HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations and Medicare Conditions of Participation for Hospitals by sharing hospital services, space, and staff with other separately certified health care entities.

Failure to maintain control of services, space, and staff can lead to dependence on another health care entity for compliance with federal regulations and put patients at risk to receive poor quality care.

Findings included:

The hospital failed to meet applicable federal requirements by:

Sharing services and programs

Sharing hospital staff

Sharing clinical care areas of the hospital

Cross Reference Tag A 043
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Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations and Medicare Conditions of Participation for Hospitals by sharing hospital services, space, and staff with other separately certified health care entities.

Failure to maintain control of services, space, and staff can lead to dependence on another health care entity for compliance with federal regulations and put patients at risk to receive poor quality care.

Findings included:

ITEM #1 - Shared Services

1. Review of a document titled "Bylaws of Confluence Health", effective date 04/11/17, showed that Confluence Health (CH) is a health system located in Wenatchee, Washington. The bylaws named Wenatchee Valley Hospital (WVH), and Central Washington Hospital (CWH) as "participating organizations" in this health system. The bylaws stated that the purpose of the health system was to integrate "hospital, physician and related health care services in a more coordinated fashion" in order to be more cost-effective.

2. Review of a document titled "Scope of Service: Confluence Health", Policy #5200672 revised 09/20/18, showed that the following services would be provided to WVH and CWH by Confluence Health:

a. Accountable Care
b. Care Management Service Line (Ambulatory)
c. Security
d. Emergency Preparedness
e. Biomedical Services
f. Human Resources
g. Food Services
h. Finance [accounting, business, supply chain]
i. Infection Control
j. Information Technology [electronic medical record]
k. Quality [quality reporting, utilization management, clinical documentation improvement]
l. Revenue Cycle
m. Risk management/Incident Management
n. Medical Staff Services
o. Compliance
p. Health Information Management
q. Legal Services

3. During the survey, surveyors found the following:

a. Pharmacy Services

1) On 11/06/18 between 3:05 PM and 4:30 PM, Surveyor #7 interviewed the CH Vice President of Ancillary Services (Staff #707) and the WVH pharmacy manager (Staff #708). During the interview, the VP stated that pharmacy services at WVH are provided under contract by CWH. WVH provides the pharmacy space and medications, and CWH provides the personnel to work in the pharmacy.

2) On 11/07/18 at 12:10 PM, Surveyor #7 interviewed a medical assistant who worked in the WVH outpatient urology department (Staff #725). During the interview, the medical assistant stated that the CWH infusion center pharmacy located on the 4th floor of WVH mixes and delivers chemotherapy for bladder instillations for WVH outpatient urology patients.

3) Review of documents titled "Pharmacy Services Agreement" (an agreement between WVH and CWH) dated 07/21/13 and a CH policy titled "Pharmacy Operations and Medication Management", Policy #3910140 revised 09/25/17, confirmed that WVH does not have its own distinct pharmacy services.

b. Utilization Review

1) On 11/07/18 between 3:30 PM and 4:15 PM, Surveyor #7 interviewed the Quality Director (Staff #710), a registered nurse case manager (Staff #711), and a licensed social worker (Staff #712). During the interview, the director stated that CH provides combined utilization review services for WVH and CWH.

2) Review of a document titled "Utilization Management Plan", Policy #4147749 revised 02/02/18, confirmed that WVH does not have its own distinct utilization review program.

c. Infection Control Program

1) On 11/08/18 between 8:50 AM and 9:40 AM, Surveyor #7 interviewed the Infection Control Program Manager (Staff #713), an employee health nurse (Staff #714), and an infection control nurse (Staff #715). During the interview, the manager stated that the infection control program is a combined service between WVH and CWH under CH.

2) Review of a document titled "Infection Control Program Plan", Policy #5223373 revised 09/20/18, confirmed that WVH does not have its own distinct infection control program.

d. Medical Record Services

On 11/08/18 between 2:30 PM and 3:00 PM, Surveyor #7 interviewed the Manager for Health Information Management [HIM] and Compliance (Staff #706). The manager stated she is employed by Confluence Health, and that HIM is a combined service for WVH and CWH. The manager stated that WVH and CWH use the same electronic medical record system ("Epic"), and that staff with the appropriate security clearance can access medical records at both hospitals simultaneously. This showed that WVH does not have its own distinct medical records services.

f. Nursing Services

1) Review of WVH's organization chart dated 11/07/18 showed that the Nurse Manager of the hospital's acute care and rehabilitation units (Staff #701) reports to the nurse director of the surgical unit at CWH (Staff #704), who in turn reports to the CH Chief Nursing Officer (Staff #709).

