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Based on interview and record review, the hospital failed to ensure a contract agreement with an active vendor who was providing services for patient care. This failure had the potential for the risk of substandard services being provided in the hospital.

Findings:

On 9/13/24 at 1448 hours, a review of the hospital's contracted services was initiated with the CNO. A sample review of contacted services for specialty beds showed the hospital had three separate vendors. Vendor A was the main service provider for specialty beds. Vendors B and C were back-up vendors for specialty beds.

When asked to provide the contract agreements for Vendors A, B and C, only contract agreements for Vendors A and B were provided.

On 9/16/24 at 0940 hours, the CNO verified the hospital had not received any specialty beds from Vendors A, B or C since 3/15/24 due to credit holds. The CNO stated the GB was aware of the issue and dealt with resolving individual credit holds in a fluid manner on a month-to-month basis based on priorities since 3/15/24. However, Vendors A, B and C were still on hold.

On 9/16/24 at 1117 hours, the above concern was shared and acknowledged by the CNO. Vendor C's contract agreement to provide specialty beds for the hospital was not provided. The CNO acknowledged the credit holds was an ongoing concern which was not addressed since 3/15/24 for Vendors A, B and C.

Based on interview and record review, the hospital failed to ensure services provided under contracted vendors were provided in a safe and effective manner by establishing complete and regularly scheduled contract evaluations for the vendors in the hospital. This failure had the potential for the risk of substandard services being provided in the hospital.

Findings:

Review of the hospital's P&P titled Organization-Wide Quality Assessment and Performance Improvement Program dated May 2024 showed senior leadership will perform evaluations of clinically contracted services in collaboration with the respective department director and report the results of the evaluation through the QAPI Committee structure to the MEC and the GB.

Review of the Governing Board Meeting Minutes date 7/25/24, showed the evaluation of contracted services from the period of 1/1 thru 12/31/21 was the most recent data reviewed by the committee. However, it was not updated to reflect the current active contracts and evaluations of the contracted service.

On 9/13/24, a review of the hospital's vendor contract evaluation was initiated.

The following selection of contract evaluations was requested or reviewed. The following was identified:

- Vendors A, B and C did not have contract evaluations for the provision of specialty air mattresses with the hospital.

- Vendor D's last contract evaluation was performed on 6/27/22.

- Vendor E's last contract evaluation was performed on 2/23.

On 9/16/24 at 1038 hours, an interview was conducted with the CNO, Quality Manager, the Vice President of Supply Chain, and Materials Manager.

When asked if there was a set schedule for ensuring all contracted vendors were evaluated regularly for a safe and effective manner, the CNO stated recently there was changes in the leadership and the process for contract evaluations needed to be addressed. The CNO stated each department in the hospital dealt directly with corporate for any issues with the vendor in that department. The CNO stated, for example, Vendors D and E were overseen by the nursing department. The CNO stated Vendor E's contract evaluation was supposed to be done annually. However, the CNO was not able to provide a schedule of contract evaluations for the sampled vendors reviewed.

The Vice President of Supply Chain stated she reviewed Vendors A, B, and C. If there were issues reported from the hospital, she talked to the vendor right away. The Vice President of Supply Chain stated it was a straight communication from the hospital to her and then to the vendor. When asked for documented evidence of a system of contract evaluation for vendors A, B and C, none was provided.

On 9/16/24 at 1115 hours, the above concerns were shared and acknowledged by the CNO and Quality Manager.

Based on interview and record review, the hospital failed to ensure the contract list was site-specific within the hospital's health system to include a complete list of all contracted services for the hospital. This failure had the potential for the risk of substandard services being provided in the hospital.

Findings:

On 9/16/24 at 1015 hours, a review of the hospital's contracted services was conducted with the CNO and Quality Manager.

Review of the hospital's contracted list showed Vendors A, B, C, and E were missing from the list provided during the survey.

When asked, the Quality Manager stated Vendor A was listed on another version of the list as long as the prompt for summoning the list included another facility type within the health system. The Quality Manager verified there was not a complete list of contracted services specific for the hospital within the health system.

On 9/16/23 at 1115 hours, the above findings were shared and acknowledged by the CNO and Quality Manager.