Nutrition Services
Cooler/Freezer Daily Program Manager tracks and
Checklist to confirm maintains the Team Huddle Reports
specific cleaning and and End of Day Reports, which
monitoring include agenda items, training
procedures are materials, and staff sign-in sheets.
included to prevent
cross-contamination
of food products.
Infection Control will
Page 81 of 141
complete a risk
assessment of the
dock area.
A- The Director and The Director of Food & Nutrition The Associate Directors, Executive Chefs or
618(B) Associate Directors Services and the Registered Operation Managers began performing daily
of Food & Nutrition Sanitarian will review and update kitchen audits using the Sanitation & Foodborne
Services met on the computer-based Food Handlers Illness Prevention Audit tool starting 9/23/19.
9/18/19 with the Certification training program to Immediate corrective actions will be taken if any
Executive Chefs and confirm the inclusion of proper sanitation issues or areas of noncompliance are
Managers to review cleaning and sanitation procedures identified and (re)training provided as needed. If
the CMS for kitchen equipment and surfaces daily kitchen audits consistently achieve results
expectations for as outlined in policies #7-08 greater than 95% for 30 consecutive days, the
ensuring that Cleaning & Sanitizing and #602 audit will be moved to weekly monitoring.
equipment and Master Cleaning Procedures and
kitchen surfaces are Schedule. The Sanitation & Foodborne Illness Prevention
cleaned and sanitized Audit results will be reported monthly at the
as outlined in policy The Director of Food & Nutrition Food & Nutrition Services Safety Committee
#7-08 Cleaning & Services and the Executive Chefs will (FNSSC).
Sanitizing and policy create an Equipment and Surface
#602 Master Cleaning Operations Manual. The The Registered Sanitarian will conduct monthly
Cleaning Procedures manual will outline the unannounced kitchen inspections using the food
and Schedule. manufacturers’ instructions on how safety inspection tool. The results will be
to clean each piece of equipment or analyzed for opportunities for improvement and
On 8/13/19 the surface. reported monthly to the Director, Food &
Director of Food & Nutrition Services, VP Clinical Support Services
Nutrition Services Using the Equipment and Surface and the Institutional Safety Committee (ISC).
and Executive Chefs Operations Manual, Food service
completed an Workers will be (re)educated on Monitoring activities will begin on or before
immediate proper procedures for: 10/26/19.
assessment of all • washing and sanitizing cutting
plastic cutting boards; The results of the review and recommendations
boards, and those • identifying and removing for improvement are reported to the QAPI
with gouges and Council monthly. The QAPI Council will provide a
Page 82 of 141
scars were discarded. cutting boards that have quarterly summation to the Governing Body.
gouges, scars and/or are not After 3 months, the QAPI Council will determine
On 8/12/19 and cleanable; whether reporting to the QAPI Council and the
8/22/19 the Director • cleaning equipment and Governing Body should continue, and whether
of Food & Nutrition surfaces; and the frequency should be adjusted (up or down)
Services and based on performance.
• reporting rusty equipment and
Executive Chefs
surfaces that are not cleanable
completed an
inventory and
In-service training for current
assessment of the
kitchen staff on cleaning and
cleanliness of all
sanitizing equipment, dishes, pots,
kitchen equipment
pans, and work surfaces used in
and surfaces:
food preparation will be provided by
• The soup
Executive Chefs and Managers. This
dispensing
training will also be included in
machine was department on-boarding for new
immediately kitchen staff.
cleaned and
sanitized on The Director of Food & Nutrition
8/12/19. Services, Executive Chefs and
Operation Manager to review and
• The shelving in reinforce Master Cleaning Schedule
the bakery was for all kitchen equipment and
removed on surfaces as outlined in policies #7-08
8/13/19. Cleaning & Sanitizing as well as #602
Master Cleaning Procedures and
• The large
Schedule on a monthly basis,
round cooking
effective 10/1/19.
kettle was
immediately Executive Chefs to complete
washed and research on possible alternative
sanitized on solutions for plastic cutting boards
8/12/19. that are safe, sanitary, durable and
Page 83 of 141
• Equipment resistant to knife gouges and scars.

identified
during the An Operations Manager for
survey was Sanitation tasks has been hired to
promptly oversee and supervise nighttime
cleaned and cleaning and sanitation of
equipment and kitchen surfaces.
sanitized.
• Work surfaces Food and Nutrition Services

identified Program Manager tracks and
during the maintains the Team Huddle Reports
survey were and End of Day Reports, which
cleaned on include agenda items, training
materials, and staff sign-in sheets.
8/12/19 and
8/22/19, or
promptly
removed from
the operation.
The Director of Food
& Nutrition Services
will hire an
Operation Manager
by 9/30/19 to
supervise nighttime
cleaning and
sanitation of
equipment and
kitchen surfaces.
A- Through (re)training Associate Directors and managers to The Associate Directors, Executive Chefs or
and monitoring, the conduct staff (re)training on policy Operation Managers will perform weekly kitchen
Page 84 of 141
618(c) Director of Food and FNS #203 General Appearance and audits using the Sanitation & Foodborne Illness
Nutrition Services in Employee Handbook Guidelines & Prevention Audit tool. Immediate corrective
collaboration with Procedures #1-02 for current actions will be taken if any sanitation issues or
department’s Foodservice Workers. This training areas of noncompliance are identified and
leadership and will also be included in department (re)training provided as needed.
management team on-boarding, annually, and as
will confirm all staff, needed. Monitoring activities will begin on or before
contractors and 10/26/19.
vendors adhere to Director of Food and Nutrition
the department’s Services will communicate the FNS Executive Chef will report the Sanitation &
policy FNS #203 policy #203 General Appearance Foodborne Illness Prevention Audit results
General Appearance and Employee Handbook Guidelines monthly at the Food & Nutrition Services Safety
and Employee and Procedures #1-02 via email to Committee (FNSSC).
Handbook Guidelines vendor partners.
& Procedures #1-02. The Registered Sanitarian will conduct monthly
This (re)training will Food and Nutrition leaders will unannounced kitchen inspections using the food
confirm the (re)train staff to Stop the Line when safety inspection tool. The results will be
department is they identify noncompliance with analyzed for opportunities for improvement and
providing services in the FNS #203 General Appearance reported monthly to the Director, Food &
a sanitary manner to policy. Nutrition Services, VP Clinical Support Services
prevent cross- and the Institutional Safety Committee (ISC).
contamination of Food and Nutrition Department
food products. Managers will correct and discipline The results of the review and recommendations
staff for failure to follow the FNS for improvement are reported to the QAPI
#203 General Appearance policy. Council monthly. The QAPI Council will provide a
Director of Food and Nutrition After 3 months, the QAPI Council will determine
Services will confirm kitchen whether reporting to the QAPI Council and the
entrances are marked with Governing Body should continue, and whether
appropriate signage. the frequency should be adjusted (up or down)
Executive Chefs will develop and
display visual cues for how to don
proper hair restraints including
Page 85 of 141
beard guards throughout kitchen.
Executive Chefs will investigate

possible alternative hair restraint
products for a better fit for staff.
Food and Nutrition Services

Program Manager tracks and
maintains the Team Huddle Reports
and End of Day Reports, which
include agenda items, training
materials, and staff sign-in sheets.
Page 86 of 141
Tag A-701 (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.
Tag A-701 The Hospital ensures that the condition of the physical plant and the overall hospital environment are developed and maintained in
such a manner that the safety and well-being of patients are assured.
A- Pull Cords Pull Cords Pull Cords Vice President and

