HospitalInspections.org

Based on review of bylaws, documents, and interviews with staff (EMP), it was determined that the facility Governing Body failed to ensure that services performed under contract were provided in a safe and effective manner.

Findings include:

Review on June 6, 2017, of the facility document, "Eagleville Hospital Amended and Restated Bylaws", dated "June 17, 2015", revealed "Article II ... Section 2.2 Commitment to Quality Care ... Eagleville Hospital is committed to providing the highest quality care to its patients. It is the responsibility of the Directors of the Hospital to assure that the Hospital fulfills this commitment. The Directors of the Hospital have the ultimate responsibility for the quality of care provided by the Hospital."

Review on June 6, 2017, of the facility documents, Eagleville Hospital Board of Directors Meeting Minutes", dated "March 23, 2017", "January 26, 2017", "November 17, 2016", and "September 29, 2016", revealed no documented evidence that the Governing Body reviewed all contracted services utilized at the facility to ensure that they were provided in a safe and effective manner.

Interview with EMP1 on June 6, 2017, at 10:05 A.M., confirmed that the facility does utilize contracted services. EMP1 also confirmed that the reviewed meeting minutes for the dates listed above, revealed no documented evidence that the Governing Body reviewed all contracted services provided at the facility to ensure that they were provided in a safe and effective manner.

Interview with EMP31 on June 7, 2017, at 11:30 A.M., confirmed that the facility is responsible for documenting Hospital Board of Directors Meeting Minutes. EMP31 also confirmed that the Board of Directors Meeting Minutes, dated "March 23, 2017", "January 26, 2017", "November 17, 2016", and "September 29, 2016", revealed no documented evidence that the Governing Body reviewed all contracted services utilized at the facility to ensure that they were provided in a safe and effective manner.

Based on interviews with staff (EMP), it was determined that the facility failed to maintain a list of all contracted services, including the scope and nature of the services provided.

Findings include:

Requests made to EMP1, on June 5, 6 ,7 and 8 for a listing of all contracted services, including the scope and nature of the services provided. None was provided.

Based on review of facility policy and procedures, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the patients' Initial Treatment Plans were signed by the patients for five (5) of ten (10) medical records reviewed (MR6, MR7, MR8, MR9 and MR10).

Findings include:

Review on April June 8, 2017, of facility "Policy No. 4000.003, Treatment Planning" dated September, 2015, revealed "... Policy: Individual treatment planning is conducted with each patient ... 6) The patient signs a statement of understanding on each treatment plan. Patient and staff sign and date the treatment plan documenting participation in the development of and any changes to the plan. In the event the patient refuses to sign the treatment plan, the counseling staff will write in "Patient refused to sign" on the treatment plan and will document the reason for the refusal in the medical record ..."

Review of MR6 on June 8, 2017, admit date June 2, 2017, revealed no documented evidence of the patient's signature or refusal to sign the Initial Treatment Plan.

Review of MR7 on June 8, 2017, admit date June 1, 2017, revealed no documented evidence of the patient's signature or refusal to sign the Initial Treatment Plan.

Review of MR8 on June 8, 2017, admit date May 26, 2017, revealed no documented evidence of the patient's signature or refusal to sign the Initial Treatment Plan.

Review of MR9 on June 8, 2017, admit date April 7, 2017, revealed no documented evidence of the patient's signature or refusal to sign the Initial Treatment Plan.

Review of MR10 on June 8, 2017, admit date June 2, 2017, revealed no documented evidence of the patient's signature or refusal to sign the Initial Treatment Plan.

Interview on June 8, 2017, with EMP20 between 10:00 AM and 4:10 PM confirmed no documented evidence of the patients' signatures or documented evidence of patient's refusal to sign the Initial Treatment Plan in MR6, MR7, MR8, MR9 and MR10.

Based on review of facility policy and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with physician or other licensed independent practitioners' (LIP) orders for one (1) of five (5) restraint medical records reviewed. (MR13).



Findings include:

Review on June 8, 2017, of facility policy "Policy No. 9600.051, Seclusion and Restraint "dated October 2016, revealed "... 4. Orders for Seclusion or Restraint ... a. Seclusion and restraint shall be ordered by the LIP authorized and privileged by the medical staff ... c. The order shall specify the method of seclusion and/or restraint to be used. (Indications for the order may be documented in nursing or progress notes)".

Review on June 8, 2017, of MR13 Clinical Specialist progress notes, admit date April 23, 2017, revealed the patient was in a four point restraint on April 23, 2017 with a start time of 5:00 PM and end time of 6:20 PM.

Review on June 8, 2017, of MR13 Physician Orders revealed no documented evidence of a physician or licensed independent practitioner order for the use of a four point restraint.

