HospitalInspections.org

Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.


Findings include:

Review of facility documentation "Excela Health Latrobe Hospital FY (fiscal year) 2018 Performance Improvement Plan" revealed, "Organizational Priorities As required by applicable rules/regulations and standards, at a minimum, monitoring and evaluation activities shall include at a minimum the evaluation of the following: ... Ancillary Services, including but not limited to radiology, laboratory services, respiratory therapy, physical/occupational and speech therapy and pharmaceutical services."

Review of facility documentation "Excela Health Latrobe Hospital FY 2018 Performance Improvement Plan" failed to include the frequency and data collection specified.

Interview with EMP2 on November 1, 2018, at approximately 11:00 AM confirmed the above findings and revealed "It's not in there."

Review of facility "Board Quality Committee" meeting minutes dated January 18, 2018, February 15, 2018, March 15, 2018, April 19, 2018, May 17, 2018, June 21, 2018, July 19, 2018, and August 16, 2018, failed to include the ancillary services, radiology, laboratory services, respiratory therapy, physical / occupational and speech therapy, and the pharmaceutical services, as per facility Performance Improvement Plan.

Interview with EMP2 on November 2, 2018, at approximately 12:30 PM confirmed the above findings and revealed "It's not there."