701 Chief Facilities
A team led by the This risk assessment, including During new construction and renovation, Office
AVP of EH&S will review of signage and emergency appropriate building codes will be applied to the
complete a risk pull cords, and use of the restrooms design of restrooms including pull cord Completion date:
assessment of will guide us on improvements in installation and signage. 10/26/19
restrooms in Mays, our call system and response to the
League City, West call system. We will develop a Missing Ceiling Tiles & Damaged baseboard
Houston, Lutheran schedule of actions if appropriate to
and Alkek. address any code deficiencies. All work orders related to this deficiency have
been completed.
A review of our Missing Ceiling Tiles & Damaged
inpatient beds and baseboard Director of EH&S or designees will conduct Zone
associated restrooms Inspection Program (ZIP) on a semiannual basis
compared to the The work orders (WO# A15741111, to evaluate the work environment and submit
2014 Guidelines for A1580048, for ceiling tile work orders when appropriate.
Design and replacement and A1574239 for
Construction of repairs to baseboard and wall) were Clinical Directors or designees will continue to
Hospitals and assigned to an employee for monitor the physical environment using the
Outpatient Facilities correction. All 3 work orders were Safety365 checklist and submit work orders to
in Lutheran and completed between 8/19/19 and the Facilities Operation Center when appropriate.
Alkek by the AVP of 8/22/19.
Patient Care and
10/26/19.
Prevention Facilities
concluded that all
these locations have
a compliant pull cord
Page 87 of 141
in the inpatient
restroom and a call
station at the
bedside. Completed
9/26/19.
Missing Ceiling Tiles

and damaged
baseboard
A work order was

created by the
Facilities Operations
Center (FOC) to
correct the ceiling
tile in the Janitor’s
closet WTC2.10.10
and to replace the
missing ceiling tile in
G7 hallway at room
G7.3229. Completed
8/22/19.
The Director of
Environmental
Health & Safety
inspected all other
ceiling tiles in both
G7.3229c and
G7.3220C on
8/22/19. No ceiling
tiles were out of
place. Completed
Page 88 of 141
8/22/19
A work order,
A1574239, was
created to repair the
baseboard in the
Alkek on the first
floor. The work was
completed on
8/19/19
Page 89 of 141
Tag A-724 (482.41(d)(2)) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.
Tag A-724 The Hospital ensures that all supplies and equipment are maintained to an acceptable level of safety and quality.
A- PM Stickers PM Stickers PM Stickers Vice President and

724 Chief Facilities
The patient lifts were The Director of Clinical Engineering Clinical area leadership or their designee will Officer
removed from educated current Clinical continue to monitor the physical environment
campus the week of Engineering Staff on PM, including with a Safety365 checklist and schedule Completion Date:
8/23/19 by Facilities reviewing asset records to maintenance as necessary. 10/26/19
Staff and the determine the most recent PM and,
Warehouse Staff. if no asset record is located, The Director of Clinical Engineering or their
scheduling the equipment for PM designee will audit 5 clinical areas monthly to
The asset records and affixing a PM sticker upon confirm that a PM sticker is affixed, and the
were reviewed and completion of the inspection. equipment was properly inspected.
an updated
preventative Clinical Engineering Staff on leave Monitoring activities will begin on or before
maintenance (PM) must complete training on PM 10/26/19.
sticker was affixed or before return to duty.
the following were Equipment that is not properly labeled or
scheduled for Container Labeling subjected to scheduled maintenance will be
maintenance and an taken out of use until labeling or PM is
updated PM sticker The equipment vendors were completed.
will be affixed after instructed to label containers.
the PM: specialized Clinical Engineering staff who failed to properly
mammography assist label or maintain equipment will receive re-
chair on the Mays Wrapped Cords education and other processes as appropriate.
Clinic at Cancer
Prevention Unit; On 9/20/19, the Environment Wrapped Cords
automated vital sign Health & Safety staff confirmed that
monitor in Lutheran 4 of 4 dressing rooms cords were The Diagnostic Imaging staff will routinely verify
building room P716; not wrapped around the signs. the cords are not wrapped around the signs in
and Storz CMAC the clinic through the Safety 365 checklist
Page 90 of 141
Anesthesia monitor Expired Supplies process.

on the Alkek Supply Chain Management will
Operation room coordinate a sweep of all patient Monitoring activities will begin on or before
suite. care areas to check for and remove 10/26/19.
expired supplies.
Container Labeling Expired Supplies
Supply Chain Management will
The bottle of provide educational information to
isopropyl alcohol was employees responsible for ordering, Supply Chain Management will perform monthly
discarded by the receiving and storing supplies on the reviews of a sample of 5 patient care areas to
Equipment revised ADM0127 Material check for expired supplies. Deficiencies will be
Coordinator. Management Service Policy, referred to departmental leaders for corrective
including expired supplies. action.
Wrapped Cords
New employee requisition training Monitoring activities will begin on or before
The cords wrapped will be updated to reflect policy 10/26/19.
around the signs in changes.
the Radiology All Corrective Actions
Outpatient Clinic .
were unwound on The results of the reviews and recommendations
8/15/19. for improvements are reported to the
Institutional Safety Committee (ISC) monthly for
Expired Supplies at least three months. After 3 months, the ISC
will determine whether reporting to the ISC
Expired supplies and should continue and whether the frequency
medications should be adjusted (up or down) based on
identified during the performance. Reporting to QAPI Council will be
survey were properly in accordance with the IRG reporting schedule
discarded. and standards.
Supply Chain
Management will
work collaboratively
with local leaders to
Page 91 of 141
identify and remove

expired supplies
from patient care
areas.
Supply Chain
Management will
revise the Materials
Management
Services Policy
(ADM0127) Material
to address expired
supplies.
Page 92 of 141
Tag A-747 (482.42) 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.
Tag A-747 The Hospital provides a sanitary environment to avoid sources and transmission of infections and communicable diseases and
maintains an active program for the prevention, control, and investigation of infections and communicable diseases.
A- Please refer to the Trophon. Current staff who utilize Trophon. HLD and Sterilization team will monitor Chair of Institutional
747 Plan of Correction for Trophon for HLD of probes were compliance with the Trophon SOP by Infection Control
A 749, which is provided educational information observations of practice. A minimum of 70 Committee.
incorporated into on the Trophon standard operating observations will be conducted monthly for three
this Plan of procedure. HLD and Sterilization months. Completion Date:
Correction. Educator met with department 10/26/19
leadership and staff champions to Monitoring activities will begin on or before
7.) Trophon. The review the new Trophon SOP for 10/26/19.
Trophon Standard departments utilizing Trophon.
Operating Procedure Each department champion or Deficiencies will be addressed by local leadership
was developed and leader or designee communicated with individual staff members through pertinent
made available in with responsible staff who signed an education and training, re-education and/or
MD Anderson acknowledgement attestation disciplinary action as appropriate.
intranet site and a regarding the information provided.
link to this document The results of the review and recommendations
was placed in Policy New staff who utilize Trophon will for improvement are reported to the QAPI
CLN0439 Instrument receive this educational information Council monthly. The QAPI Council will provide a
and Equipment: as part of on-boarding. quarterly summation to the Governing Body.
Cleaning, After 3 months, the QAPI Council will determine
Disinfection and CIVCO Water Bath Cleaning whether reporting to the QAPI Council and the
Sterilization. On Procedure - Sugarland Governing Body should continue, and whether
9/24/19, the the frequency should be adjusted (up or down)
Instrument and Education was provided through based on performance.
Equipment: Cleaning, written communication for the
Disinfection & current therapists/assistants of the
Sterilization Policy manufacturer's instructions for use, CIVCO Water Bath Cleaning Procedure -
(CLN0439) was including cleaning and logging Sugarland
Page 93 of 141
clarified to reflect processes on 9/20/19, face to face

that Manufacturer on 9/25/19 and at the Town Hall in The Clinical Supervisor or designee will review
Instructions for Use October by ad-Interim the water bath cleaning logs on a monthly basis.
will be utilized to Administrative Director of Therapy
validate HLD Services on 8/20/019. Monitoring activities will begin on or before
processes and 10/26/19.
procedures. New employees will receive this
educational information as part of Deficiencies will be addressed by local leadership
CIVCO Water Bath on-boarding. with individual staff members through pertinent
Cleaning Procedure - education and training, re-education and/or
Sugarland disciplinary action as appropriate.
Infection Control
reviewed the The results of the review and recommendations
"Simulation Water for improvement are reported to the Infection
Bath Cleaning Control Committee monthly for at least three
Guideline" to verify it months. After 3 months, the Infection Control
is current with the Committee will determine whether reporting to
acceptable standards the Infection Control Committee should
of infection control continue, and whether the frequency should be
and patient care. adjusted (up or down) based on performance.
The guideline lacked Reporting to QAPI Council will be in accordance
instructions to use with the IRG reporting schedule and standards.
the manufacturer's
instructions for use
when cleaning the
water bath and to
clarify requirements
for cleaning log
documentation. The
necessary revisions
to the guideline were
completed on
9/18/19
A- 8.) 8.) 8.) Infection Control will monitor compliance with
Page 94 of 141
747 the policy by observations of a sample of patients

