HospitalInspections.org

Based on facility document review and interview, it was determined that the Governing Body failed to require that an operational and capital budget was approved for 2017. This deficient practice poses the risk that the hospital operating and capital budget which was not approved, could impact the health and safety of patients, if it is not known how staff, supplies, equipment and services will be paid, and that there is no provision for capital expenditures spanning 3 years.

Findings include:

The Governing Board Adhoc Meeting Agenda dated 08/22/17, revealed: "New Business and Updates...Approval of 2017 budget for Phoenix and NW Phoenix locations...." An e-mail dated 08/22/2017 and timed at 0902 AM, revealed: "...We need to have an ad hoc governing board meeting to approve the 2017 budget...please see the attached budget for Phoenix and Phoenix NW...please respond with a yes to approve...."

The CEO confirmed in an interview conducted on 08/21/2017, that s/he is e-mailed monthly financial documents from Texas and that she has not seen the 2017 operational or capital budgets. Additionally, the CEO confirmed that the Governing Board had not approved the 2017 operational or capital budget.

The CEO provided on 08/22/2017, two budget documents titled: "Phoenix" and "Northwest" both dated 2017. The CEO indicated that the budget was a "capital budget", but neither document identified the type of budget, and the content did not meet the requirements for a capital budget to include: sources of financing for each anticipated capital expenditure in excess of $600,000 or a lesser amount that relates to any of the following: acquisition of land, improvement of land, buildings and equipment or the replacement, modernization, and expansion of buildings and equipment.

Based on review of hospital documents and interview, it was determined that the hospital failed to comply with the provisions of Quality Assurance Performance Improvement (QAPI) to include that the governing body failed to ensure that the QAPI program reflected the complexity of the hospital's organization and services, and included services under contract or arrangement which included dialysis. This deficient practice poses a significant risk for patient's receiving dialysis, when there is no monitoring of performance measures specific to dialysis.

Findings include:

The 2017 Governing Board meeting minutes revealed no documentation regarding Performance Improvement/Quality Management specific to dialysis, which is a contracted service.

The Director of Quality Management RN # 3, confirmed in an interview conducted 08/21/2017, that dialysis is a contracted service and that there was no hospital data collected specific to dialysis.

Based on review of hospital documents and interview, it was determined that the hospital failed to comply with the provisions of Quality Assurance Performance Improvement (QAPI) to include that the governing body, medical staff and administrative officials were responsible and accountable that an on-going program for quality improvement and patient safety to include medical errors was defined, implemented and maintained. This deficient practice poses a significant risk to the patient's health and safety if medical errors are not tracked, reviewed and reported to improve quality care.

Findings include:

The 2017 Governing Board meeting minutes revealed no documentation regarding a Performance Improvement/Quality Management program specific to medical errors.

The Director of Quality Management RN # 3, confirmed in an interview conducted 08/21/2017, that medical errors are not identified and tracked in the Quality Management program.