HospitalInspections.org

Based on staff interviews and facility documents, the facility failed to have a quality assurance program that evaluated all patient care services and other services affecting patient health and safety.

Findings were:

Review of the facility ' s 2012-2013 "Quality Assurance/Infection Control" Committee meeting minutes revealed participation of the following disciplines:
? April 5, 2012: Quality Assurance, Radiology, Dietary, Pharmacy, Financial, Nursing, Maintenance/Safety, Medical Records, Housekeeping, Clinic, Dietary and Lab.
? June 11, 2012: Housekeeping, Business Office/Medical Records, Quality Assurance
? October 9, 2012: Radiology, Housekeeping, Dietary, Laboratory, Business Office
? April 10, 2013: Maintenance, Housekeeping, Medical Records, Financial, Radiology and Quality Assurance

Per facility statement signed by the Administrator, "The following departments participate in the ...Quality Assurance/Performance Improvement Program: Lab, Radiology, Dietary, Nursing, Housekeeping, Business Office, Maintenance/Safety."

The above findings were confirmed in an interview with the facility Administrator on the afternoon of 5/22/13 in the Conference Room.