The Hospital’s who are placed on Protective Precautions. A
Isolation Policy minimum of 10 observations will be conducted
(CLN0432) will be each week and will include the following elements:
revised to include: Order sets within OneConnect will
• Use of be revised in accordance with the 1. Appropriate use of PPE
standardized policy revisions. 2. Appropriate signage
terminology of 3. Staff knowledge of correct equipment
"Protective Signage will be revised in decontamination procedure (wipe down
Precautions" to accordance with the policy revisions with Sani Wipes upon entering and exiting
replace and will include pictures of the room).
discontinued required PPE.
terminology of Monitoring activities will begin on or before
"Protective 10/26/19.
Isolation," Educational Information on policy,
"Reverse signage and orders changes will be The results of the review and recommendations
Isolation," and distributed through institutional for improvement are reported to the QAPI
"Neutropenic communications tools. Council monthly. The QAPI Council will provide a
Precautions." quarterly summation to the Governing Body.
• Establish After 3 months, the QAPI Council will determine
standards for whether reporting to the QAPI Council and the
PPE Governing Body should continue, and whether
requirements the frequency should be adjusted (up or down)
for protective based on performance.
precautions.
• Establish Deficiencies will be addressed by local leadership
standards for with individual staff members through pertinent
equipment and education and training, re-education and/or
environmental disciplinary action as appropriate.
decontaminatio
n and cleaning
for C. difficile.
Policy revisions will
Page 95 of 141
be submitted for
approval by ECMS
and the Governing
Body on or before
10/22/19.
A- 9.) Through training, In-person training will be provided The performance of hand hygiene during venous
747 education and for current hemodialysis nurses catheter and vascular access care during initiating
monitoring, the using the "Infection Control in and termination of hemodialysis will be
nursing managers for Hemodialysis" training presentation. monitored through direct observations
Hemodialysis and The training will include policy performed by staff assigned by the Director of
dialysis leadership requirements for hand hygiene Clinical Nursing for Hemodialysis. A minimum of
team members, in techniques and the proper use of 20 observations per week will be completed.
partnership with PPE, including the correct donning
Infection Control, will and doffing sequence. Monitoring activities will begin on or before
confirm hemodialysis 10/26/19.
nurses adhere to
institutional policies The results of the review and recommendations
CLN0452 Hand for improvement are reported to the QAPI
Hygiene Policy and Council monthly. The QAPI Council will provide a
CLN0441 Infection quarterly summation to the Governing Body.
Control Associated After 3 months, the QAPI Council will determine
with Vascular Access whether reporting to the QAPI Council and the
Devices (VADs) Governing Body should continue, and whether
Policy. the frequency should be adjusted (up or down)
Deficiencies will be addressed by local leadership

with individual staff members through pertinent
education and training, re-education and/or
disciplinary action as appropriate.
Page 96 of 141
A- 10.) On 8/22/19, The changes to screening Compliance with the new process will be
747 immediate action procedures were communicated to monitored by auditing documentation of the
was taken by EH & WB staff in writing and Hepatitis B screening process for new hires.
Employee Health & included the following information:
Well-being (EH&WB) Monitoring activities will begin on or before
to cease accepting Effective immediately, updated 10/26/19.
verbal history of Hepatitis B immunization screening
Hepatitis B series at Pre-Placement Exam (PPE) for Results will be reported to the Infection Control
vaccination Post-offer Applicants with potential Committee monthly and will continue for three
completion. An exposure to blood and body fluids months.
email was sent on will consist of one of following:
8/23/19 to all 1. Documentation of completion of The results of the review and recommendations
EH&WB medical staff 3 dose series for improvement are reported to the QAPI
and administrative 2. Documentation of a positive titer Council monthly. The QAPI Council will provide a
staff outlining this - Ab to HBsAg quarterly summation to the Governing Body.
change in process. A After 3 months, the QAPI Council will determine
follow up discussion whether reporting to the QAPI Council and the
was held with staff to Governing Body should continue, and whether
confirm clarification the frequency should be adjusted (up or down)
on implementation based on performance.
of the amended
Hepatitis B
vaccination screening
process.
The language in the

HIV/HBV Policy (ADM
0348) will be edited
to align with EH&WB
processes to require
Page 97 of 141
documentation of
completion of 3 dose
series or
documentation of a
positive titer - Ab to
HBsAg
A- 11.) An Appropriate workforce members Compliance with maintaining a sanitary

747 educational module will complete the educational environment will be monitored through focused
will be developed by module. environment of care rounding conducted weekly
Infection Control to for one month and then monthly for two months
address issues Appropriate workforce members on by area leaders and/or Infection Control staff
related to leave must receive the education members. Actions will be taken to address
maintaining a before return to duty. identified issues.
sanitary
environment. New workforce members will Monitoring activities will begin on or before
receive this education as part of on- 10/26/19.
Corrective actions for boarding as appropriate.
area specific A summary of aggregate rounding results will be
deficiencies are reported to the Infection Control Committee
described below. monthly.

A-747 TEMPERATURE / Electronic monitors will be installed Maintenance of appropriate temperature and/or
Page 98 of 141
HUMIDITY in areas identified in the survey. humidity will be monitored monthly for three
To address issues months by the AVP for Patient Care Facilities or
related to monitoring The monitoring process will be designee.
the temperature and communicated in writing to current
/or humidity in areas staff members responsible for the Monitoring activities will begin on or before
where sterile storage of sterile supplies with 10/26/19.
supplies that require temperature and/or humidity
temperature and/or monitoring requirements. The The results of the monitoring and
humidity control are information will include instructions recommendations for improvement are reported
stored, the hospital on the appropriate response to to the Institutional Safety Committee monthly for
ordered electronic alarms. at least three months. After 3 months, the
monitoring Institutional Safety Committee will determine
equipment, which Staff members responsible for the whether reporting to the Institutional Safety
provide an alarm storage of sterile supplies with Committee should continue and whether the
notification when temperature and/or humidity frequency should be adjusted (up or down) based
temperature and/or monitoring requirements and on on performance. Reporting to QAPI Council will
humidity exceeds leave must receive training before be in accordance with the IRG reporting schedule
parameters. return to duty. and standards.
New staff members responsible for

the storage of sterile supplies with
temperature and/or humidity
monitoring requirements will
receive this educational information
as part of on-boarding.
A 747 PAIN MANAGEMENT

CLINIC
Clean Utility Room
The soiled
ultrasound machine
was immediately
cleaned.
The sterile and
Page 99 of 141
unsterile supplies
were relocated to
separate shelving.
Exam Room 3
The identified torn
mattress and bed
were removed from
service and a new
mattress and bed
were ordered
9/30/19.
The wall was

repaired.
Procedure Room
The sterile and
unsterile supplies
were relocated to
separate locations.
The damaged drywall
was patched and
painted. Repair was
completed on
8/20/19.
A-747 MOHS AND Current Clinical Staff, including, Compliance with the SOP will be monitored by
DERMASURGERY faculty, Nurse and Medical Assistant the Mohs Center Administrative Director or
CENTER were provided education on this designee by performing a minimum of 30
Staff will no longer Standard Operating Procedure with observations each month for three months.
prepare procedure Team Huddles on 9/23/19. Staff
trays in advance of signed an acknowledgement form Monitoring activities will begin on or before
patient arrival. A attesting to receipt of the 10/26/19.
Page 100 of 141

