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Based on staff interviews and document review, the hospital failed to measure, analyze, and monitor the effectiveness of their selected quality indicators.

On 02/23/2016 at 12:30 p.m., the surveyors reviewed the hospital document titled, " Annual Program Evaluation 2015 / Performance Improvement Plan 2016 ". The surveyors also reviewed Performance Improvement (PI) Meeting Minutes December 2015, January 2016, and February 2016. Both documents contained quality indicators, some data, and numerous goals; however, the analysis consisted of numerical calculations. The Performance Improvement Meeting Minutes did not contain discussion that the data was used to evaluate the effectiveness and safety of the services.

On 02/23/2016 at 12:30 p.m., the Assistant Executive Director and the Director of Program Evaluation stated the extent of quality analysis for the Performance Improvement Program was reflected in the Performance Improvement Plan and (PI) Meeting Minutes.

Based on staff interviews and document review, the infection control officer failed to ensure a staff immunization program was implemented according to nationally recognized guidelines.

Findings:

On 02/23/2016 at 12:30 p.m., the surveyors reviewed the hospital titled, "Annual Program Evaluation 2015, Performance Improvement Plan 2016. " This plan documented, "Program Goals for FY-2016 ...continue to monitor TB and Hepatitis B immunizations ...immunizations will be tracked by Infection Control Officer and goal is 75-85% staff compliance. " CDC documents healthcare workers, who provide direct patient care, are at risk for exposure to serious and sometimes deadly diseases. CDC documents 100% of these healthcare workers should get appropriate vaccines. CDC recommended the following vaccines: Hepatitis B, Influenza, measles, mumps, rubella (MMR) Varicella or documentation of serological immunity.

On 02/23/2016 at 12:20 p.m., the Assistant Executive Director provided the surveyors with a list of heathcare providers who rendered direct patient care. She provided the current documentation of these staff member's immunization status. The staff immunization spreadsheet reflected the staff 's current status for: TB testing, measles/mumps/rubella (MMR), varicella, and influenza. On this document, for multiple staff members, who were identified as direct caregivers, the immunization information was blank. The surveyors asked for the complete immunization or qualifying equivalent validation for those direct caregivers, and none was provided.