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Based on a review of facility documents and staff interview (EMP), it was determined that the Governing Body failed to ensure that services performed under contract were evaluated.

Findings include:

On July 12, 2022, a review of the document, "Clinical Services Provided to Washington Health System Greene by Contract" dated July 1, 2022, revealed ten clinical contracts for the facility.

On July 12, 2022, a review of the "Annual Contract Services Evaluation- FY21," revealed evaluation of 14 clinical services performed via contract for the facility.

On July 13, 2022, it was noted that the contract for nutritional services had not been evaluated in FY21. The last evaluation of this contract was noted to be September 24, 2020. These findings were confirmed by EMP10 at 1:15pm.

On July 14, 2022, a document review revealed that the evaluation of contracted services for FY21 was reviewed by the Medical Executive Committee on October 19, 2021. Review of "Washington Health System- Greene Board of Directors Meeting Minutes" for 12/15/21 and 3/8/2022 do not demonstrate evidence that contracted clinical service evaluations were summarized and/or reviewed. This finding was confirmed by EMP2 at 12:00pm.

Based on a review of facility documents and credential files (CF), and staff interview (EMP), it was determined that the facility failed to ensure that medical staff reappointments met criteria for reappointment in 9 of 10 credential files reviewed (CF1, CF2, CF3, CF5, CF6, CF7, CF8, CF9, CF10).

Findings include:

A review of Medical Staff Bylaws, Policies and Rules and Regulations of Washington Health System Greene, Credentials Policy, Dated December 15, 2021, revealed, "5.A.2 (c). "....Additionally, the following factors will be evaluated as part of the reappointment process: ... the results of the Hospital's performance improvement, ongoing professional practice evaluations, and other peer review activities, taking into consideration practitioner-specific information compared to aggregate information concerning other individuals in the same or similar specialty.....4.A.1 (e)(6)adequate professional liability insurance coverage for the clinical privileges requested...."

A review of facility credential files revealed that Peer Review was not a part of the re-appointment file for CF3, CF6, and CF10. These findings were confirmed by EMP17 on July 12, 2022, at 11:30am.

Further review of credential files revealed that notification from the governing board to the applicants regarding the status/approval of their application was not included in CF1, CF2, CF3, CF5, CF6, CF7, CF8, CF9, and CF10. On July 12, 2022, at 10:00am, EMP17, confirmed that the notification letters could not be located.

A review of CF4 revealed that privileges were granted via the governing body on 12/15/2021. The letter to the applicant from the governing body reveals that the letterhead was from the facility's health system. The letter in CF4 states that privileges were granted for another hospital and not Washington Hospital Greene. During an interview EMP17 confirmed the findings on July 17, 2022, at 10:40am.

A review of CF10 revealed that the practitioner failed to maintain professional liability insurance at the required state minimum. On July 12, 2022 at 11:45am, EMP17 acknowledged that the coverage did not meet the 1M/3M required by the state.

Based on a review of facility documents and credential files (CF) and staff interview (EMP), it was determined that the facility failed to review Ongoing Professional Practice Evaluations (OPPE) for telemedicine re-appointments for one of two credential files reviewed (CF6).

Findings include:

Review of Medical Staff Bylaws, Policies and Rules and Regulations of Washington Health System Greene, Credentials Policy, (Last Revised- December 15, 2021), 4.A.7 (c)(1) revealed, "A request for telemedicine privileges may be processed through the same process for Medical Staff Applications, as set forth in this Policy. In such case, the individual must satisfy all of the qualifications and requirements set forth in this Policy, except those relating to geographic locations, coverage arrangements, and emergency call responsibilities."

A review of stroke telemedicine revealed that no peer review or OPPE were available during the re-appointment process of CF6. EMP17 confirmed these findings on July 12, 2022, at 11:15am.

Based on review of facility documentation, observation, and staff interview (EMP), it was determined the facility failed to ensure medications were kept secured.

Findings include:

On July 12, 2022, a review of the facility policy titled, "Pharmacy Policy & Procedure Manual, Policy #3, reviewed: October 2021," revealed, "Section III - Medications...S. Storage of Medications...Proper storage of medications on nursing units is to be strictly observed. 1. Internal Medications - kept under lock at all times in medicine carts in room servers or locked medication room."

A tour of the ambulatory outpatient department was conducted on July 11, 2022, at 12:00pm. During the tour it was noted that the door to the clean utility was unlocked. Inside this room the following medications were observed to be unsecured in a ziplocked bag setting on the counter next to the sink: Solumedrol 125 mg IV push, Epinephrine Injectable Amp 0.5mg, and Diphenhydramine 50 mg IV push.

During an interview at the time of the observation, EMP9 confirmed the door must not have latched and that medications were on the counter to be returned to pharmacy.

Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to ensure that the utilization review plan and utilization review committee were separate from other hospitals in the facility's health system.

Findings include:

On July 14, 2022, review of a facility document "Utilization Review Committee Meeting Washington/Greene Hospitals" revealed that the committee meetings are combined for two facilities and not separate.

Interview with EMP16 on July 14, 2022, at 12:00pm confirmed that the committee are not separate. When asked if the hospital had an exception to this requirement EMP16 stated that the facility did not. When asked about the frequency of the Utilization Review Committee meetings, EMP16 reported that the committee meets quarterly on average but sometimes every six months. EMP16 further explained that COVID-19 interrupted those meetings greatly. Additionally, no meeting schedule was outlined in the plan.

Based on a tour of the facility and staff interviews (EMP), it was determined that the facility failed to maintain a clean and sanitary environment.

Findings include:

During a tour of the facility on July 11, 2022, from 11:25am unitl 12:45pm the following was observed:
1. At 11:26am, a tour of room, 375, designated as "Housekeeping," revealed running water into a discolored sink. Also noted was a rust-colored puddle of water on the floor, with peeling flooring. It was also noted that a vent cover was missing on the wall. Confirmed at 12: 37pm by EMP2, EMP5, and EMP6.
2. At 11:29am a dust covered infant incubator, warmer, and bassinet in a hallway of lockers labeled EVS and Utilization Management. Confirmed at 12:39pm by EMP2.
3. At 11:30am, an open electrical box was observed in the Respiratory Storage Room, 353, while accompanied by EMP 7. Confirmed by EMP5 and EMP 6 at 12:36pm.
4. At 11:32am, a baseboard electrical outlet, across from room 353, was noted to be damaged as a piece of the outlet cover was missing creating a safety hazard. Confirmed by EMP6 at 12:36pm.
5. At 11:42am a tour of the Pulmonary Function Lab revealed dust and dead bugs on the windowsill. EMP7 confirmed findings. When asked what the cleaning schedule for the room was, EMP7 reportedly did not know.
6. At 11:45am, the Pulmonary Function Lab was toured with EMP7. Running water was noted in the toilet room. The hot water knob and spout were noted to be corroded. This finding was validated with EMP6 at 12:40pm.
7. At 11:45am, the Pulmonary Function Lab was toured with EMP7. The floor-based air exchange module was dirty both visually and to touch. Confirmed by EMP6 at 12:40pm.
8. At 11:52am restrooms in the cardiac testing unit were found to have dust around the sinks as well as brown/black build up around the baseboards and around the bottom of the toilets. At this time the window at the end of the hallway was observed and found to have various types of dead bugs on the windowsill as well as dust and dirt. EMP7 confirmed findings.
9. At 11:57am four out of seven lights in the cardiac testing unit hallway were observed to have bugs in them. EMP7 confirmed findings.
10. At 12:15pm in room 322 on the outpatient unit, a towel on the windowsill was observed to be sitting there, stained a dark brown color. EMP4 confirmed findings.
11. At 12:20pm in rooms 321, 322, 323, and 324 on the outpatient unit, layers of dust were observed on all beds as well as suction containers on the walls. EMP6 confirmed findings.
12. At 12:22pm in room 324, a bedside table was observed to have patient care supplies in the drawers, including a normal saline flush, IV tubing, and a blood draw vacutainer. EMP9, EMP5, and EMP2 confirmed findings.
13. At 12:45pm, while touring with EMP6, a communications box with exposed communication wiring was noted in the 3rd floor hallway.

During a tour of nursing unit 3G on July 12, 2022, from 12:52pm until 1:43pm with EMP11, the following was observed:

1. Under the sink in the clean utility room the following items were found, paper towels, toilet paper and bags. EMP11 cofirmed the findings.

2. Patient room 304, the negative pressure isolation room, a dead bug was found on the windowsill behind the window blinds, there was dust on the windowsill and thick dust on the cardiac monitor. The patient bathroom had a soiled ceiling tile in the shower and there was visible dirt/stains in the ceiling vent in the bathroom. EMP11 cofirmed the findings.

During a tour of nursing unit 3G on July 13, 2022, from 08:51am until 09:39am with EMP11, the following was observed:

1. Patient rooms 307 and 308 had dust on the windowsill and the cardiac monitor. These findings were confirmed by EMP11.
2. Dark spots were noted in the ceiling light fixtures, unknown if they were dirt or bugs in patient rooms 308, 309,310, 312 and 313. These findings were confirmed by EMP11.

Based upon a review of facility documents and interview (EMP) it was determined that the antibiotic stewardship program was not integrated with the hospital's QAPI programs.


