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Based on review of Board of Trustees meeting minutes, review of Departmental quality data and interviews with the President, the Chief Medical Officer, the Chief Nursing Officer, the Chief of Anesthesia, the the Quality Coordinator, the Nurse Educator and the Manager of Quality Management April 27-29, 2010, it was determined that the hospital failed to have an effective governing body that ensured that all areas of the hospital were participants in the hospital-wide Quality Improvement Plan for 2009 and 2010 and followed the plan.

Findings include:

1. A review of BOT meeting minutes from April 14, 2009 through March 30, 2010, revealed that the committee failed to discuss Medical Staff indicators that had not met target, indicators that needed to be added and indicators that would be dropped as indicated in the 2009 PI plan.

2. An interview with the CNO and the MQM on April 28, 2010, revealed that there was no quality data for contracted services or complaints. Additionally, they stated that only if trends were identified, were complaints included as part of the quality process.

3. There was no documentation that Nuclear Medicine had chosen indicators and had been part of the hospital-wide Quality Improvement Plan. This was confirmed by the Imaging Director.

4. During an interview on April 28, 2010, the CNO stated that nothing had been passed on to the BOT regarding UR quality initiatives.

5. A review of the PIC meeting minutes from April 22, 2009 through January 20, 2010 failed to have any discussion regarding UR quality. This was the committee where all departments' and/or services' quality initiatives were to be discussed.

6. The CNO stated on April 28, 2010 that things were taken out of meeting minutes due to the adversarial relationship with the other hospital in the area.

7. When the President was asked why there was little discussion about quality initiatives in the BOT meeting minutes, the President stated, on April 28, 2010, that when the CNO and others presented quality to the BOT, it was not written as PI in the minutes.

8. The MQM stated that the hospital recognized that there were big problems with quality, and therefore, started looking at everything on March 31, 2010.

9. The minutes of the Departments of Medicine, and Family Practice from March 2009 through March 2010 were reviewed. When performance improvement indicators did not achieve target levels, the minutes failed to document that any actions were planned or taken in order to achieve the target levels, as described in the PAMC Quality Plan, section " Methodology and Methods " .

10. The minutes of PAMC Medical Staff Performance Improvement Council from March 2009 through March 2010 were reviewed. The documentation failed to include that the committee reviewed or discussed the performance improvement outcomes as required in the Medical Staff Bylaws, Article X, Section 10.5.3, "Duties".

11. The performance improvement indicators for Anesthesia Services were " postoperative pain management " and " anesthesia awareness " . However, these indicators were already at the planned level of performance. There was no evidence in department meeting minutes or the Quality Plan throughout the period March 2009 to March 2010 that any improvement was planned or achieved. Furthermore, there was no evidence that additional performance improvement indicators were added in order to improve the safety or quality of care for patients receiving anesthesia. This was verified in an interview on April 27, 2010 with the CNO and the MQM.

12. The performance improvement indicator for Radiology was " One hundred percent, (100%) review of readings performed by Nighthawks " . There was no evidence that this activity required improvement as this indicator was at one hundred percent, (100%) throughout the period March 2009 through March 2010. There was no evidence of any discussion or consideration for replacing this indicator with a performance improvement activity for which improvement could be demonstrated. This was verified in interviews during the survey with the CNO and the MQM.

13. There was no medical staff performance indicator for the Emergency Department physicians from the period March 2009 through March 2010. A proposed initiative for quality improvement for 2010 was for the initiation of " Ottawa Ankle Rules ". During a telephone interview with the COEM on April 29, 2010, the Chief confirmed that this initiative would primarily result in a change in nursing practice. The COEM stated that this initiative would not require any changes in practice by the Emergency Department physicians, and therefore could not be considered a Medical Staff indicator.

14. The review of the PIC and the Executive Committee meeting minutes revealed that the Medical Staff at PAMC failed to analyze their performance against the 2009 targets and make corresponding changes, additions, or deletions to the indicators in the 2010 Quality Plan. The March 2010 Executive Committee minutes reflect that the CNO presented the 2010 Quality Plan, but the Executive Committee took no action to approve or accept this plan receiving the report as " Informational " only.

15. During interviews with the President of the Medical Staff and the Chair of the Performance Improvement Council during the survey both reported that they felt the minutes reflected an accurate reporting of the discussions and actions taken.

16. However, an interview with the President of PAMC on April 27, 2010, revealed that the minutes of committee meetings did not reflect exactly what happened at the meetings because the information would become accessible to their competitors.

17. During an interview with the CNO on April 28, 2010, the CNO stated that the BOT had never asked for any more information on Medical Staff quality.


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

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Based on review of meeting minutes, review of Quality Plans, review of Departmental Quality data and interviews with hospital staff April 27-29, 2010, it was determined that the governing body failed to ensure that the program was effective, data driven and reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those services furnished under contract or arrangement); and focused on indicators related to improved health outcomes and the prevention and reduction of medical errors.

