HospitalInspections.org

At the time of the revisit on 01/20/2015, this deficiency was not corrected.
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Based on review of review of hospital documents, policies and procedures and meeting minutes and interviews with staff, the hospital failed to analyze infection practitioner surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

Concerns identified in meeting minutes showed no review and analysis to determine if corrective actions need to be developed or if current policies and procedures were followed.

The above information was confirmed by the infection control practitioner on the afternoon of January 20, 2015.

At the time of the revisit on 1/20/2015, this deficiency was not corrected.
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Based on review of hospital documents and meeting minutes and interviews with hospital staff, the hospital failed to have an effective quality assurance program (QAPI) that analyzed data, implemented corrective action to ensure the quality and appropriateness of all patient care that was furnished, with follow-up to ensure the corrective actions were effective and maintained.

Findings:

The hospital's Quality Improvement Plan (QAPI Plan) documented the QAPI program has active continuous improvement cycles of Plan, Do, Check and Act and would involve all departments/services. Meeting minutes provided since the survey on 11/06/14, did not reflect this was being done.

The above information was confirmed by the infection control practitioner and hospital administrator on the afternoon of January 20, 2015.