Interview on June 8, 2017, with EMP20 at 2:55 PM confirmed no documented evidence of a physician or licensed independent practitioner order for the use of a four point restraint.

Based on review of facility policy and procedures, personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure staff restraint training was completed as part of orientation and before participating in the application of restraints of a patient for three (3) of thirteen (13) personnel files reviewed. (PF6, PF7, and PF10).

Findings include:

Review on June 6, 2017, of facility policy "Policy No. 9600.051, Seclusion and Restraint " dated October 2016, revealed "... Staff Training and Competency ... a. Staff who may be involved in the use of seclusion and restraint receive Crisis Prevention Institute (CPI) training, seclusion/restraint competency and ongoing training ..."

Review on June 6, 2017, of PF6, date of hire December 22, 2016., revealed no documented evidence the CPI training was completed as part of orientation and before participation in the application of restraints.

Review on June 6, 2017, of PF7, date of hire December 22, 2016., revealed no documented evidence the CPI training was completed as part of orientation and before participation in the application of restraints.

Review on June 6, 2017, of PF7, date of hire March 16, 2017., revealed no documented evidence the CPI training was completed as part of orientation and before participating in the application of restraints.

Interview on June 6, 2017, with EMP16 at 2:00 PM confirmed no documented evidence of CPI training completed as part of orientation and before participating in the application of restraints for PF6, PF7, and PF10.

Interview on June 7, 2017, with EMP8 at 9:20 AM confirmed CPI training was to be completed within the first month of hiring and annually.

Based on review of policy and procedures, facility documents, review of medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to meet the requirements of the Quality Assurance and Performnce Improvement (QAPI) Condition of Participation by failing to provide evidence of a relevant, ongoing, hospital wide Quality Assessment Performance Improvement (QAPI) program that included a method and frequency for data collection for two (2) of two (2) quality indicators reviewed (Falls, Medication Errors). (A 273), by failing to provide evidence showing an effective, data-driven, hospital-wide Quality Assessment/Performance Improvement (QAPI) program that involved all hospital departments/services and focused on indicators relating to improved patient health outcomes. (A 308).




Cross reference:
482.21- Governing Body, Standard
482.21 (a), (b) (1) ,(b) (2) (i) ,(b) (3)- Qapi

Based on a review of facility documents and interviews with staff (EMP), it was determined that the facility failed to establish an ongoing Quality Assessment Performance Improvement (QAPI) program that included a method and frequency of data collection for the hospital-wide quality program and failed to include the method and frequency of data collection in two (2) of two (2) quality indicators reviewed (Falls and Medication Errors).

Findings include:

Review on June 5, 2017 of facility policy, "Policy and Procedure Manual ... Subject: Quality Management Program," revealed, " ... Scope and Responsibility: Quality Management (QM) is a hospital-wide responsibility. All programs and departments have QM functions designed to ensure high quality care is provided to all patients. ... The Clinical Quality Analyst audits medical records for compliance with standards and regulatory requirements, formulates data for tracking and trending and provides support and direction to departments and individuals as they develop and analyze their performance measures. ... Procedures: Quality Management utilizes the Plan, Do, Check, Act (PDCA) Performance Improvement Model. ... "

Requests were made to EMP1, on June 5, 6, 7, and 8, 2017, for documented evidence to evaluate whether data regarding reports of serious and adverse events documented in MR1, MR2, MR3, MR4, and MR5 were being measured, analyzed and tracked by the facility using the PDCA Model. None was provided.

Requests were made to EMP1, on June 5 and 6 2017 for a list of Performance Indicators that were being measured, analyzed, and tracked for improved health outcomes. EMP1 provided an undated, untitled list with no evidence of being reviewed or approved by the Governing Body.

Requests were made to EMP1 on June 5, 6, and 7, 2017 for QAPI review data to complete Quality Indicator Tracers for Falls and Medication Errors, as these types of incidents were identified by facility frequently on Serious/Adverse Event list. None was provided.

Requests were made to EMP1 on June 5, 6, 7 and 8, 2017 for QAPI review data regarding contracted services.

Requests were made to EMP12 on June 6, 2017 for Infection Control Risk Assessment and related QAPI review data.

Reviewed on June 7, 2017 at 10:00 AM, of facility document, "2016 Infection Control Risk Assessment," revealed "... Potential Risks/Problems: ... Appropriate OR (operating room) attire ... ." Further revealed, documented performance measures and analysis for "Appropriate OR attire" is part of facility's Infection Control Risk Assessment and Analysis. Further revealed, facility does not have an OR, but "appropriate OR attire" is part of facility's infection control risk assessment. Further revealed no documented evidence to support documented Infection Control Risk Assessment data and no QAPI review data provided.

