HospitalInspections.org

Based on record review and interview, the facility's leadership failed to maintain and demonstrate evidence of its Quality Assurance and Performance Improvement [QAPI] program reflecting the complexity of the hospital's organization and Outpatient Services.

The findings include:

Review of the Off-site Outpatient Facility's Quality Assurance and Performance Improvement [QAPI] documentation conducted on 11-15-12 revealed pieces of information in different areas, not consolidated and well-defined as the facility's QAPI documentation and evidence of an existing Performance Improvement program.

Interview with the main Hospital's Director of Quality and Patient Safety conducted on 11-14-12 at 140pm revealed that "the revamps which occurred in the system affected the department". He explained that reports done by different individuals and collaboration of reports prevented the timely documentation of the Quality Assurance (QA) summary.

Interview with the main Hospital's Director of Quality and Patient Safety conducted on 11-15-12 at 955am revealed that there is no documentation of the QA process regarding Infection Control from the off-site Outpatient Facility. He explained that the Vigilant Alert System (VAS) information needs to be linked to the Physician screen from the main Hospital to all the off-site Outpatient Facilities. He added that "monitoring and surveillance are done but documentation" needs improvement.

Interview with the Chief Nursing Officer of Outpatient Services conducted on 11-15-12 at 255pm confirmed that there is no well-defined QA report/summary of Infection Control indicators. There was no documented evidence of collaboration of the facility's QA data with the main Hospital and its Leadership. She stated that Infection Control and QA documentation is a work in progress for this off-site Outpatient Facility.