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Based on staff interviews, observation and review of facility documents, the governing body of the facility failed to ensure services furnished under contract complied with all applicable conditions of participation and standards for the contracted services. The failure created the potential for a negative patient outcome.

Finding:
On 12/21/10, a requested list of current services provided by contract was unable to be provided. Interviews were conducted at approximately 2:00 p.m. with the Coordinator of Regulatory Affairs, the Vice President, Patient services and Chief Nursing Officer and the Director of Clinical Excellence and Patient Safety. A list of all contracts for supplies and services was provided. There was no indication the contracts were assigned to a person or department responsible for review, monitoring and evaluation to determine the effectiveness of the contract. There was no process in place to ensure all hospital clinical contracts were assessed and information forwarded to the Governing Body to ensure performance and quality of services provided met all required required standards and applicable conditions of participation.

Based on staff interviews and review of facility documents, the governing body of the facility failed to ensure the contracted services had internal quality assurance activities to track performance failures. The findings created the potential for negative patient outcome.

The findings were:

On 12/21/10, interviews were conducted at approximately 2:00 p.m. with the Coordinator of Regulatory Affairs, the Vice President, Patient Services and Chief Nursing Officer and the Director of Clinical Excellence and Patient Safety. The facility failed to provide documentation that the contracts were assigned to a person or department responsible for reviewing, monitoring and evaluating the effectiveness of the contract. There was no process in place to ensure all hospital clinical contracts were assessed and quality assurance information forwarded to the Governing Body to ensure oversight and effectiveness by the appropriate personnel or department responsible for the contracted services provided to the facility.

Based on a review of staff documents and staff interviews, the governing body failed to ensure the hospital maintained a complete list of all contracted services, as required.

The findings were:

On 12/21/10, a list of contracted services was requested from the Coordinator of Regulatory Affairs. A list was produced from January 2007 and contained twelve clinical services including environmental services, patient transport services and medical staffing for respiratory therapists. An interview with the Coordinator of Regulatory Affairs at approximately 11:00 a.m. revealed there was a more recent list of services but s/he was having trouble locating it. Interviews were conducted at approximately 2:00 p.m. on 12/21/10 with the Director of Clinical Excellence and Patient Safety and the Vice President, Patient Services and Chief Nursing Officer. A list of contracts was provided. The list of contracts contained both contracts for supplies and services provided at the facility. There was no indication which hospital department was responsible for evaluating the services provided or monitoring to ensure the services were being provided as stated. The facility was unable to ensure quality assurance information was forwarded to the Governing Body to determine the contracted services met all required standards.