2) On 12/18/18 at 11:55 AM, the CH Vice President of Risk and Regulatory (Staff #702) and the CH Vice President of Quality (Staff #705) confirmed that the WVH nurse manager reports to the CWH nurse director. This showed that WVH does not have its own distinct nursing services.

g. Radiological Services

1) On 12/18/18 at 1:13 PM, Surveyors #2 and #7 interviewed the CH Vice President of Quality (Staff #205) and the CH Vice President of Risk and Regulatory (Staff #203) regarding radiological services provided to inpatients at WVH. During the interview, Staff #203 stated that WVH patients utilize a freestanding radiology department for radiological services. WVH owns the freestanding clinic, but the clinic is not part of the hospital under the state hospital license. Staff #205 stated that there is no contract or service agreement between WVH and the radiology clinic defining the rendering and evaluation of services.

2) On 12/18/18 at 2:13 PM, Staff #205 told the surveyors that x-ray technicians that work with WVH patients do so as employees of WVH. These technicians bill WVH for working hours and are oriented to their work areas at WVH. All other radiological staff members are employees of other CH entities who provide radiological services to WVH patients.

g. Laboratory Services

On 12/18/18 at 1:15 PM, Surveyors #2 and #7 interviewed the CH Vice President of Risk and Regulatory (Staff #203) regarding laboratory services at WVH. During the interview, Staff #203 stated that the laboratory at WVH recently closed and services moved to CWH with exception of a "stat lab" for items that need rapid turnaround times. WVH and CWH had not developed a contract regarding the use of CWH laboratory services for WVH patients. Staff working in the "stat lab" are employees of WVH, but all other laboratory employees work for other branches of CH.


ITEM #2 - Shared Spaces

1. On 12/18/18 from 10:00 AM to 11:00 AM, Surveyors #2 and #7 conducted a facility tour of the WVH Mares building with the CH Engineering Director (Staff #201), the CH Director of Facilities Services (Staff #202), the CH Vice President of Risk and Regulatory (Staff #203), and a registered nurse quality specialist (Staff #204). On the fourth floor of WVH Mares building, the WVH gastrointestinal procedural area, WVH rehabilitation gym, the CWH infusion and oncology unit, and a freestanding gastrointestinal clinic share a common reception, lobby, and entrance area. Patients utilize the same reception area to check in to their respective hospitals and use the same entrance and post-reception hallway to reach each respective entity.

2. Document review of the WVH floor plans showed that the WVH gastrointestinal procedure area, the WVH rehabilitation gym, the CWH infusion and oncology unit, and the freestanding gastrointestinal clinic have a single lobby and reception area. Each entity utilizes a single hallway beyond the reception area for patient access.

3. On 12/18/18 at 11:00 AM, Surveyors #2 and #7 interviewed the CH Engineering Director (Staff #201) regarding the floor plans and the shared spaces observed on the facility tour. He confirmed the above observations.


ITEM #3 - Shared Staff

1. On 11/06/18 at 9:00 AM, Surveyor #7 interviewed the Nurse Manager for the hospital's acute care and rehabilitation units (Staff #701). During the interview the manager stated that the hospital does not have an emergency department. She stated that if patients experience emergency medical conditions while in the hospital, a team of health care providers respond. If the emergency occurs between the hours of 7:00 AM and 9:00 PM, the designed team includes the physician on duty in the Wenatchee Walk-In Clinic (WIC), a rural health clinic located on the main floor of the hospital. Review of documents titled "Guideline: WVH Rapid Response Team", Policy #4196088 revised 02/15/18; and "Code Blue Facility Work Plan - Mares Building", Policy #41156169 revised 02/13/18, confirmed that WVH relies on staff from another certified health care entity to provide emergency care for patients.

