HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Program. The governing body failed to ensure the QAPI program included monitoring of the contracted services provided for the Deaf, Special Education Services, Pet Therapy Services, Language Interpreter Services and Linen Services.

Findings:
Review of the Quality Improvement Plan and the Performance Improvement Indicators for 2015 revealed no documented evidence that services provided for the Deaf, Special Education Services, Pet Therapy Services, Language Interpreter Services and Linen Services were included in the QAPI program.

In an interview on 7/28/15 at 10:38 a.m. with S3Quality, she confirmed there were no quality indicators/measures currently monitored, through the QAPI program, for the contracted services referenced above.

Based upon review of Infection Control Policies and Procedures, personnel files, and staff interview, the hospital failed to ensure: 1) respiratory fit testing was provided at regular intervals for personnel at risk, and 2) all personnel had evidence of immunity to Varicella. Findings:

1) Review of the Infection Control Policies and Procedures revealed policies for Personal Protective Equipment (PPE) identified the equipment to be used; however, there failed to be information related to the application of the face mask to ensure proper closure of the mask around the nose and mouth. Review of 7 of 7 personnel files (S9-S14) revealed there was no documented training related to correct application of the face mask.

Interview with S4RN/Infection Control Director on 7/27/15 at 1:30 pm confirmed the Infection Control Policy and Procedure did not include directions for the correct application of the face mask and the personnel were not trained on this procedure.

2) Review of the Infection Control Policies and Procedures revealed there was not a policy related to testing personnel on Varicella immunity. Review of 7 of 7 personnel files (S9-S14) revealed there failed to be documented evidence the employees were tested for Varicella immunity. Interview with S4RN/Infection Control Director confirmed Varicella immunity was not conducted on personnel.