HospitalInspections.org

Based on interviews and examination of administrative documents, the hospital failed to develop the institutional plan and budget under the direction of the governing body and by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff of the institution.

Findings:

On 1/6/10 at 1:20 p.m. staff 1 was interviewed about the hospital's overall institutional plan. Staff 1 said neither the budget nor the overall operational plan was developed under the direction of the governing body (Governing Board). She said neither were approved by the Governing Board. On 1/7/09 at 2:20 p.m. staff 1 said the governing body does some assessment of needs for the budget and has started doing strategic planning. However, staff 1 said the Governing Board was currently not developing the institution's operational plan and operating budget.

Staff 1 was asked to provide evidence from the minutes of the Governing Board to demonstrate that it was involved in the preparation of the overal institutional plan including the budget. She was unable to provide documentation which affirmed that the overall institutional plan was developed under the direction of the Governing Board. Examination of minutes of meetings of the Governing Board for 2009 also did not show evidence of the development of the overall operational plan and budget.