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Based on interview with facility staff and review of records the governing body failed to be responsible for all services furnished in the hospital under contracts. The governing body failed to ensure that a contractor of services (including one for shared services and joint ventures) furnished services that would permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. One of two contracts had not had a quality improvement review.

Findings:

Review of facility documents revealed the contract for transcription services and the contract for translation services were not included on the hospital's list of contracts (refer to A0085). Also there was no documentation of quality improvement review of the services provided under the contract for translation services (refer to A0084). In an interview on 10/09/2019 at 10 a.m. the Chief of Quality agreed that the list of contracted services was incomplete and there was no documentation of review of the translation services.

Based on interview with facility staff and review of records the governing body failed to ensure that the services performed under a contract were provided in a safe and effective manner.

Findings:

Review of facility documents provided revealed they did not include the review of the translation services provided under contract. In interviews on 10/09/2019 the Chief of Quality, the Director of Materials Management, and the CIO all stated they were not aware of any performance improvement review of the translation services.

Based on interview with facility staff and review of records the hospital failed to maintain a list of all contracted services, including the scope and nature of the services provided. Two of two requested contracts were not on the hospital's list.

Findings:

Review of the hospital's list of contracted services revealed the contract for the transcription services provided in surgery and the contract for the translation services provided to hospital patients were not included in the list. In an interview on 10/09/2019 at 10 a.m. the Chief of Quality agreed that neither of the contracts were included on the list.

Based on interview with facility staff and review of documents the hospital's governing body failed to ensure that the performance improvement program reflected the complexity of the hospital's services and involved all hospital departments and services (including those services furnished under contract or arrangement).

Findings:

Review of the facility's list of contracted services revealed that the contract for translation services provided by an outside vendor was not included on the list. In an interview on 10/09/2019 at 10 a.m. the Chief of Quality agreed that the contract for the transcription service was not on the list and was not aware of any quality improvement review of the service provided. In further interviews both the Director of Material Management and the CIO stated that although they had approved use of the service and were paying for the service, respectively, neither was involved in the review of the services provided. As a result, it was not possible to determine if the service provided by the translators was effective and if the needs of the patients and the hospital were met.

Based on interview with facility staff and review of records the facility failed to ensure that the medical staff bylaws were enforced when a patient received an incomplete medical history and physical examination (H&P) prior to an elective surgery. One of five open medical records reviewed contained an incomplete medical history and physical examination.

Findings:

Review of the medical record of patient 202 revealed that he had received a H&P on 10/02/2019. This H&P was incomplete since it did not contain the results of an examination of the patient's heart and lungs. The hospital's rules and regulations of the medical staff from 12/31/2018 stated a patient scheduled for elective surgery shall have a completed H&P which must contain at least a physical examination of the heart and lungs, among other things. In an interview on 10/08/2019 at 9:30 a.m. the Director of Surgical Services agreed that the patient's H&P was missing documentation of an examination of the patient's heart and lungs.

Based on interview with facility staff and review of records the facility failed to ensure that all records contained a medical history and physical examination (H&P) completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. One of five open medical records did not contain a complete H&P.

Findings:

Review of the medical record of patient 202 revealed it did not contain a completed H&P prior to surgery. The H&P in the patient's medical record was completed on 10/02/2019 but did not contain documentation of an examination of the patient's heart and lungs for his surgery on 10/8/2019. In an interview on 10/08/2019 at 9:30 a.m. the Director of Surgical Services agreed that the patient's H&P was missing documentation of an examination of the patient's heart and lungs.