Timberlawn violates multiple Conditions of Medicare Participation over three month period, Risks Termination of CMS funding

On May 13, 2015, the Centers for Medicare and Medicaid Services (CMS) conducted an unannounced complaint investigation survey and found that the facility continued to violate the conditions of Medicare program participation around patient rights. Since February 2015, the facility has been repeatedly cited for continued noncompliance with upholding patient’s rights.

During the May 13 CMS survey, CMS found that the hospital once again failed to uphold patient’s rights by not ensuring a safe care setting. CMS found that not all patient rooms on the Bloss unit were being monitored by the 2 mental health technicians. During a tour of the facility, CMS surveyors found that one patient in Room 160 closed his door twice during a 19 minute period.  The hospital’s Chief Operating Officer made rounds at that time and walked by Room 160’s closed door without inquiring about the patient status and/or opening the door.

CMS also found that 2 patients were not adequately monitored, and the two had engaged in a  nonconsensual sexual encounter without staff knowledge. Even though the victim patient was placed on close observation 15 minute checks, she informed staff that she was raped by a male patient. CMS interview with a staff member revealed that at the time of the alleged rape, he was in the office doing paperwork because “the unit was full with 24 patients APOWW’s (individuals that were apprehension by Peace Officer without warrant).

CMS also found that the Bloss Unit exceeded the allowed bed capacity of 24 beds on 2 days. On 5/7/15, the unit exceed bed capacity by three patients. On 5/8/15, the unit had 30 patients, which left 6 patients without a bed. As a result, patients had to sleep on couches and chairs and patients’ privacy was not ensured. CMS noted that “[t]his practice placed patients and/or staff the likelihood for injury due to overcrowding. It further compromised the provision of care that meets the patients’ psychomedical and psychosocial needs.”

CMS determined that Timberlawn failed to adequately address its survey violations from its February 2015 inspection survey, its April 2015 hospital survey, its April 2015 psychiatric hospital survey, and May 2015 survey, and found that the facility remained out of compliance with the following Medicare conditions of participation:

  • Patient Rights
  • QAPI
  • Nursing Services
  • Special Medical Record Requirements for Psych Hospital
  • Special Staff Requirements for Psych Hospitals

As a result of this continued noncompliance, CMS notified Timberlawn on May 29, 2015 that it had until June to correct its deficiencies, otherwise its Medicare Agreement and associated federal funding would terminate on July 13, 2015. In August, CMS terminated the facility from the Medicare Program, but the facility is recently undergoing a process to re-enroll in the program, subject to CMS inspections for compliance.