Findings include:


A review of Washington Health System Greene's Pharmacy Policy and Procedure Manual, dated October 2021, Section V: Interdepartmental; Section D- Antimicrobial Stewardship Purpose stated that the committee is to"...promote rational antimicrobial use for inpatients at Washington Health System.....Section D, #10- Metrics: b) Minimally, metrics will be reported quarterly to the patient safety committee and infection control committee."


Further review revealed the facility policy did not specifically address antibiotic stewardship at Washington Health System Greene. Instead, it addresses the system, as a single entity.


A review of the facility's "Pharmacy and Therapeutics Committee of Washington Health System Greene" meeting minutes revealed the following:

Meeting minutes dated 10/06/2021, reveals that no data was presented to the committee regarding antimicrobial stewardship. "Pharmacy is continuing to monitor for inappropriate usage of restricted antibiotics."

Meeting minutes dated 2/3/2022, revealed that no data was presented to the committee regarding antimicrobial stewardship. "Pharmacy is continuing to monitor for inappropriate usage of restricted antibiotics. Clinical pharmacists at Washington now providing intervention and consult to hospitalists."

Meeting minutes dated 4/6/2022, revealed that no data was presented to the committee regarding antimicrobial stewardship. "Pharmacy is continuing to monitor for inappropriate usage of restricted antibiotics. Clinical pharmacists at Washington now providing intervention and consults to hospitalists. Antimicrobial Usage Dashboard monitoring. "


Meeting minutes dated May 5, 2022, revealed that no data was presented to the committee regarding antimicrobial stewardship. "Pharmacy is continuing to monitor for inappropriate usage of restricted antibiotics. Clinical pharmacists at Washington now providing intervention and consults to hospitalists."


During an interview on July 13, 2022, at 12:45pm, EMP18 was unable to describe the Antibiotic Stewardship Program stating that she was new to the position.


A review of Policy ID WHSG-IC.042, Infection Prevention and Control Authority Statement, dated 01/02/2020, Duties and Responsibilities: #6, revealed, "reviews result of antimicrobial susceptibility trends."


A review of the Infection Prevention and Control Plan, dated 09022020, IV. Elements of the Program, O. revealed, "The Infection Preventionist is an active member of the Antibiotic Stewardship meeting. Data is presented at the Infection Prevention and Control Committee."


A review of the Infection Prevention and Control Committee of Washington Health System Greene meeting minutes revealed the following:


Meeting minutes dated 01/05/2022, revealed, "Greene overall antibiotic usage for 2021 QTR 4 has increased and is higher than comparison hospitals. Quinilone utilization has increased this quarter. Usage is significantly higher than other hospitals this size. Carbapenum utilization has shown an increase. Usage is slightly lower than other hospitals. Ceftriaxone, 3/4 Generation Cephalosporine, Zosyn, and Vancomycin utilization rate is above other comparison hospitals." Further review of the meeting minutes revealed no discussions of findings. Additionally, the meeting minutes recommendation/action revealed, "Continue to monitor."


Meeting minutes dated 04/26/2022, revealed, "No new data for antibiotic usage. The antibiotic stewardship committee continues to meet on a regular basis." Additionally, Medmined (TM) antibiotic utilization data was included in the meeting packet which shows the facility with overall higher utilization rates per 1,000 patient days compared to other hospitals.

During an interview on July 13, 2022, at 11:30am, EMP19 confirmed that although the data is contained within the meeting packet, there was minimal discussion.


A review of the "Quality Council for Washington Health System Greene" meeting minutes dated April 28, 2022, and January 27, 2022, revealed that the minutes lacked discussion surrounding antibiotic stewardship.


During an interview on July 12, 2022, at 1:00 pm, EMP2 stated that the department managers are permitted to choose their quality indicators.

Based on a review of facility documentation, observations, and staff interview (EMP), it was determined the facility failed to follow acceptable practices for safe use of radioactive materials.

Findings include:

The facility policy titled: "Policy # NM.35, General Rules for the Safe Use of Radioactive Materials, Reviewed July 2021," was reviewed on July 12, 2022. This policy revealed, "Procedure:...5. There will be no eating, drinking, smoking or application of cosmetics in any area where radioactive material is stored or used."

During a tour of the outpatient Cardiology department on July 11, 2022, at 11:45 AM, Room 341 was observed to have a Radioactive materials sign posted outside of the door. Inside this room a treadmill was observed along with a microwave, coffee pot, and a refrigerator.

An interview was conducted with EMP 14 on July 12, 2022, at 12:55 PM. EMP 14 explained the process of utilizing the radioactive isotope during cardiac stress testing. EMP 14 confirmed the isotope is transported up to Room 341 and injected into the patient in that area. Further interview confirmed that there should not be food or drink in any area where radioactive material is used.