2. Review of a document titled "Employee Lease Agreement", effective date 10/01/18, showed that CWH agreed to lease employees to WVH on an as-needed basis. The agreement identified job categories that included nurses, medical assistants, receptionists, and certified nursing assistants. On 11/07/18, Surveyor #7 reviewed a document titled "List of Shared Staff between CWH and WVH." The list identified seven individuals that worked at CWH and WVH, including a patient care technician (Staff #716), four registered nurses (Staff #717, #718, #719, #720), and two food services workers (Staff #721, #722). On 12/18/18 at 11:50 AM during an interview with Surveyor #7, the CH Vice President of Risk and Regulatory (Staff #702) and CH Vice President of Quality (Staff #705) stated that the shared employees' hours were tracked and accounted for under separate CWH and WVH cost centers but that the employees received one paycheck from CH when working at both hospitals.

3. On 12/18/18 at 1:10 PM during a telephone interview with Surveyor #7, the CH Vice President (VP) of Nursing (Staff #723) stated that wound care nurses that are CWH employees provide complex wound care for patients at WVH on an as-needed basis. The VP stated there is no known contract between the hospitals for providing this service.

4. On 12/18/18 at 1:05 PM, Surveyors #2 and #7 interviewed the CH Nutrition Director (Staff #206) regarding the use of dieticians at WVH. Staff #206 stated that CWH dieticians provide care to WVH patients. The CWH dieticians can see any dietetic consults or orders for WVH patients in the electronic medical record and travel to WVH to perform work as needed. These employees work and are billed as CWH employees, not WVH employees. On 12/18/18 at 2:13 PM, The Vice President of Risk and Regulatory (Staff #203) stated that there is no dietetic services contract or written service agreement between WVH and CWH.

5. On 12/18/18 at 1:20 PM, Surveyor #2 and #7 interviewed the CH Vice President of Risk and Regulatory (Staff #203) regarding utilization of WVH facilities employees in non-WVH spaces within the Mares building. She stated that WVH employs all physical environment staff (facilities, engineering, environmental services, etc.) that perform work in the Mares building. Therefore, WVH employees perform work in CWH-owned areas, the WVH rural health clinics, and the freestanding clinics. No contract or service agreement was in place for providing these services.
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Based on interview and review of patient rights information, the hospital failed to provide written notice to all patients that a doctor of medicine (MD) or doctor of osteopathy (DO) was not present in the hospital twenty-four hours a day, seven days per week.

Failure to provide such notice limits the patient's ability to make informed decisions about his or her healthcare.

Reference: 42 CFR 489.20(w):
"(1) In the case of a hospital as defined in § 489.24(b), to furnish written notice to all patients at the beginning of their planned or unplanned inpatient hospital stay or at the beginning of any planned or unplanned outpatient visit for observation, surgery or any other procedure requiring anesthesia, if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with § 482.13(b)(2) of this subchapter. For purposes of this paragraph, a planned hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. An unplanned hospital stay or outpatient visit begins at the earliest point at which the patient presents to the hospital."

Findings included:

1. On 11/06/18 at 9:05 AM, Surveyor #7 interviewed the nurse manager of the hospital's acute care and rehabilitation units (Staff #701). During the interview, the manager stated that an MD or DO was not on site twenty-four hours per day, seven days per week to provide care for patients.

2. Review of the list of patient rights given to inpatients and outpatients when admitted to the hospital for care showed it did not include information for patients that an MD or DO was not on site twenty-four hours per day, seven days per week.

3. On 11/08/18 at 1:00 PM, Surveyor #7 interviewed the Vice President of Risk and Regulatory Compliance (Staff #702). During the interview, the Vice President confirmed that the hospital did not have a process for providing this information to patients.
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Based on observation and review of hospital policies and procedures, the hospital failed to ensure staff prevented cross contamination of cleaned and dirty items during cleaning of the surgical suites.

Failure to prevent cross-contamination in the surgical setting puts patients at risk of infection.

Findings included:

1. Review of the hospital policy titled "Operating Room Housekeeping Procedures, under the heading "Terminal Cleaning at the End of Day" showed that hospital staff should clean the surgical suite from top to bottom and from clean areas to dirty areas.

2. On 11/08/18 between 3:00 PM and 4:00 PM, Surveyor #1 observed an environmental service staff member (Staff Member #101) perform a terminal clean of a surgical suite. During the cleaning, the surveyor observed the following:

While cleaning the surgical table, the staff member disassembled the arm pads and placed the unclean portion of the arm pads on top of the clean sections of the surgical table. After cleaning the arm pads, the staff member placed uncleaned yellow gel pads on top of the surgical table and continued to disinfect the yellow gel pads on top of the surgical table. After removing these items, the surgical table did not get wiped down with disinfection solution.