Standard Operating information and agreement to

Procedure (SOP) was follow the SOP. New employees will Clinical leaders will address any deficiencies with
developed as receive this educational information the individual staff member through pertinent
guideline on as part of on-boarding. education and training, re-education and/or
prepping trays on disciplinary action as appropriate.
demand on 9/20/19.
The results of the monitoring and
recommendations for improvement are reported
to the Infection Control Committee monthly for
at least three months. After 3 months, the
Infection Control Committee will determine
whether reporting to the Infection Control
Committee should continue and whether the
and standards
A-747 LEMAISTRE
Head and Neck Clinic
The leaking pipe was
repaired on 8/15/19.
A-747 MAYS BUILDING
(ACB) 8TH FLOOR
The damaged
mattresses on the
8th floor of ACB were
removed and
replaced on 9/19/19.
A-747 PHARMACY Pharmacy Managers will monitor Compliance will be monitored through weekly
To address the the overall physical environment for pharmacy environmental rounds. Results will be
deficiencies related cleanliness through weekly focused reported to Pharmacy leadership who will
to the overall environmental rounding in address any deficiencies with individual staff
physical environment pharmacy areas. Ongoing members through pertinent education and
cleanliness, cleanliness will be assessed and training, re-education and/or disciplinary action
Page 101 of 141

Pharmacy Managers documented by Pharmacy Quality as appropriate.

will conduct weekly Assurance.
pharmacy Monitoring activities will begin on or before
environmental Communication was sent to 10/26/19.
rounds. Pharmacy personnel to confirm
that, during the receiving process,
Other deficiencies tops are to be affixed to bottles. The results of the monitoring and
were corrected as recommendations for improvement are reported
follows: to the Infection Control Committee monthly for
Pharmacy Manager at least three months. After 3 months, the
removed and Infection Control Committee will determine
disposed of the whether reporting to the Infection Control
bottle on floor on Committee should continue and whether the
8/12/19. frequency should be adjusted (up or down) based
The rolling wooden be in accordance with the IRG reporting schedule
pallet was replaced and standards
immediately with a
plastic printer stand
on 8/12/19.
Pharmacy leadership
confirmed the
equipment in
question was actually
used for warming
medications rather
than weighing
medications. The
warmer was cleaned
on 8/12/19 and new
warmer was put in
place on 9/27/19.
Page 102 of 141

The mixer was

IV storage room off IV storage room off of main

of main pharmacy pharmacy
Baseboard
replacement was Educational information was
completed on provided to inpatient and
9/29/19. outpatient Pharmacy staff through
written communication to Pharmacy
staff on 8/12/19 instructing staff to:
The room was
cleaned of dirt and • Maintain cleanliness in the IV
debris. Supplies storage room and to properly
were removed from store IV fluids (out of packing
cardboard boxes and boxes; not on floor)
paper sacks and the • Properly store cleaning agents
boxes and sacks below clean/sterile supplies
were discarded. • Follow procedures to visually
Housekeeping added inspect IV fluids returned from
cleaning and patient care areas prior to
sweeping of this area restocking in the pharmacy.
to checklist as of
9/23/19. Monitoring for compliance with
these practices was added to a daily
Pharmacy Assistant Manager
checklist.
Inpatient and outpatient Pharmacy

staff on leave must receive
educational information before
return to duty.
Inpatient and outpatient Pharmacy
Page 103 of 141

staff will receive this educational

information as part of on-boarding.
First Floor Inpatient
Pharmacy
On 8/21/19 cleaning
agents were moved
to the bottom-shelf
and other items were
moved higher on the
shelving.
On 8/12/19 the
Super Sani Cloths
were relocated to
storage with all other
cleaning agents.
Inpatient Pharmacy
Inventory Storage
Room
The computer
workstation was
replaced.
Emergency Center
The bottom
medication bins in
the medication
dispenser were
cleaned to remove
dust and dirt on
8/22/19.
The refrigerator was
cleaned immediately.
Page 104 of 141

P4 Medication Room
The refrigerator was
A-747 INPATIENT SERVICE West Houston: West Houston:
HOSPITAL BASED Patient treatment room Patient treatment room
Physical Therapy Current West Houston staff that Monitoring for compliance with proper packaging
The cast saw was receive sterile instruments were will be conducted by HLD staff in West Houston
cleaned and returned provided educational information by performing, at a minimum, weekly inspections
to clean storage. about expectations for proper for improper packaging. Instruments packaged
packaging and inspection prior to improperly will be pulled and reprocessed
Dirty supplies were storage during a staff huddle immediately.
removed from the conducted by Clinical Educator on
room and cleaned. 9/20/19. Monitoring activities will begin on or before
10/26/19.
OUTPATIENT Mohs Dermasurgery Center
SERVICES OFF Sterile storage room The results of the monitoring and
CAMPUS: Current Mohs Dermasurgery Center recommendations for improvement are reported
League City staff members who stock the sterile to the Infection Control Committee monthly for
Infection Control supply room were informed of the at least three months. After 3 months, the
confirmed with change in practice during face-to- Infection Control Committee will determine
League City staff that face huddles 8/21/19 and 9/24/19. whether reporting to the Infection Control
instruments Committee should continue and whether the
transported to and Mohs Dermasurgery Center staff frequency should be adjusted (up or down) based
from League City are members who stock the sterile on performance. Reporting to QAPI Council will
transported by supply room and on leave must be in accordance with the IRG reporting schedule
Package Express and receive training before return to and standards.
that Package Express duty.
does not transport
soiled linen per the New Mohs Dermasurgery Center
contract. staff members who stock the sterile
supply room will receive this
West Houston: educational information as part of
Patient treatment on-boarding.
Page 105 of 141

room
Immediate action
was taken to re-
sterilize the
improperly packaged
instruments.
Remaining inventory
was inspected to
confirm proper
packaging techniques
were used; no
additional
improperly items
were identified.
Clean storage room

The crutches and
walkers were
relocated to a
storage shelf.
Page 106 of 141

Mohs Dermasurgery
Center
Sterile storage room
Practice was changed
to cease storage of
the stainless steel
cart in the sterile
supply room on
8/21/19.
Instruments are to
be off-loaded outside
the storage room
and brought into the
room with the cart
remaining outside
the room.
Once off-loading is
completed, the cart
is to be wheeled
back to the back
hallway for use later
in the day.
The liquid sanitizer

was removed from
the shelf above
paper goods and
sterile instruments
and stored
appropriately on
8/21/19.
Holiday decorations
Page 107 of 141

and paper goods

were removed from
the clean storage
room on 9/12/19
A hook was installed

near the call light
system cord to keep
it off the floor on
8/26/19.
Sugarland
Infection Control
confirmed with
Sugarland staff that
instruments
transported to and
from Sugarland are
transported by
Package Express and
that Package Express
does not transport
soiled linen per the
contract.
RADIATION
ONCOLOGY AND ICU
Storage room
GB.3789
Removed the mop
buckets, mops,
buffer and buffing
supplies and stored
appropriately.
Page 108 of 141

Storage room
GB.3676
Rolls of toilet tissue
were removed from
under the sink in
GB.3676 in the
Radiation Treatment
Center and stored
appropriately.
Storage room
GB.3618
The biohazard
container was
relocated to the
other side of the
exam table so that it
does not come in
contact with the
supplies.
ETV Holding Room

G7.3534.
All of the corrugated
boxes have been
removed from the
room.
Sump Room GB.3786

The sump room was
cleaned. All trash,
pieces of metal, hair
nets and muddy
Page 109 of 141

water were removed

from the sump room.
MEDICAL ARTS
CENTER OF THE
WOODLANDS
New ceiling tiles
were installed inside
of the janitor's
closet.
Page 110 of 141

Tag A-749 (482.42(a)(1)) The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling
infections and communicable diseases of patients and personnel.
Tag A-749 The Hospital ensures that the Infection Control Officer(s) develop a system for identifying, reporting, investigating, and controlling
infections and communicable diseases of patients and personnel.
A- 1.) TMC Laundry: TMC Laundry: TMC Laundry: Chair of Institutional

