HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations and Medicare Conditions of Participation for Hospitals by sharing hospital services, space, and staff with other separately certified health care entities.

Failure to maintain control of services, space, and staff can lead to dependence on another health care entity for compliance with federal regulations and put patients at risk to receive poor quality care.

Findings included:

The hospital failed to meet applicable federal requirements by:

Sharing services and programs

Sharing hospital staff

Sharing clinical care areas of the hospital

Cross Reference Tag A 043
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Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations and Medicare Conditions of Participation for Hospitals by sharing hospital services, space, and staff with another separately certified health care entity.

Failure to maintain control of services, space, and staff can lead to dependence on another health care entity for compliance with federal regulations and put patients at risk to receive poor quality care.

Findings included:

ITEM #1 - Shared Services

1. Review of a document titled "Bylaws of Confluence Health", effective date 04/11/17, showed that Confluence Health (CH) is a health system located in Wenatchee, Washington. The bylaws named Wenatchee Valley Hospital (WVH), and Central Washington Hospital (CWH) as "participating organizations" in this health system. The bylaws stated that the purpose of the health system was to integrate "hospital, physician and related health care services in a more coordinated fashion" in order to be more cost-effective.

2. Review of a document titled "Scope of Service: Confluence Health", Policy #5200672 revised 09/20/18, showed that the following services would be provided to WVH and CWH by Confluence Health:

a. Accountable Care
b. Care Management Service Line (Ambulatory)
c. Security
d. Emergency Preparedness
e. Biomedical Services
f. Human Resources
g. Food Services
h. Finance [accounting, business, supply chain]
i. Infection Control
j. Information Technology [electronic medical record]
k. Quality [quality reporting, utilization management, clinical documentation improvement]
l. Revenue Cycle
m. Risk management/Incident Management
n. Medical Staff Services
o. Compliance
p. Health Information Management
q. Legal Services

3. During the survey, surveyors found the following:

a. Pharmacy Services

1) On 11/06/18 between 3:05 PM and 4:30 PM, Surveyor #7 interviewed the CH Vice President of Ancillary Services (Staff #707) and the WVH pharmacy manager (Staff #708). During the interview, the VP stated that pharmacy services at WVH are provided under contract by CWH. WVH provides the pharmacy space and medications, and CWH provides the personnel to work in the pharmacy.

2) On 11/07/18 at 12:10 PM, Surveyor #7 interviewed a medical assistant who worked in the WVH outpatient urology department (Staff #725). During the interview, the medical assistant stated that the CWH infusion center pharmacy located on the 4th floor of WVH mixes and delivers chemotherapy for bladder instillations for WVH outpatient urology patients.

3) Review of documents titled "Pharmacy Services Agreement" (an agreement between WVH and CWH) dated 07/21/13 and a CH policy titled "Pharmacy Oprations and Medication Management", Policy #3910140 revised 09/25/17, confirmed that CWH provides pharmacy services for WVH patients.

b. Utilization Review

1) On 11/07/18 between 3:30 PM and 4:15 PM, Surveyor #7 interviewed the Quality Director (Staff #710), a registered nurse case manager (Staff #711), and a licensed social worker (Staff #712). During the interview, the director stated that CH provides combined utilization review services for WVH and CWH.

2) Review of a document titled "Utilization Management Plan", Policy #4147749 revised 02/02/18, confirmed that CWH does not have its own distinct utilization review program.

c. Infection Control Program

1) On 11/08/18 between 8:50 AM and 9:40 AM, Surveyor #7 interviewed the Infection Control Program Manager (Staff #713), an employee health nurse (Staff #714), and an infection control nurse (Staff #715). During the interview, the manager stated that the infection control program is a combined service between WVH and CWH under CH.

2) Review of a document titled "Infection Control Program Plan", Policy #5223373 revised 09/20/18, confirmed that CWH does not have its own distinct infection control program.

d. Medical Record Services

On 11/08/18 between 2:30 PM and 3:00 PM, Surveyor #7 interviewed the Manager for Health Information Management [HIM] and Compliance (Staff #706). The manager stated she is employed by Confluence Health, and that HIM is a combined service for WVH and CWH. The manager stated that WVH and CWH use the same electronic medical record system ("Epic"), and that staff with the appropriate security clearance can access medical records at both hospitals simultaneously. This showed that CWH does not have its own distinct medical records services.

g. Laboratory Services

On 12/18/18 at 1:15 PM, Surveyors #2 and #7 interviewed the CH Vice President of Risk and Regulatory (Staff #203) regarding laboratory services at WVH. During the interview, Staff #203 stated that the laboratory at WVH recently closed and services moved to CWH with exception of a "stat lab" for items that need rapid turnaround times. WVH and CWH had not developed a contract regarding the use of CWH laboratory services for WVH patients.


