HospitalInspections.org

Based on interview, record review and policy review the governing body failed to ensure that all departments and services were included in the facility-wide Quality Assurance and Performance Improvement (QAPI) Program for two departments (Social Services and Activity Therapy) of 15 departments reviewed. The facility also failed to ensure that the data collected for one department (Geriatric Psychiatric Unit, unit for treating psychiatric illnesses of the elderly) was trended for identifiable problems. These failures had the potential to affect all patients' health and quality of services provided. The facility census was 15.

Findings included:

1. Record review of the facility policy titled, "Quality Assessment and Performance Improvement-Patient (QAPI) Safety Plan," dated 05/2015, showed directive for facility staff that each department will be required to participate in QAPI. The QAPI committee will act as an advisory body to coordinate and monitor the quality and appropriateness of all direct patient and ancillary services provided by the facility.

2. Record review and subsequent interview on 04/27/16 at 10:45 AM, showed no involvement by Social Services and Activity Therapy of Performance Improvement Goals, data collection, or evaluation. Staff A, Quality Risk Manager confirmed that neither department had any QAPI.

During an interview on 04/26/16 at 3:08 PM, Staff BB, Social Worker, stated that she was unaware of who evaluated the quality and appropriateness of the care for Social Services.

During an interview on 04/27/16 at 1:40 PM, Staff N, Director, Geriatric Psychiatric Unit, stated that once a month she completed one medical record review which included all services within the record, but did not trend any data collected.

During an interview on 04/27/16 at 2:17 PM, Staff B, Chief Nursing Officer and Chief Operating Officer, stated that the facility needed to involve all services in the QAPI program.

















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