The Centers for Medicare and Medicaid Services (CMS) found Holly Hill Mental Health Services not to be in compliance the conditions of Medicare participation due to “failing to ensure an effective Quality Assessment and Performance Improvement program.” CMS determined that the facility failed to ensure that corrective actions were implemented and monitored for effectiveness following repeated incidents of alleged sexual activity and misconduct on the adolescent patient unit.
In March 2012, a 13-year-old girl reported having consensual sexual relations with a 17-year old boy housed on the same unit. The unit’s motion detection system had not been activated, even though the system was functional. After this incident, the facility instituted new monitoring policies. But CMS found that “the hospital failed to ensure all staff were trained on the new policy regarding the motion detection system activation” and there was “no monitoring” of the corrective action taken following the above-mentioned incident. In July, a 12-year-old boy reported having sexual contact with a 13-year-old boy in his room at night. 15-minute checks had not been correctly performed during the time of the alleged contact and the motion detection system was again not activated. At the time of the CMS survey conducted in August, CMS surveyors found that the hospital “had no formal re-training of the 15-minute observation rounds” and that the monitoring of the rounds was “inconsistent.”
On the adult unit, CMS found issues with medication delivery. One patient normally took Hyzaar to treat high blood pressure. However, this drug was not available in the facility’s formulary. The patient was not given any blood pressure medication for the first two days of his hospital stay, and then was prescribed Cozaar and HCTZ (hydrochlorothiazide) as a substitution. Nursing staff could not remember why the patient was not given medication for the first two days.
In order to correct its deficiencies, the facility was required to submit a plan of correction.