HospitalInspections.org

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:


C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire for all patients. Findings include:

See the individually and below cited K-tags:
K-291
K-321
K-324
K-345
K-346
K-351
K-353
K-354
K-511
K-712
K-753
K-761
K-908
K-918

Based on record review and interview, the facility failed to implement and maintain an effective, ongoing, data-driven, facility wide quality assessment and performance improvement program resulting in the facility being potentially unaware of improvements in providing patient care services or in the environment effecting all patients served by the facility. Findings include:

On 6/4/2024 at 1030, review of the provided quality assessment and performance improvement (QAPI) information from March 2024 revealed an agenda for discussion of benchmarks, patient experience reports/grievance, regulatory compliance, and education. Several unexplained pages of scores and graphs were present along with the "Michigan Critical Access Hospitals (MICAH) Qualtiy Network Organizational Chart 2022" and "Relevant Measures for MI (Michigan) Peer Group 5 CAHs" from May 2021. Current ED (emergency department) scoreboard information was present.

On 6/4/2024 at 1045, CNO (chief nursing officer) Staff B, who was also the head of quality/risk management/compliance, was queried as to if there were other information or data including meeting minutes to review for the past 12 months. She provided the "Quailty Improvement Plan" policy.

During the QAPI meeting on 6/4/2024 at 1126, CNO Staff B stated the facility "sometimes" has quarterly meetings for QAPI. When queried as to what was discussed in quality, she stated, "Pharmacy, patient issues and experience, complaints,and grievances." She further stated there were no QAPI notes or meeting minutes as the person assigned to take the notes and minutes no longer worked for the facility. She indicated there was a separate meeting for infection control and policies. When queried as to if maintenance issues were discussed, she stated that the previous facilities director used to come to the meeting, and the current director was invited to come, but had not yet come to a meeting. Staff B was asked if there were any current performance improvement projects to which she stated, "Med scanning was identified as an issue." When asked to show and discuss the issue involved, what was being done to correct the issue, time frame for monitoring and assessment, she stated all of the documentation was kept in (name of electronic medical record system) and reports could be run for needed data. If it was determined the project was not working, the plan was to educate the staff. She further stated the data was "not kept" nor was it tracked and/or trended. Staff B was then asked what quality information was presented to the governing body to which she stated that "pieces and parts of quality" were reported and included such information as Blue Cross, projects, and patient volumes.

Review of facility policy #15160613 titled "Quality Improvement Plan" last revised 2/2023 states, "Each Clinical Department participates in a hospital wide Quality Improvement (QI) program desgned to monitor, evaluate and improve the quality, appropriateness and outcomes of clinical services by: Planning, designing, measusring, assessing, improving new or revised processes of patient care and service; Identifying opportunities through continuous assessment of systems and processes of care through a collaborative, interdisciplinary focus; Implementing solutions and actions which will bring about the desired change, to; Facilitate a positive patient outcome, while; Maintaining a safe environment for personnel, patients and visitors... The primary goals off the performance improvement plan are to continually and systematically plan, design, measure, assess, and improve performance of priority focus areas, imporve health care outcomes and reduce and prevent medical/health care errors... Information and the findings of discrete performance improvement activities and adverse patient events are used to detect trends, patterns and performance or potential problems that affect more than one department/service...Performance measures with relatd performance outcomes will be established as a means to systematically monitor the identified processes for review in an ongoing manner, and to provide operational linkages between the risk management functions related to the clinical aspects of patient care and safety and the performance improvement functions. Performance expectations will be established for any new or revised processes undertaken y the hospital. Performance measures will be specific and measurable. Performance measures will be structured and related to both the processes and outcomes of patient care. The following criteria will be utilized to assure that the indicator chosen for data collection is the most appropriate for monitoring the performance of a patient care or service process, system or function: The measure can identify the events it was intended to identify; The measure has a documented numerator and a denominator statement or description of the population to which the measure is applicable; The measure has defined data elements and allowable values; The measure can detect changes in performance over time; The measure allows for comparison over time winin the organization or between the organization and other entities; The data intended for collection is available and attainable; Results can be aggregated and reported in a way that is useful to the organization and other interested parties."