Findings include:

1. The PAMC Quality and Performance Improvement Plan 2009 stated, " Parkview Adventist Medical Center maintains and supports organization-wide performance improvement (PI) based on a systematic approach to quality management: designing, measuring, assessing and improving both clinical and operational processes and outcomes. Specific indicators of both key processes and outcomes of care are designed, measured and assessed and acted upon by the appropriate departments or services, the medical staff and the governing body."

2. A review of Radiology Performance Improvement initiatives indicated that Nuclear Medicine failed to participate in any performance improvement activities for 2009 and none had been identified for 2010. This was verified with an interview with the Director of Imaging on April 29, 2010.

3. A review of the hospital's policy and procedure, titled 'Restraint', stated that the content of physician's orders for restraint must include "Type of restraint". Review of the quality indicators for restraint use failed to include the review of physician orders for the type of restraint to be applied. This was verified during an interview with the Clinical Educator on April 29, 2010.

4. A review of the Utilization Review Plan revealed that under V. Meetings it stated, "The Utilization Review Committee will meet and report to the PI council a minimum of quarterly." There was no documentation of such a quality report within one (1) year of PIC documented meeting minutes.

5. A review of BOT meeting minutes from April 14, 2009 through March 30, 2010 revealed that the committee failed to discuss Medical Staff indicators that had not met target, indicators that needed to be added and indicators that would be dropped as indicated in the 2009 PI plan.

6. The minutes of the Departments of Medicine, and Family Practice from March 2009 through March 2010 were reviewed. When performance improvement indicators did not achieve target levels, the minutes failed to document that any actions were planned or taken in order to achieve the target levels, as described in the Parkview Adventist Medical Center Quality Plan, section " Methodology and Methods " .

7. The minutes of PAMC Medical Staff Performance Improvement Council from March 2009 through March 2010 were reviewed. The documentation failed to include that the committee reviewed or discussed the performance improvement outcomes as required in the Medical Staff Bylaws, Article X, Section 10.5.3, "Duties" .

8. The performance improvement indicators for Anesthesia Services were " postoperative pain management " and " anesthesia awareness " . However, these indicators were already at the planned level of performance. There was no evidence in department meeting minutes or the Quality Plan throughout the period March 2009 to March 2010 that any improvement was planned or achieved. Furthermore, there was no evidence that additional performance improvement indicators were added in order to improve the safety or quality of care for patients receiving anesthesia. This was verified on interviews during the survey with the COA and the MQM.

9. The performance improvement indicator for Radiology was " One hundred percent, (100%) review of readings performed by Nighthawks " . There was no evidence that this activity required improvement as this indicator was at one hundred percent, (100%) throughout the period March 2009 through March 2010. There was no evidence of any discussion or consideration for replacing this indicator with a performance improvement activity for which improvement could be demonstrated. This was confirmed in interviews with the CNO and the MQM.

10. There was no medical staff performance indicator for the Emergency Department physicians from the period March 2009 through March 2010. A proposed initiative for quality improvement for 2010 was for the initiation of " Ottawa Ankle Rules " but during an interview with the Chief of Emergency Medicine, it was reported that this initiative will primarily result in a change in nursing practice. The Chief was not aware of any requirements for a change in practice by the Emergency Department physicians.

11. The Medical Staff at PAMC failed to analyze their performance against the 2009 targets and made corresponding changes, additions, or deletions to the indicators in the 2010 Quality Plan. The March 2010 Executive Committee minutes reflect that the Vice President for Patient Care Services presented the 2010 Quality Plan but the Executive Committee took no action to approve or accept this plan receiving the report as " Informational " .

12. During an interview on April 28, 2010, the CNO stated, " I know that certain things regarding quality are discussed at the PI Council, but when I went to the minutes the discussion was not there. I was there, and I know things were discussed."

13. During interviews, the President of the Medical Staff and the Chair of the Performance Improvement Council both reported that they felt the minutes reflected an accurate reporting of the discussions and actions taken.

14. During an interview with the CNO and the MQM, it was stated that it was known that they needed to do a lot of work on quality and the real work had just begun three (3) weeks prior.

15. An interview with the President of PAMC revealed that the minutes did not reflect exactly what was discussed at meetings because of the fear that a competing hospital in the area would be aware of their plans, actions, and problems.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on a review of the minutes of Parkview Adventist Medical Center Performance Improvement Council, the Medical Staff Executive Committee, Departments of Medicine, Family Practice, Surgery, and Emergency Medicine, the Parkview Adventist Medical Center Quality Plan 2009 , the Medical Staff Bylaws, and interviews with the President of the Medical Staff, Chair of the Performance Improvement Council, Chief of Emergency Medicine, Chief Nursing Officer, Quality Coordinator, and President of the Hospital, April 27-29, 2010, it was determined that Parkview Adventist Medical Center Medical Staff failed to be responsible for the quality of care provided to patients by the hospital.