749 TMC laundry TMC Laundry will contact Materials Compliance with requirements to deliver clean Infection Control
leadership was Management 30 minutes prior to linens in a clean vehicle is monitored through the Committee.
notified Monday, any delivery or pickup. The product use of a checklist completed at the time of
8/19/19, that all will not be unloaded from truck delivery. Completion Date:
delivery trucks and until Materials Management 10/26/19
clean linen will be personnel are present to inspect Monitoring activities will begin on or before
inspected by and complete a checklist to confirm 10/26/19.
Materials cleanliness of the vehicle and of the
Management staff product arriving. Materials Monitoring will continue for three months.
upon arrival Management staff will reject any
confirming carts or vehicle loads that do not A monthly report will be provided to the
requirements for meet delivery and/or transport Infection Control Committee on metric
cleanliness are met. requirements for clean transport. performance.
There is to be no
dust, dirt, tape The results of the review and recommendations
residue, or torn for improvement are reported to the QAPI
plastic, and that Council monthly. The QAPI Council will provide a
adequate shrink- quarterly summation to the Governing Body.
wrapping and use of After 3 months, the QAPI Council will determine
plastic covers to whether reporting to the QAPI Council and the
protect product from Governing Body should continue, and whether
environment is the frequency should be adjusted (up or down)
required. based on performance.
Doors: Doors:
Facilities was It was determined that the double Doors:
Page 111 of 141

consulted for doors located at the back of the Door functioning and utilization and air pressure
guidance on the soiled linen room were not needed monitoring is conducted by Facilities. A smoke
need for the double so these doors were removed and puff test is performed at least weekly. The
doors in the soiled the space was filled with concrete position of the second set of double doors is
linen area to remain block to create a continuous wall to observed during the air pressure checks to
open from a life separate the soiled and clean linen confirm the doors are not propped open. Results
safety perspective; areas. are recorded in a log and deficiencies are
Infection Control was The completed work was reviewed reported and promptly corrected.
also consulted on the by Facilities, Environmental Health
need for both sets of and Safety, Infection Control and The results of the review and recommendations
double doors to Materials Management. for improvement are reported to the QAPI
remain open from an Council monthly. The QAPI Council will provide a
infection control quarterly summation to the Governing Body.
perspective. It was After 3 months, the QAPI Council will determine
determined that the whether reporting to the QAPI Council and the
corridor doors (first Governing Body should continue, and whether
set of double doors) the frequency should be adjusted (up or down)
are part of the fire based on performance.
barrier and the
magnetic hold backs
were left in place.
The second set of

double doors (at the
back of the vestibule)
are not needed for
fire safety, however
these doors should
remain closed from
an Infection Control
perspective to
maintain air pressure
differentials so the
magnetic hold backs
Page 112 of 141

were removed and

this set of doors
remain closed until
manually opened.
A- 2.) Relocated Educational information was Compliance with requirements to deliver clean
749 surgical scrubs to provided to linen staff through face- linens in a clean vehicle is monitored by the
shrink-wrapped carts to-face staff meetings on the change Materials Management Director or designee
where they are in practice regarding the through the use of a checklist which is completed
protected from requirement for surgical scrubs to at the time of delivery.
contamination. be shrink-wrapped from top to
bottom and covered with a plastic During the delivery process, the Materials
Changed practice to cover during delivery, storage and Management Director or designee will perform a
wrap surgical scrubs distribution. sample inspection of each shipment delivered by
top to bottom with TMC by the following method:
shrink-wrap and Linen staff members on leave must
cover with a plastic receive educational information - One cart/bin will be pulled and 10 items
cover to avoid before return to duty. will be reviewed for stains.
contamination
during delivery, New linen staff employees will - In addition, monthly inspections of the
storage and receive this educational information TMC laundry will be performed by the
distribution. as part of on-boarding. Materials Management Director or
designee to assess the soiled sort area,
Relocated the lockers cart wash area, folding area, prep (load
from the clean linen and wrap) area, and the sterile pack
space to an adjacent room. Concerns will be shared promptly
area. with the laundry general manager.
Corrected the "soiled - Results of compliance monitoring will be

equipment" sign to shared with the TMC laundry during
read "equipment." quarterly meetings and will be reported
monthly to the Infection Control
Developed and Committee.
implemented a
shipment checklist The results of the review and recommendations
Page 113 of 141

which requires for improvement are reported to the QAPI

checking the Council monthly. The QAPI Council will provide a
following items; linen quarterly summation to the Governing Body.
carts covered with After 3 months, the QAPI Council will determine
undamaged plastic, whether reporting to the QAPI Council and the
free of dust/ Governing Body should continue, and whether
dirt/debris/tape the frequency should be adjusted (up or down)
residue, covers fully based on performance.
extended, shipping
documents attached
to cart condition of
vehicle interior
(swept/Floor clean).
Checklist requires
signature of staff
performing the check
and date.
A- A full time The housekeeper assigned to the The dock coordinator will maintain a log of dock
749 Housekeeper was dock for general cleaning and activity and will report weekly the number of
assigned to dock. cardboard removal was informed of complaints received and number of unsafe
the specific responsibilities for this practices identified related to the separation of
The schedule for position. The specific clean and dirty on the loading dock.
power washing of responsibilities were incorporated
the dock was into the housekeeping on-boarding Monitoring activities will begin on or before
changed to weekly. program. 10/26/19.
Strategies were Facilities scheduled the weekly Monitoring will continue weekly for three
identified to improve power washing with the months and will be reported to the Institutional
traffic control on the housekeeping contractor to be Safety Committee.
dock and the performed on Friday nights or
construction Saturdays. The results of the review and recommendations
dumpsters. for improvement are reported to the QAPI
In order to facilitate maintaining an Council monthly. The QAPI Council will provide a
area of separation for receipt of quarterly summation to the Governing Body.
Page 114 of 141

food service materials/shipments, After 3 months, the QAPI Council will determine
the 7, 8, and 9 bays were dedicated whether reporting to the QAPI Council and the
to their use. The bays are identified Governing Body should continue, and whether
by the use of barricades. And/or the frequency should be adjusted (up or down)
demarcated lines based on performance.
A Dock Coordinator position has

been approved to support flow,
adherence to separation
requirements, cleanliness, and
scheduling and traffic control on the
Main dock (1515 Holcombe Blvd.).
Construction dumpsters at the dock

were covered and separated from
the loading dock by a temporary
solid barrier so as prohibit the flow
of contaminants to the food service
operations.
Construction debris coming to and
exiting from the dock are
transported in covered gondolas.
Materials Management identified

clean and dirty flows for deliveries
to avoid undue exposure to
contaminants. Clean linen coming
into the dock is in protected cover
as is soiled linen moving through the
dock to TMC laundry.
A- 3.) Decontamination An Infection Preventionist Compliance will be monitored through weekly
749 operations in presented Infection Control leadership rounding with results reported to staff
Materials education to current Materials during staff meetings. A log of rounding activity
Management were Management staff on 8/16/19 at will be maintained. A monthly compliance report
Page 115 of 141

relocated to allow for 2:30 PM and 11 PM. Objectives will be provided to the Infection Control
the space to be covered during the education Committee.
renovated. Prior to included: hand hygiene, PPE
the move, (donning and doffing), Monitoring activities will begin on or before
equipment was re- Transmission-based precautions 10/26/19.
cleaned and the (types of isolation with PPE
space was terminally requirements), soiled linen Monitoring will continue for three months.
cleaned by transport and equipment cleaning.
Housekeeping. Carts The results of the review and recommendations
were inspected and A decision was made to use bleach for improvement are reported to the QAPI
cleaned by Materials for all equipment in the Materials Council monthly. The QAPI Council will provide a
Management staff Management decontamination quarterly summation to the Governing Body.
with bleach prior to room. Materials Management Staff After 3 months, the QAPI Council will determine
their return to assigned to the durable medical whether reporting to the QAPI Council and the
service. If carts were equipment and linen were Governing Body should continue, and whether
unfit for continued instructed to use bleach wipes for the frequency should be adjusted (up or down)
service they were cleaning and disinfection of all based on performance.
removed from equipment coming to this area.
service and Equipment surface damage will be
discarded. Racks assessed and addressed.
were inspected and
cleaned by Materials Materials Management staff
Management staff assigned to the durable medical
with bleach prior to equipment and linen on leave must
their return to receive educational information
service. If racks were before return to duty.
unfit for continued
service they were New Materials Management staff
removed from assigned to the durable medical
service and equipment and linen will receive
discarded. Shelves this educational information as part
were cleaned by of on-boarding.
Materials
Management staff
Page 116 of 141