ITEM #2 - Shared Spaces

1. On 12/18/18 from 10:00 AM to 11:00 AM, Surveyors #2 and #7 conducted a facility tour of the WVH Mares building with the CH Engineering Director (Staff #201), the CH Director of Facilities Services (Staff #202), the CH Vice President of Risk and Regulatory (Staff #203), and a registered nurse quality specialist (Staff #204). The tour showed the following:

a. On the fourth floor of WVH Mares building, the WVH gastrointestinal procedural area, WVH rehabilitation gym, the CWH infusion center and oncology unit, and a freestanding gastrointestinal clinic share a common reception, lobby, and entrance area. Patients utilize the same reception area to check in to their respective hospitals and use the same entrance and post-reception hallway to reach each respective entity.

b. On the fourth floor, the CWH oncology unit transitions directly into a nephrology clinic belonging to the CH rural health clinic. The two entities utilize the same non-public hallway and have a shared workstation where they intersect. No signage or demarcation line was present to distinguish that there were two separate entities.

2. Document review of the WVH floor plans showed that the WVH gastrointestinal procedure area, the WVH rehabilitation gym, the CWH infusion center and oncology unit, and the freestanding gastrointestinal clinic have a single lobby and reception area. Each entity utilizes a single hallway beyond the reception area for patient access. The floor plans also showed the shared space between the CWH oncology unit and the CH nephrology clinic.

3. On 12/18/18 at 11:00 AM, Surveyors #2 and #7 interviewed the CH Engineering Director (Staff #201) regarding the floor plans and the shared spaces observed on the facility tour. He confirmed the above observations.


ITEM #3 - Shared Staff

1. Review of a document titled "Employee Lease Agreement", effective date 10/01/18, showed that CWH agreed to lease employees to WVH on an as-needed basis. The agreement identified job categories that included nurses, medical assistants, receptionists, and certified nursing assistants. On 11/07/18, Surveyor #7 reviewed a document titled "List of Shared Staff between CWH and WVH." The list identified seven individuals that worked at CWH and WVH, including a patient care technician (Staff #716), four registered nurses (Staff #717, #718, #719, #720), and two food services workers (Staff #721, #722). On 12/18/18 at 11:50 AM during an interview with Surveyor #7, the CH Vice President of Risk and Regulatory (Staff #702) and CH Vice President of Quality (Staff #705) stated that the shared employees' hours were tracked and accounted for under separate CWH and WVH cost centers but that the employees received one paycheck from CH when working at both hospitals.

2. Review of WVH's organization chart dated 11/07/18 showed that the Nurse Manager of the hospital's acute care and rehabilitation units (Staff #701) reports to the nurse director of the surgical unit at CWH (Staff #704), who in turn reports to the CH Chief Nursing Officer (Staff #709). On 12/18/18 at 11:55 AM, the CH Vice President of Risk and Regulatory (Staff #702) and the CH Vice President of Quality (Staff #705) confirmed that the WVH nurse manager reports to the CWH nurse director.

3. On 12/18/18 at 1:10 PM during a telephone interview with Surveyor #7, the CH Vice President (VP) of Nursing (Staff #723) stated that wound care nurses that are CWH employees provide complex wound care for patients at WVH on an as-needed basis. The VP stated there is no known contract between the hospitals for providing this service.

4. On 12/18/18 at 1:05 PM, Surveyors #2 and #7 interviewed the CH Nutrition Director (Staff #206) regarding the use of dieticians at WVH. Staff #206 stated that CWH dieticians provide care to WVH patients. The CWH dieticians can see any dietetic consults or orders for WVH patients in the electronic medical record and travel to WVH to perform work as needed. These employees work and are billed as CWH employees, not WVH employees. On 12/18/18 at 2:13 PM, The Vice President of Risk and Regulatory (Staff #203) stated that there is no dietetic services contract or written service agreement between WVH and CWH.

5. On 12/18/18 at 1:20 PM, Surveyor #2 and #7 interviewed the CH Vice President of Risk and Regulatory (Staff #203) regarding utilization of WVH facilities employees in non-WVH hospital spaces within the Mares building. She stated that WVH employs all physical environment staff (facilities, engineering, environmental services, etc.) that perform work in the Mares building. Therefore, WVH employees perform work in a CWH-owned area (CWH infusion center and oncology unit). No contract or service agreement was in place for providing these services.
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