HospitalInspections.org

Based on a request for review of all documents related to the testing and maintenance of the patient care related electrical equipment (PCREE), and interviews with the Chief Compliance Officer and Facility Manager, the facility failed to provide the risk assessment, testing and maintenance documentation to determine compliance. Non-compliance renders the equipment unreliable, including life support and emergency equipment, which poses risk to life safety of patients and staff.

The findings included:

On 9/26/18 between 1:30 p.m., and 5:30 p.m., the surveyors requested the documentation to show the inventory, and testing and maintenance for PCREE revealed that the documentation is not available to the facility without a representative from the Contract Service Provider being onsite. The Facility Manager said that they were onsite and he would call them and ask for the documentation to be provided. After multiple calls the Facility Manager said that they had left the facility and refused to return to provide the documentation needed. The surveyors requested a copy of the contract with the Biomedical service company to see what scope of work the contractor covered, and a copy of the facility list of contracted services.

At 3:55 p.m., the compliance officer and the Facility Manager provided the list of contracted services. The Contract Service Provider was not on the list. The facility also provided a letter from this service provider which indicates the equipment used for testing. The letter further states that a summary report will be provided upon completion of testing. At the time of this finding the Facility Manager said that these summaries are not provided to plant operations. When questioned, the Chief Compliance Officer claimed no knowledge of this because "It's not in my subject matter of expertise." At the time of this finding the Chief Compliance Officer acknowledged that the facility does not have a contract with this service provider for testing and maintenance of (PCREE). She said, when questioned, that in order to have such a contract the contract requires two levels of approval from the Chief Executive Officer and the Corporate Chief Executive Officer.

Records for the testing, repairs, and maintenance is required to be maintained in accordance with the facility record keeping policies.

Without a contract, a scope of services, a list of (PCREE), a risk based assessment that demonstrates the frequency of testing, and at least samples of recent testing and maintenance results compliance with regard to this testing and maintenance could not be determined.