with bleach and

housekeeping
performed a terminal
clean before the
space was released
and reoccupied after
completion of the
renovation prior to
their return to
service. Equipment
was removed and
cleaned by Materials
Management staff
with bleach prior to
their return to
service. Facilities
constructed a wall
with a door between
the clean and dirty
sides of the space. In
order to create a
functioning space,
the following items
were also addressed:
air pressure
differentials,
sprinklers and sink
drain/covers.
A- 4.) Please refer to
749 the Plan of
Correction for A747
#8, which is
incorporated into
this Plan of
Page 117 of 141

Correction.
A- 5.) The regular Educational information was Compliance with disinfection between patient
749 cleaning cycle was provided to transportation services use, weekly deep cleaning, and cleanliness of
improved to include staff members regarding storage rooms will be monitored by
a weekly deep appropriate disinfection between transportation supervisors and managers.
cleaning of patient use and weekly deep
wheelchairs and cleaning on 8/21/19. Written Monitoring activities will begin on or before
stretchers on a communication will be provided to 10/26/19.
rotating schedule in transportation services staff
addition to the daily members stating no linen will be The results of the review and recommendations
high-touch surface stored in the transportation storage for improvement are reported to the QAPI
disinfection area. Council monthly. The QAPI Council will provide a
performed between quarterly summation to the Governing Body.
patient use. Transportation services staff After 3 months, the QAPI Council will determine
members on leave must receive whether reporting to the QAPI Council and the
Appropriate products educational information before Governing Body should continue, and whether
were identified for return to duty. the frequency should be adjusted (up or down)
use: Bleach wipes based on performance.
after use by C. Diff New transportation services staff
patients; Super Sani members will receive educational Deficiencies will be addressed with individual
(Quat) wipes for all information as part of onboarding. staff members through pertinent education and
other use. training, re-education and/or disciplinary action
A routine cleaning schedule will be as appropriate.
Soiled linen and trash established with environmental
bins were removed services to clean the storage rooms.
from clean storage
areas.
A- 6.) The housekeeping Training on these procedures was Compliance with isolation room cleaning
749 Standard Operating provided in a classroom setting for performance will be monitored via weekly
Procedures for environmental services staff housekeeping inspections performed by
cleaning patient members which included hands-on housekeeping leadership. Real-time feedback is
rooms at both training. During this course, the provided during daily housekeeping team leader
discharge and during policy/procedures for isolation rounds.
daily patient room cleaning were used to guide
Page 118 of 141

cleanings were training. Testing was performed to Monitoring activities will begin on or before
revised to include evaluate the knowledge of the 10/26/19.
the following the current environmental services staff
CDC guidelines for: members. Completion dates were Results are reported out to housekeeping
documented and retraining was leadership with plans for improvement
1.) Proper donning scheduled to occur annually. implemented when necessary. Deficiencies will
and doffing of PPE; be addressed by local leadership with individual
2.) Processes for Environmental services staff staff members through pertinent education and
proper hand hygiene members on leave must receive training, re-education and/or disciplinary action
to be followed upon training before return to duty. as appropriate.
entering and/or
exiting the patient New environmental services staff The results of the review and recommendations
room to remove members will receive this for improvement are reported to the QAPI
trash, biohazardous educational information as part of Council monthly. The QAPI Council will provide a
waste, or for any on-boarding. quarterly summation to the Governing Body.
other reason; and, After 3 months, the QAPI Council will determine
3.) Processes for whether reporting to the QAPI Council and the
wiping down all Governing Body should continue, and whether
equipment taken out the frequency should be adjusted (up or down)
of the room. based on performance.
Page 119 of 141

Tag A-940 (482.51) If the Hospital provides surgical services, the services must be well organized and provided in accordance with acceptable
standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance
with the complexity of services offered.
Tag A-940 The Hospital ensures that surgical services are well organized and provided in accordance with acceptable standards of practice.
The Hospital also ensures that outpatient surgical services are consistent in quality with inpatient care in accordance with the complexity of
services offered.
A– All reusable gowns, On-site vendor support was The transition to disposable gowns, drapes and Associate Vice
940 drapes, and towels provided from 8/17/19 – 9/26/19 to towels was a permanent change. President for
(A-C) were removed and assist with the transition from Perioperative
surgical services reusable linens to disposable gowns, Services
converted to sterile drapes and towels.
disposable gowns, Completion Date:
drapes, and towels 10/26/19
in both OR locations.
A– A cargo van with an Standard Operating Procedures The cargo van temperature and humidity logs will
940 all metal interior and were developed and implemented be reviewed by the Materials Management
(D) air conditioned was for pick-up and delivery by Materials Manager or designee retrospectively each week
obtained for the Management personnel who are for three months to confirm the temperature and
transport of case involved in sterile instrument humidity is kept within the appropriate range.
carts containing transport. These SOPs include
sterile and unsterile instructions for preparation and Monitoring activities will begin on or before
instruments between sanitizing the vehicle, processes for 10/26/19.
MOH's and Sterile temperature and humidity
Processing. A monitoring, and documentation The results of the review and recommendations
monitoring device requirements for acceptance for for improvement are reported to the QAPI
which provides pick-up and delivery. Training of Council monthly. The QAPI Council will provide a
constant readouts of current Materials Management quarterly summation to the Governing Body.
temperature and personnel was performed regarding After 3 months, the QAPI Council will determine
humidity was these procedures. whether reporting to the QAPI Council and the
installed in the cargo Governing Body should continue, and whether
Page 120 of 141

van. The Current Materials Management the frequency should be adjusted (up or down)
temperature and personnel on leave must receive based on performance.
humidity are training before return to duty.
recorded for clean Deficiencies will be addressed by local leadership
instrument New Materials Management with individual staff members through pertinent
transport. personnel will receive this education and training, re-education and/or
educational information as part of disciplinary action as appropriate.
on-boarding.
A– The use of the One Communication was sent to OR A sample of 30 cases (or 100% if less than 30
940 Tray Sterilization Nursing Staff and Surgery Providers cases) in which a vendor provided an implant
(E) system was regarding immediate cessation of requiring sterilization will be reviewed by AVP of
discontinued on the use of the One Tray system and Perioperative Services or designee monthly to
8/22/19. reinforcing that implant sterilization ensure that the sterilization cycle was completed
must be complete prior to patient before patient arrival to the OR.
Multiple meetings arrival to the operating room suite
were held with on 8/22/19. This will be reinforced Monitoring activities will begin on or before
Sterile Processing at Perioperative and Surgery 10/26/19.
leadership, meetings.
Perioperative Vendor compliance for timely implant delivery
Services leadership, Education was provided on 8/23/19 will be monitored at least monthly for three
Nursing, and for Sterile Processing Staff on the months by Sterile Processing Department
Surgeons on 9/18- immediate cessation of the use of Leadership.
19/19 to review the One-Tray system and the need
national standards to complete full cycle sterilization The results will be reported at least monthly to
and guidelines on for all implantable devices. Sterile Processing Leadership and quarterly to the
the use of OR Committee.
Immediate Use Sterile Processing Staff members on
Steam Sterilization leave must receive education before The results of the review and recommendations
(IUSS) in order to return to duty. for improvement are reported to the QAPI
determine any Council monthly. The QAPI Council will provide a
needed updates to New Sterile Processing Staff quarterly summation to the Governing Body.
the perioperative members will receive this education After 3 months, the QAPI Council will determine
SOPs. as part of on-boarding. whether reporting to the QAPI Council and the
Page 121 of 141