Interviews with EMP30 and EMP4 on June 7, 2017 at 11:30AM confirmed the "2016 Infection Control Risk Assessment" and related data provided cannot be validated through documented evidence.

Interview with EMP1 on June 8, 2017 at 2:00 PM confirmed facility does not have any QAPI review data regarding contracted services.

The facility failed to provide adequate evidence to show that the facility had an effective, data-driven, hospital-wide QAPI program that involved all hospital departments and services and that focused on indicators related to improved health outcomes.

Based on review of facility documents, medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to provide evidence showing an effective, data-driven, hospital-wide Quality Assessment/Performance Improvement (QAPI) program that involved all hospital departments/services and focused on indicators relating to improved patient health outcomes.


Findings include:

Review on June 5, 2017 of facility policy, "Policy and Procedure Manual ... Subject: Quality Management Program," revealed, " ... Scope and Responsibility: Quality Management (QM) is a hospital-wide responsibility. All programs and departments have QM functions designed to ensure high quality care is provided to all patients. ... The Clinical Quality Analyst audits medical records for compliance with standards and regulatory requirements, formulates data for tracking and trending and provides support and direction to departments and individuals as they develop and analyze their performance measures. ... Procedures: Quality Management utilizes the Plan, Do, Check, Act (PDCA) Performance Improvement Model. ... "


Review on June 7, 2017 at 10:00 AM, of facility document, "2016 Infection Control Risk Assessment," revealed "... Potential Risks/Problems: Appropriate OR (operating room) attire ... ." Further revealed, documented performance measures and analysis for "Appropriate OR attire." Further revealed, facility does not have an OR, but "Appropriate OR attire" is part of facility's infection control risk assessment and analysis. Further revealed no documented evidence to support Infection Control Risk Assessment data and no QAPI review data provided.


Requests were made to EMP1, on June 5, 6, 7, and 8, 2017, for documented evidence to evaluate whether data regarding reports of serious and adverse events documented in MR32, MR33, MR34, and MR35 were being measured, analyzed and tracked by the facility using the PDCA Model. None was provided.

Requests were made to EMP1, on June 5 and 6 2017 for a list of Performance Indicators that were being measured, analyzed, and tracked for improved health outcomes. EMP1 provided an undated, untitled list with no evidence of being reviewed or approved by the Governing Body.

Requests were made to EMP1 on June 5, 6, and 7, 2017 for QAPI review data to complete Quality Indicator Tracers for Falls and Medication Errors, as these types of incidents were identified by facility frequently on Serious/Adverse Event list. None were provided.


Requests were made to EMP12 on June 6, 2017 for Infection Control Risk Assessment and related QAPI review data relevant to the hospital services. None were provided.


Interviews with EMP30 and EMP4 on June 7, 2017 at 11:30 AM confirmed the "2016 Infection Control Risk Assessment" and related data provided cannot be validated through documented evidence.

Interview with EMP1 on June 8, 2017 at 2:00 PM confirmed facility does not have any QAPI review data regarding contracted services.

Based on review of policy and procedures, facility documents, review medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to meet the requirements of the Utilization Review Condition of Participation by failing to comply to their own established Utilization Review (UR) Plan. (A655), failing to provide documented evidence for evaluating the appropriateness/clinical necessity of admissions/continued stays. and failing to provide written notification of cases determined to be medically unnecessary to appropriate staff and patients. (A656), and failing to review professional services provided, to determine medical necessity and to promote the most efficient use of available services. (A658).

Cross references:
482.30(c) Scope And Frequency of Review
482.30(d) Determinations Of medical Necessity
482.30(f) Review of Professional Services

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to comply to their own established Utilization Review (UR) Plan.

Findings include:

Review on June 7, 2017 of facility document, "Utilization Management Plan," dated May 2016, revealed " ... Scope and Responsibility: The UR Committee is responsible for evaluating the appropriateness and clinical necessity of admissions/continued stays and professional services, as well as to conduct extended stay reviews. The Utilization Review Committee will review cases referred for review of appropriateness and/or clinical necessity of admission and/or continued stay, outlier cases based on extraordinary high cost, and outlier cases based on extended length of stay. ... The UR Committee will serve in the role of medical audit committee and conduct periodic review of the care rendered to patients in every section and service of the Hospital, including length of stay, admission and professional services furnished. The UR Committee will serve in the role of medical care evaluation committee. The objectives of medical care evaluation are to assure services are appropriate to patient needs and are of acceptable quality. ... Responsibility of Chairperson: schedule medical records for review by the UR Committee, oversee the review process, ensuring physicians involved in the review of a record do not have a conflict of interest and that a determination is made in each case being reviewed. Document and inform appropriate staff members of findings and recommendations. Responsibilities of Committee Members: Participate in reviews of medical records, making a determination in each case reviewed. Honor the Confidentiality and Conflict of Interest Policies.

