HospitalInspections.org

Based on review of the plan of correction from the 6/18/15 survey and interview, the provider failed to initiate:
*Audits.
*Reviews.
*Monitoring.
*Checklists.
*Logs.
*Meeting minutes.
*Monthly quality assurance performance improvement (QAPI) meetings to ensure priorities were set and solutions were implemented to focus on the cited deficiencies from the recertification survey conducted on 6/18/15.
Findings include:

1. Review of the plan of correction submitted for the 6/18/15 survey revealed the following:
*A057, had a completion date of 8/2/15.
- The following statements were listed under that plan of correction:
--"Work order (WO) completion will be monitored at least weekly by a member of the QA committee."
---The work orders had not been monitored by a member of the QAPI committee.
--"The QAPI will meet every month x [times] 3 and then at least quarterly. They will review (1) facility (life safety) concerns as documented by checklists and WO for timely completion and trends. (2) Infection control (IC) concerns. (3) Quality events for patients, non-patients and employees. Identified concerns or trends will be forwarded to the ED (executive director) who will share this inform at the BOD [board of directors] quarterly meetings."
---There had been no QAPI meetings since the survey.
--"ED will appoint a QAPI/IC (infection control) chairperson to communicate ongoing DOH [Department of Health] concerns as listed. The IC chairperson will monitor quality occurrences and establish a team to address QAPI and IC issues and record proceedings via [by] minutes."
---The IC person revealed she was unaware she had been appointed as the IC chairperson and had no documentation. Refer to A747.
*A491, had a completion date of 7/24/15.
- The following statements were listed under that plan of correction:
--"AMT [anesthetist technician] will use monitoring sheet to perform an audit of each CRNA [certified registered nurse anesthetist] x [times] 3 over the course of 9 months."
--- The audits had been started on 8/3/15.
--"ED communicated this concern to CRNA's manager for their education."
---There was no documentation of the communication between the ED and the CRNA manager.
---There was no indication who would report the findings to QAPI and the BOD.
*A701, had a completion date of 8/2/15.
- The following statements were listed under that plan of correction:
--"WOs will be reviewed at least weekly by a member of the QA committee. This will be addressed at the QA meeting, which will meet every month x [times] 3 and then at least quarterly."
---No one from the QAPI committee had reviewed the WOs.
---There had been no QAPI meetings since the survey.
--"Trends identified at the QA meetings will be reported to the ED who will report to the BOD."
---There had been no QAPI meetings since the survey. Therefore, no trends had been identified.
*A747, had a completion date of 8/2/15.
-Refer to A747.

Interview on 8/12/15 at 3:30 p.m. with the ED confirmed there had not been a complete week of data identified for any of the deficiencies addressed in the survey on 6/18/15. She also confirmed not all staff had attended the trainings she had given on-site. She had no plan to ensure how the staff who had not attended the training would receive training. She was not aware the head of housekeeping had not kept records of what her training entailed and who was at the training. She revealed she was not aware all the corrective actions stated in the plan of correction must be implemented by the completion date. She stated she had thought the completion date was the start of the corrective actions and assurance plans listed in the plan of correction.