HospitalInspections.org

1. Based on review of quality assurance reports and staff interviews, it was determined that the facility did not implement data analysis of patient care indicators relevant to outpatient program or specialty clinics.

Findings include:

Review of Ambulatory Care QAPI meeting minutes on 10/23/12 and staff interview on 1/15/13 found that there was no specific implementation of data collection or measurement of indicators as planned to assess quality of care provided in the pediatric high risk or other ambulatory care specialty clinics. This finding does not apply to the pediatric Infectious Disease clinic, which was voluntarily suspended by the facility on 12/19/12, and was not in operation at the time of this survey.

Review of Performance Improvement Committee meeting minutes dated 10/23/12 on 1/15/13 found there were no clinical patient care indicators to measure patient care for each operating specialty clinic. It was noted that there were plans to have a performance improvement project implemented at every specialty clinic. This was in response to findings of lack of testing and follow up of laboratory work identified during a previous Allegation survey conducted by the New York State Department of Health on 9/20/12.

Review of the report on 1/15/13 from the Ambulatory Care Network for the period 12/12 stated that the facility needed to revise the Quality Assurance plan to address the deficiencies cited, during the prior survey, for the death of an infant with prenatal HIV exposure. This document noted that subspecialty clinics were incorporated into the Ambulatory Care QAPI Plan. This document also specified the expectations for clinical indicators in clinic areas covering pediatrics, adolescent, adult preventative care, prenatal care, and PI clinics in specialty clinics "to include identification of high volume, high risk and problem prone clinical opportunities for improvement."

A third document was provided on 1/15/13 which listed Ambulatory care Subspecialty Clinic Performance improvement Indicators for 2013. This data collection tool listed indicators for each of 30 specialty clinics. Review of these proposed performance improvement (PI) indicators for 2013 found specific indicators were developed and data collection is prospectively planned for each specialty clinic. However, no data was collected or analyzed at the time of review of this tool on 1/15/13.

At interview with Administrative staff on 1/15/13, it was reported that the facility did not yet implement data collection for analysis of planned clinical patient care indicators for specialty care clinics as noted in the plan of correction dated 12/12. The plan of correction noted that the indicators would be developed by 12/17/12 and maintaining would begin in January 2013. This implementation of data collection had not yet begun at the time of follow -up interview with Performance Improvement staff on 1/25/13.

Of note, it was stated at interview with Administration on 1/10/13 at 10AM that the services of the pediatric high risk clinic was suspended voluntarily by the hospital during a conference call with representatives of New York State Department of Health on 12/19/12. Review of documents furnished by the facility found an e-mail transcription dated 12/28/12 from the Assistant Director of the Bureau of Ambulatory Care Services of the AIDS Institute addressed to the Administrators of the Hospital. This document summarized the voluntary clinic suspension of the pediatric HIV clinic at the hospital, which was underway as of 12/21/12 and which noted that children were in the process of being transferred to other programs.

This is a repeat deficiency for the failure to implement data collection and analysis of QAPI indicators for the remaining clinics in operation by January 2013.

Cross-refer to findings noted also under tag A273 for Event ID # 7XBQ11.




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Based on review of documents, procedures, and staff interviews, it was determined the facility did not meet requirements for the Condition of Participation for Outpatient Services. The facility did not fully implement changes in procedures for the comprehensive testing and follow up of infants at risk for HIV.

Findings include:

The Condition of Participation for Outpatient Services shall remain out of compliance as verified during the 1/14/13 re-visit survey for the following reasons:

1. The facility did not implement all activities, including correct policy revision and revised referral procedures, to reflect the changes made after the closure and voluntary suspension by the hospital of the pediatric HIV-ID clinic on 12/19/12.

At interview with Administration on 1/10/13 at 10AM, it was stated that the services of the pediatric high risk clinic was suspended voluntarily by the hospital after a conference call with representatives of New York State Department of Health on 12/19/12. Review of documents furnished by the facility found an e-mail transcription dated 12/28/12 from the Assistant Director of the Bureau of Ambulatory Care Services of the AIDS Institute addressed to the Administrators of the Hospital. This document summarized the voluntary clinic suspension of the pediatric HIV clinic at the hospital, which was underway as of 12/21/12 and which noted that children were in the process of being transferred to other programs.

2. The facility has not submitted a revised plan of correction to the NYSDOH for ambulatory care to reflect revised protocols and practices in the outpatient area, including revision of procedures, staff training, and QAPI activities to ensure safe patient care.

3. The facility has not implemented the plan of correction to analyze quality assurance data from specialty clinics. While indicators were developed specific to specialty clinics, no data collection or analysis has yet been performed during the site visit conducted between the dates of 1/10 and 1/15/13. The plan of correction from the Allegation Survey of 9/20/12 found that the plan to develop clinical indicators for subspecialty clinics on 12/17/12 and "review and maintaining" would begin in January 2013.
(Cross refer to citations written under tag A273.)
( This matter is also cited under the QAPI regulations for the Completion Survey (Event ID 7XBQ11))

4. The facility has not fully revised and accepted the HIV maternal-child testing procedures. Both revisions of procedures for Maternal Pediatric HIV prevention and care program, and Pathology Department procedures for NYSDOH HIV testing of high Risk Infants were in draft format and were not fully approved at the time of the survey.

5. Procedures document contradictory time frames for required collection of newborn HIV screening and testing specimens.
Review of the revised draft policies on 1/15/13 for "Maternal-Pediatric HIV prevention and Care program policy and procedure (revised 12/12)" and Department of Pathology "NYSDOH HIV testing of high risk infants" finds different requirements noted for the required timeline of collection of specimens and documentation. The pathology policy requires the whole blood specimen to be collected less than 48 hours after birth which should be received at Wadsworth lab within 72 hours of collection. However, the Maternal Pediatric HIV prevention policy requires the nurse to complete documentation and to send the newborn screening blood collection to Wadsworth Lab within 24 hours.


6. Follow up phone discussion with hospital administrative staff in the department of performance improvement on 1/25/13 found that the facility has not developed facility specific procedures for the mandatory Newborn Screening Program for all conditions, including HIV (heelstick), and defers to New York State Wadsworth Guidelines for this requirement. This requirement for mandatory newborn HIV screening of all newborns differs from the procedures to test infants who are HIV exposed. While the Maternal Pediatric HIV prevention policy refers to the screening requirement and need for screening blood specimen collection to be sent to Wadsworth within 24 hours, it refers to New York State Guidelines and does not adapt it specifically to facility needs.

7. Follow-up interview with Performance Improvement staff on 1/25/13 confirmed that on 1/23/13, contact with NYSDOH AIDS Institute staff recommended revision of the policy titled, "Maternal-Pediatric HIV prevention and Care program policy and procedure (revised 12/12)" to include changes since the temporary clinic suspension on 12/19/12. The policy was to be amended to include that follow up is to be conducted at Infectious Disease clinic for adults and at pediatric high risk clinic for the baby.
However, this policy does not incorporate specific procedures to be followed, including specialized referrals to other facilities to be accomplished upon confirmed positive HIV DNA PCR or RNA testing of the infants in the outpatient clinic.

Cross refer also to Tag A1076 for the Completion survey, Event ID #7XBQ11.








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