HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) monitoring was performed on the Case Management department in the year 2018 and two of of three services provided under contract or arrangement.

Findings include:

Review on March 14, 2019, of the facility document "Performance Improvement Plan," dated September 6, 2017, revealed, " ... Section III: Organizational Structure A. The LVH (Lehigh Valley Hospital) Board of Trustees has the ultimate responsibility to oversee quality and patient safety and performance improvement at LVH. The LVH Board meets quarterly and is predominantly focused on quality, patient safety and performance improvement ... D. Network Quality and Patient Safety Council (NQ&PSC) ... is responsible for defining, prioritizing, overseeing and monitoring quality, patient safety and performance improvement activities directly and indirectly related to patient care at LVH ... Section VII: Reporting and Monitoring A. Reporting 2. Key departments, service lines and committees submit reports with performance metrics at least annually to NQC. The key performance improvement metrics are reviewed by the Board of Trustees at least annually ... ".

Review on March 14, 2019, of the facility document "2018 Network Quality Council Annual Report Schedule," revealed Case Management was scheduled for review by the Network Quality and Patient Safety Council in September.

Review on March 14, 2019, of facility's "Network Quality and Patient Safety Council," meeting minutes dated September 5, 2018, revealed, the Case Management department QAPI data was not reported or discussed at this meeting.

Review on March 14, 2019, of facility document "Board of Trustees," dated November 14, 2018, revealed, " ... 5.4 Department Metrics Quality Metrics for the following areas: ... ." Further revealed Case Management Department was not listed as one of those areas. Further review of the document revealed contracted services for Sign Language Interpretive Services, Ambulance Service/Intrafacility and Hospice Transport were not listed.

Interview with EMP9 on March 14, 2019, at approximately 1:30 PM confirmed the facility's Performance Improvement Program does not contain documentation for monitoring the Case Management Department for the year 2018 and could not provide documented evidence of QAPI monitoring for 2 out of 3 services provided under contract or arrangement.

Review of facility document, "CY 2019 ... Contracted Services," on March 15, 2019, at approximately 11:00 AM revealed, " Contract ... Sign Language Interpretive Services ... Ambulance Service/Intrafacility and Hospice Transport ... Travel RN's/Ancillary Staff ... ".

Request made to EMP9 on March 15, 2019, at approximately 1:00 PM for Performance Improvement Quality Data related to contracted services for Sign Language Interpretive Services, Ambulance Service/Intrafacility and Hospice Transport and Travel RN's/Ancillary Staff. No information was provided for Sign Language Interpretive Services, Ambulance Service/Intrafacility and Hospice Transport.