Two Perioperative Vendors will be reminded in writing the frequency should be adjusted (up or down)
Services Standard that implant delivery must allow for based on performance.
Operating proper sterilization.
Procedures were Deficiencies will be addressed by local leadership
revised as a result of IUSS educational information will be with individual staff members through pertinent
this review: provided at Sterile Processing education and training, re-education and/or
Department meetings. disciplinary action as appropriate.
• Perioperative
Services Sterile Sterile Processing staff and OR
Process: Nursing staff will receive
Guidelines for educational information on updates
Immediate-Use to the Standard Operation
Steam Procedure.
Sterilization; and
• Perioperative
Guidelines for
Vendor Provided
(Loaner)
Instrumentation
and Sterile
Implants.
A– Language was added Affected Surgical Scrub Techs and

940 to the position Clinical Nurses were educated on
(F) description to clarify the job specific competency
expectations for checklist during multiple OR Staff
competencies for Meetings. An acknowledgement of
the Surgical Scrub the competency checklist and
Tech and for the revised position description was
Clinical Nurse in signed by affected Surgical Scrub
surgical and Techs and Clinical Nurses.
procedural areas. A Competencies will be validated for
checklist was affected Surgical Scrub Techs and
Page 122 of 141

created to clarify the Clinical Nurses by the employee’s

job specific manager. Thereafter, competencies
competencies for will be incorporated in the
the Surgical Scrub employee’s annual performance
Tech and the Clinical evaluation.
Nurse in the OR.
New employee on- Affected Surgical Scrub Techs and
boarding was Clinical Nurses who have been on
modified to include leave must have validated
completion of the competencies before they return to
job-specific duty. New hires will complete the
competency job- specific competency checklist
checklist. during the on-boarding period
and/or residency.
Employee files were
reviewed and The Associate Directors or designees
expired job specific will assess that required
competencies were competencies have been
updated for the satisfactorily completed for Surgical
individual staff Scrub Techs and Clinical Nurses.
member.
A– Also refer to A 747,

940 #11 for additional
(G) actions taken to
address deficiencies
in maintaining a
sanitary
environment,
including the
education and
environmental
rounding
implemented to
Page 123 of 141

address these issues.
Actions taken to
address area-specific
findings are as
follows:
MAYS ASC
PRE-OP SUPPLY CART
Sterile and clean
non-sterile supplies
were separated and
stored on separate
shelves.
The uncovered linen

was covered.
ANESTHESIA SUPPLY
ROOM
The container of
clean anesthesia
circuits was
relocated to the
proper storage
location.
OPERATING ROOM 3
The non-intact
linoleum was
repaired and the
area above was
repainted.
Page 124 of 141

CATH
LAB/INTERVENTION
AL
RADIOLOGY/PACU
PACU SUPPLY
CLOSET
Sterile and clean
were separated and
stored on separate
shelves.
EMERGENCY SUPPLY
CART
Sterile and clean
were separated and
stored in separate
drawers.
Expired items were

removed and
discarded.
NURSES DESK
The laminate was
repaired.
CATH LAB SUPPLY

CLOSET (G3.3445)
The storage bins on
the floor were
relocated to the
proper location.
Page 125 of 141

Sterile and clean

were separated and
stored in separate
bins.
The corrugated
boxes were
removed.
CATH LAB SUPPLY

CLOSET (G3.3473)
The room was re-
organized.
The supplies on the

floor were relocated
to the proper
location.
The corrugated
boxes were
removed.
Sterile and clean

were separated and
stored in separate
bins.
The Medtronic
pacemaker generator
unit was sequestered
Page 126 of 141

from clinical use until

clinical engineering
completed its review
on 8/20/19. An asset
tag along with an
inspection sticker is
now on the device.
ENDOSCOPY CENTER
PROCEDURE ROOM 7
The wedge
positioner was
removed from
service and
discarded.
The room was re-

organized.
The Bair Hugger on

the floor was
relocated to a proper
storage location.
The portable
ultrasound machine
and the mobile
computer station
were cleaned.
The vinyl pad was

removed from the
floor, was cleaned
and properly stored.
Page 127 of 141

PROCEDURE ROOM 6
The trash and soiled
linen were removed.
The wheel coverings
on the anesthesia
machine were
cleaned.
The supply cart with

rusted wheel casters
was removed from
service and
discarded.
The air conditioning

vent was properly
positioned and
cleaned.
The plastic storage

bins on the metal
cart containing
Gastrointestinal
supplies were
cleaned.
Unpackaged
irrigation needles
were discarded and
are now being stored
in original packaging.
The corrugated
Page 128 of 141

boxes were removed

and the biopsy
forceps were placed
in a proper storage
location.
The rubber band was

removed from the
sterile supply packs.
Storage drawers and

cabinets were re-
organized to
separate sterile and
clean, non-sterile
supplies and office
supplies.
MAIN OR
SUPPLY CORE A
The baseboard was
repaired.
The plastic bins were

cleaned.
BioMed performed
preventive
maintenance on the
bipolar machine and
affixed the
appropriate sticker.
The equipment
Page 129 of 141

storage room was

cleaned.
In the anesthesia
storage room, the
cabinet and the walls
were repaired and
the room was
cleaned. Patient
supplies were
removed from the
floor and placed in a
proper storage
location.
Sterile and clean

were separated and
stored on separate
shelves. The Doppler
was removed.
The anesthesia gas

storage cabinet was
cleaned and the
white paper bags
were removed.
STERILE CORE B
The plastic bumper
guard was replaced.
The floor was
repaired. The
autoclave was
Page 130 of 141

immediately cleaned
and a scheduled
cleaning process was
implemented.
The plastic storage

container was
removed from the
floor and properly
stored.
The rubber band was

removed from the
sterile supply packs.
OPERATING ROOM 1
The floor and the
metal strips were
repaired.
The metal racks with

were replaced and
the bins and shelves
were reorganized.
OPERATING ROOM
16
The floor was
repaired.
OPERATING ROOM
21
The Bair Hugger was
Page 131 of 141

removed from the

floor and was
storage location.
The plastic plate was

removed from the IV
pole and the IV pole
was cleaned.
The metal table with

was replaced.
The plastic film

coating was removed
and the anesthesia
machine was
cleaned.
The headlamp was

removed from
service.
The floor was

repaired.
OPERATING ROOM
22
The baseboard was
repaired.
PREOPERATIVE
AREA, ROOM P503
Page 132 of 141

The mattress was

removed and
replaced.
MAIN OR PAVILION
TOWER
The storage bins
were cleaned.
The sterile packs

were re-sterilized
with visible
sterilization
indicators.
INTERVENTIONAL
RADIOLOGY
The sterile trays
were removed from
the cart and
storage location.
The air conditioner

return vent was
cleaned.
CATH LAB
The baseboard was
repaired.
The plaster under
the hand sanitizer
was repaired.
Page 133 of 141

The trim for the glass

protector window
was repainted.
The drawer with

brownish spillage
was cleaned.
The air conditioner

return vents were
cleaned.
Expired blood
collection tubes were
removed and
discarded.
The C-arm, the

ceiling and the
counter were
cleaned.
ENDOSCOPY UNIT
A process was
implemented to
clean the ManoScan
protective case.
Expired blood
collection tubes were
removed and
discarded.
STORAGE ROOM
Unused and
Page 134 of 141

unnecessary items
were either
relocated or
discarded. The
storage room was
reorganized and
cleaned for proper
storage of
equipment and
supplies. Supplies
were not stored
above the red line.
The ceiling tile was

replaced.
Corrugated boxes
were removed and
supplies were
storage location.
The clean linen bags

were removed.
The patient cleaning

supplies and the
sweetener were
removed from the
cleaning supplies
cabinet.
ENDOSCOPY UNIT
Page 135 of 141