Review on June 7, 2017 of facility document, Utilization Review Committee Meeting, dated October 19, 2016, revealed, " ... Data Focus: ... The data focus included: External Admissions, Continued Stay Admissions, Total Admissions, Patient Days, Average Daily Census ... The monthly data does not have sufficient validity. It would be more valuable to look at daily or weekly data. ... Case Review: No data available for case reviews. "

Review on June 7, 2017 of facility document, Utilization Review Committee Meeting, dated May 30, 2017, revealed " ... Denials ... Concurrent Review Data ... Currently the data is not identifying any meaningful trends. ... A better drill down of data will provide a means to identify concerns and decrease overall number of denials. ... Denials for the Older Adult Unit are done by staff on the unit and communicated to finance."

Review on June 8, 2017 of facility document, Utilization Review Cases, no date, revealed, a documented case review of twenty-four (24) cases with respect to reason for referral, description of case, committee findings and notes. Further review revealed, nineteen (19) of twenty-four (24) cases had no documented committee findings. Further review revealed, case review for MR31, " ... Description: No medical or psych notes for 10 day stay ... . Further review revealed, no documented committee findings for MR31 case review."

Interview with EMP17 on June 8, 2017 at 11:00 AM, confirmed there are cases that the UR committee has determined as medically unnecessary for licensure period 2016-2017.

A request was made to EMP17 on June 8, 2017 for a list of cases determined to be medically unnecessary and documented evidence that written notification of cases determined to be medically unnecessary was given to appropriate staff and patients. None was provided.

Interview with EMP7 on June 8, 2017 at 11:00 AM confirmed Older Adult UR case reviews are completed by the Older Adult Unit.

A request was made to EMP1, EMP15, EMP17 and EMP30 on June 8, 2017 for documented evidence of review of professional services provided with respect to Medicare and Medicaid patients. None was provided.

Based on review of facility documentation and staff interview (EMP), it was determined that the facility's Utilization Review Committee failed to provide documented evidence for evaluating the appropriateness/ clinical necessity of admissions/continued stays.; failed to provide written notification of cases determined to be medically unnecessary was given to appropriate staff and patients.

Findings include:

Review on June 7, 2017 of facility document, "Utilization Management Plan," dated may 2016, revealed " ... Scope and Responsibility: The UR Committee is responsible for evaluating the appropriateness and clinical necessity of admissions/continued stays and professional services, as well as to conduct extended stay reviews.

Review on June 8, 2017 of facility document, Utilization Review Cases, no date, revealed, a documented case review of twenty-four (24) cases with respect to reason for referral, description of case, committee findings and notes. Further review revealed, nineteen (19) of twenty-four (24) cases had no documented committee findings. Further review revealed, case review for MR31, " ... Description: No medical or psych notes for 10 day stay ... ." Further revealed, no documented committee findings for MR31 case review.

Interview with EMP17 on June 8, 2017 at 11:00 AM, confirmed there are cases that the UR committee has determined as medically unnecessary for licensure period 2016-2017.

A request was made to EMP17 on June 8, 2017 for a list of cases determined to be medically unnecessary and documented evidence that written notification of cases determined to be medically unnecessary was given to appropriate staff and patients. None was provided.

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to review professional services provided, to determine medical necessity and to promote the most efficient use of available services.

Review on June 7, 2017 of facility document, "Utilization Management Plan," dated May 2016, revealed " ... Scope and Responsibility: The UR Committee is responsible for evaluating the appropriateness and clinical necessity of admissions/continued stays and professional services, ... ."

A request was made to EMP1, EMP15, EMP17 and EMP30 on June 8, 2017 for documented evidence of review of professional services provided with respect to Medicare and Medicaid patients. None was provided.

Based on review of facility documents, personnel files (PF) and interviews with staff (EMP12 and EMP16), it was determined the facility failed to ensure the individual designated as the Infection Preventionist was qualified through ongoing education, training, experience or certification to oversee the Infection Control program.

Findings include:
Review on June 6, 2017, of facility document "Eagleville Job Description ... Title: Infection Preventionist" dated June 2012, revealed "... Qualifications ... Experience in infection control ... "
Review on June 6, 2017, of EMP13 personnel file revealed no documented evidence of ongoing education, experience or specialized training in infection control.
Interview on June 6, 2017, with EMP12 and EMP16 at 2:10 PM, confirmed no documented evidence of ongoing education, experience or specialized training in infection control in EMP13 personnel file.
Interview with EMP12 at 2:10 PM, further confirmed EMP13 did not have any additional training or certification in infection control.