Findings include:

1. The minutes of the Departments of Medicine and Family Practice from March 2009 through March 2010 were reviewed. When performance improvement indicators did not achieve target levels, the minutes failed to document that any actions were planned or taken in order to achieve the target levels, as described in the Parkview Adventist Medical Center Quality Plan, section " Methodology and Methods " .

2. The minutes of PAMC Medical Staff Performance Improvement Council from March 2009 through March 2010 were reviewed. The documentation failed to include that the committee reviewed or discussed the performance improvement outcomes as required in the Medical Staff Bylaws, Article X, Section 10.5.3, "Duties" .

3. The performance improvement indicators for Anesthesia Services were " postoperative pain management " and " anesthesia awareness " . However, these indicators were already at the planned level of performance. There was no evidence in department meeting minutes or the Quality Plan throughout the period March 2009 to March 2010 that any improvement was planned or achieved. Furthermore, there was no evidence that additional performance improvement indicators were added in order to improve the safety or quality of care for patients receiving anesthesia. This was confirmed in interviews during the survey with the COA and the CNO.

4. The performance improvement indicator for Radiology was " One hundred percent, (100%) review of readings performed by Nighthawks " . There was no evidence that this activity required improvement as this indicator was at one hundred percent, (100%) throughout the period March 2009 through March 2010. There was no evidence of any discussion or consideration for replacing this indicator with a performance improvement activity for which improvement could be demonstrated. This was verified in interviews with during the survey with the CNO and the MQM.

5. There was no medical staff performance indicator for the Emergency Department physicians from the period March 2009 through March 2010. A proposed initiative for quality improvement for 2010 was for the initiation of " Ottawa Ankle Rules ". During a telephone interview with the COEM on April 29, 2010, the COEM confirmed that this initiative would primarily result in a change in nursing practice. The COEM stated that this initiative would not require any changes in practice by the Emergency Department physicians, and therefore could not be considered a Medical Staff indicator.

6. The review of the PIC and the Executive Committee meeting minutes revealed that the Medical Staff at PAMC failed to analyze their performance against the 2009 targets and make corresponding changes, additions, or deletions to the indicators in the 2010 Quality Plan. The March 2010 Executive Committee minutes reflect that the CNO presented the 2010 Quality Plan, but the Executive Committee took no action to approve or accept this plan receiving the report as " Informational " only.

7. Interviews with the President of the Medical Staff and the Chair of the Performance Improvement Council, during the survey, revealed that they felt the minutes reflected an accurate reporting of the discussions and actions taken.

8. However, an interview with the President of PAMC on April 27, 2010, revealed that the minutes of committee meetings did not reflect exactly what happened at the meetings because the information would become accessible to their competitors.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on observation, interviews with key staff, and record review on April 27 - 29, 2010, it was determined that the facility failed to meet the requirements of the National Fire Protection Association Life Safety Code 2000 edition (for further information see Tag A0710).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on observation, interviews with key staff members and record review on April 27 - 29, 2010, the hospital failed to meet the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

Findings include:

Facility failed to:

a. provide a fire barrier between the building and a nonconforming building (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K011);

b. ensure that exit components are enclosed with construction having a fire resistance rating of at least one hour (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K033);

c. arrange exit access such that exits are readily accessible at all times (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K038);

d. ensure that a fire alarm system is installed according to NFPA 72 (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K051);

e. install, test and maintain the fire alarm system in accordance with NFPA 70 (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K052);

f. ensure that the sprinkler system was installed in accordance with NFPA 25 (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K056);

g. maintain the automatic shutdown of a ventilation fan as required by NFPA 2001 (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K130);

h. adhere to guidelines established by Code of Federal Regulations for the installations of Alcohol Based Hand Rubs (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K130); and

i. ensure that relocatable power taps were not utilized in patient care areas as required by NFPA 70 (for further information see Form CMS-2567, Life Safety Code Recertification Survey dated 4/29/10, Tag K147).

Based on review of the Discharge Planning policy and interviews with key hospital staff from April 27-29, 2010, it was determined that there was no documented evidence that the hospital had reassessed its discharge planning process on an on-going basis. Additionally, there was no documentation that a review of discharge plans was occurring to ensure that they were responsive to discharge needs.

Findings include:

1. The Discharge Planning Policy No: 4-016 did not contain any requirement for a reassessment of the process.

2. During interviews with a Case Manager on April 28 and 29, 2010, it was verified that no official reassessment of the discharge planning process had occurred in 2009 and there was no plan to accomplish this in 2010.