Staff members involved in

ManoScan probe cover cleaning
were educated on the correct
process for cleaning. This
information was also added to their
competencies.
Staff members involved in

ManoScan probe cover cleaning on
leave must receive training before
return to duty.
New employees that will be

involved in involved in ManoScan
probe cover cleaning will receive
this educational information as part
of on-boarding.
Page 136 of 141

Tag A-1005 (482.52(b)(3)) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation
completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48
hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed
in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect
current standards of anesthesia care.
Tag A-1005 The Hospital ensures that post anesthesia evaluations are completed in accordance with State law and with hospital policies and
procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care.
A- A Post Anesthesia Current Anesthesia Providers will be The Safety and Quality Officer for the Division Safety and
1005 Care and Discharge educated on the Post Anesthesia Department of Anesthesiology and Perioperative Quality Officer,
policy that addresses Care and Discharge policy and will Medicine or designee will monitor compliance Division of
the following items sign an “Acknowledgement and with the Post Anesthesia Care and Discharge Anesthesiology,
will be developed, Attestation,” indicating notification policy by auditing 70 patient records each month Critical Care and
which includes: of this policy change. for three months. Pain Medicine
• Guidelines for Anesthesia Providers on leave must Monitoring activities will begin on or before Completion Date:
when it is review the Post Anesthesia Care and 10/26/19. 10/26/19
appropriate for Discharge policy and complete an
the Post- attestation before return to duty. The results of the review and recommendations
Anesthesia for improvement are reported to the Division
Assessment to be New Anesthesia Providers will Safety and Quality Officer monthly for at least
completed; which review the Post Anesthesia Care and three months. After 3 months, the Division
include that the Discharge policy as part of Safety and Quality Officer will determine whether
patient is awake, onboarding. reporting to the Division Safety and Quality
able to participate Officer should continue and whether the
in the assessment, frequency should be adjusted (up or down) based
and sufficiently on performance. Reporting to QAPI Council will
recovered from be in accordance with the IRG reporting schedule
anesthesia for the and standards
discharge process
to continue. Individual Anesthesia Provider deficiencies will be
addressed through pertinent education and
Page 137 of 141

• Confirm that the training, re-education and/or referral for

Post-Anesthesia confidential peer review through the medical
Assessments will staff, if appropriate.
only be completed
once the patient is
sufficiently
recovered from
anesthesia.
• Vital signs must

be performed and
validated within
fifteen minutes of
Post-Anesthesia
Assessment.
The Policy will be

submitted for
approval by ECMS
and the Governing
Body on or before
10/22/19.
Page 138 of 141

Tag A-1076 (482.54) If the Hospital provides outpatient services, the services must meet the needs of the patients in accordance with
acceptable standards of practice.
Tag A-1076 The Hospital ensures that outpatient services meet the needs of the patients in accordance with acceptable standards of practice.
A- Please refer to the VP, Ambulatory

1076 plans of correction Operations and
for A094, A144, Access
A146, A392, A724,
A749, A1077, and Completion Date:
A283 each of which 10/26/19
is incorporated into
this Plan of
Correction.
Page 139 of 141

Tag A-1077 (482.54(a)) Outpatient services must be appropriately organized and integrated with inpatient services.
Tag A-1077 The Hospital ensures that outpatient services are appropriately organized and integrated with inpatient services.
A- A multi-disciplinary Unit Huddles will be conducted by SI reports resulting from improper scheduling will Administrative
1077 leadership team Unit leaders for current inpatient be investigated by designated ATC leadership, Director of
representing hematology nurses on the process designated inpatient nurse leadership and Ambulatory Infusion
Ambulatory for coordinating ambulatory Patient Safety. If trends are identified, these will
Treatment Centers infusion appointments and use of be reported to the QAPI Council. Completion Date:
(ATCs), Pharmacy, the coordination tool. 10/26/19
Patient Experience, Monitoring activities will begin on or before
Patient Education, Current inpatient hematology 10/26/19.
Inpatient Nursing, nurses on leave must receive
and Case educational information before Clinical leaders will address any deficiencies with
Management met to return to duty. New inpatient the individual RN and/or PSC through education,
identify hematology nurses will receive this re-education and/or progressive disciplinary
opportunities for educational information as part of action, as appropriate.
improvement in the nursing unit on-boarding.
coordination of care
for Hematology Unit Huddles will be conducted by
inpatients who are Unit leaders for current ATC Patient
discharged with a Services Coordinators (PSCs) on the
home infusion pump. process for coordinating ambulatory
infusion appointments and use of
An attachment, the report. Additionally, ATC-PSCs
ATT3309, for Policies will be educated on submission of a
CLN3281 Discharge Safety Intelligence (SI) report for
Planning Policy and incidents where a patient’s ATC
CLN0641 Discharge appointment is not appropriately
of a Patient from an coordinated.
Inpatient Unit was
developed. Current ATC-PSCs on leave must
receive educational information
Page 140 of 141

ATT3309 will be before return to duty. New ATC-

submitted for PSCs will receive educational
approval by ECMS on information as part of new
or before 10/22/19. employee unit on-boarding.
A coordination tool
was developed for
the inpatient units to
guide the process for
patient discharge
with a home infusion
pump, including
patient education
and organization and
integration between
inpatient and
outpatient services.
A report was
developed for the
ATC to identify
patients who will be
discharged with a
home infusion pump
to facilitate
coordination of
scheduling.
Page 141 of 141

Mdacc Cms Poc Final 10-03-19

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The University of Texas MD Anderson Cancer Center

Plan of Correction – August 23, 2019 Survey

A000 Initial Comments

indication that the appointment of the individual, Dr.

A new format for

The Governing Body

indicators (KPIs) and conducted by the Associate and outcomes sufficiency.

Supply Chain Management will conduct a review

Monitoring will begin on or before 10/26/19.

On 9/19/19 the On 9/19/19 the Director of

Sourcing and Contract

clinical review of KPIs On or before 10/22/19, ADM0128

Sourcing and Contract

Contract stakeholders will review

In addition, the • Medical emergency

(Code Blue) medical supplies

A- Please refer to the Associate VP,

Tag A-117 (§482.13(a)(1)) Patient Rights: Notice of Rights

A- Between 9/6/19 and Outpatients: Outpatients: Assoc. VP, Patient

The results of the review and recommendations

Tag A-131 (§482.13(b)(2)) Patient Rights: Informed Consent

assistants and other health care

On 9/17/19, Anesthesia Providers

The Department of Anesthesiology

Tag A-143 (§482.13(c)(1) Patient Rights: Personal Privacy

Tag A-144 (§482.13(c)(2)) Patient Rights: Care in a safe setting

midazolam, for pain

limitation of the summation to the Governing Body. After 3

The Contract Nurse

the process for in-person training on following

tracked and should continue and whether the frequency

Monitoring activities will begin on or before

The Unit Leaders or designees will address

all wands to be pre and post weights for

On 8/15/19, during Educational information on the

The Contract Dialysis

and part of the safeguard

language that: taken:

• describes staff On G10NW, the specimen collection

G22 staff will be included in the

A locking mechanism will be

confidentiality of PHI in surgical

On or before 10/22/19, ADM0128

Sourcing and Contract Management

renew, or enter into new

Contract stakeholders will review

will be catalogued by the

The Governing Body will expand the

defined in Appendix 2 of the

The QAPI Council PowerPoint

and the Governing indicated.

The restraint policy

The Restraint policy

Tag A-283 (482.21(b)(2)(ii), (c)(1), (c)(3)

A- For deficiencies Chief Operating

Tag A-286 (482.21(a), (c)(2), and (e)(3))

A- Please refer to the Chief Operating

A- Please refer to the Chief Nursing

improvement in staffing during focus group sessions;

opportunities to nursing to discuss modifications of

• Role of wound care nurse Unit Leaders or designee will perform a

will include: Inpatient nurses, DI nurses and CT

The Divisional policy

diagnosis, and incorporated in the on- boarding