HospitalInspections.org

Based upon record review and interviews, the hospital failed to ensure the list of contracted services was updated. This was evidenced by the failure to add or remove contracts/agreements from the list. The contract list also failed to identify the service being offered, whether the services was on or off site, the volume or frequency of the service provided, and when the services was available.

Findings:

During the tour of the pharmacy drug room on 11/10/21 at 10:30 a.m. Staff F, who provides oversight of the pharmacy services, revealed Contract M was used to provide the pharmacy with drugs and biologicals. Interview on 11/10/21 at 1:15 p.m. with Staff B revealed the hospital had a transfer agreement with Contract N for patients who required a higher level of care.

Review of the Quality Assurance/Performance Improvement Meeting Minutes dated 05/13/21 revealed Contract M and Contract N were identified as being reviewed through the program.

Review of the list of contracted services revealed Contract M and Contract N was not on the list. Further review of the list revealed the service being offered by the contracted entity was not identified, whether the service was on or off site, the volume or frequency of the service and when the service was available. During this review, Staff B was asked if the hospital had an updated list of contracts and his response was he would check.

On 11/11/21 at 9:20 a.m. interview with Staff B revealed he could not find an updated list of contracted services and confirmed the list had not been updated to included the added contracts.