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Based on record review the Governing Body (GB) failed to maintain a list of all contracted services, including the scope and nature of the services provided.

Findings include:

The Clinical Contracted Services list did not include the following Contracted Services:
A.) Psychiatric Emergency Service (PES),
B.) Neonatology for the Special Care Nursery,
C.) Newborn Audiology, or
D.) Illuminate (patient callback service) were contractor services that furnished care or services to patients at the Hospital.

Based on records reviewed, and interviews the Hospital failed to comply with the following requirements of §482.55, Emergency Services.

Findings include:

1.) The Quality Assessment and Performance Improvement (QAPI) Plan, dated Fiscal Year 2015, indicated Contracted Services were evaluated for performance, however the Hospital document titled Measure, dated January through April, did not indicated QAPI data regarding the Psychiatric Emergency Service (PES), Neonatology Services for the Special Care Nursery, Newborn Audiology Services or the Illuminate (patient callback) Contracted Services. The Hospital did not provide QAPI data for the Contracted Services of PES, Newborn Audiology, or Illuminate.

2.) The PES Contract titled, Agreement for Emergency Department Coverage, dated 5/4/2007, indicated that each PES staff shall perform all services in accordance with all Hospital rules, regulations, procedures, policies and Medical Staff By-Laws and Medical Staff Rules and Regulations as communicated to the Group or Clinicians (PES staff). Surveyor #1 interviewed the Senior Director of Quality and Patient Safety (QPS) at 1:00 P.M. on 7/1/15. The Senior Director of QPS said that PES had their own forms and did not follow the Hospital policy.

3.) The Hospital document titled Patient Rights and Responsibilities, dated 6/23/15, indicated that the patient could expect reasonable continuity of care when appropriate and to be informed of realistic alternatives when hospital care was no longer appropriate, including continuing healthcare requirements following discharge from the hospital. The Hospital policy titled The Treatment of Behavioral Medicine Patients Boarding in the Emergency Department, dated 6/20/13, In the event that the patient has stabilized enough to be discharged from the Emergency Department, a thoughtful and comprehensive aftercare plan will be developed for the patient. The Hospital policy titled Behavior Medicine Patient Management, dated July 2012, indicated that if hospitalization was not necessary, the mental health clinician was responsible for arranging follow-up services and providing written discharge instructions. The Hospital policy titled Discharge of Patients, dated July 2012, indicated that all patients discharged from the Emergency Department would have the medical record completed with the disposition, discharge time, diagnosis, and condition on discharge documented. All patients will be given discharge instructions for care and follow-up. The Hospital policy titled Mission of the Emergency Departments at Metrowest Medical Center, dated July 2012, indicated that all patients who were discharged from the Emergency Department would receive printed discharge instructions.

Patient #1's Medical Record, dated 3/26/15 through 4/1/15, indicated that due to the need for safety and stabilization, after cutting himself/herself and requiring 74 stitches to repair the cuts, Patient #1 required inpatient psychiatric hospitalization level of care. Review of Patient #1's Medical Record did not indicate a PES Treatment Recommendations Instruction Sheet with the psychiatric follow-up plan of care for Patient #1's discharge from the ED. ED Nurse's Note, for Patient #1, dated 4/2/15 at 4:42 P.M., did not indicate discharge instructions regarding a psychiatric plan for follow-up and referral. Discharge Instructions, for Patient #1, date not documented did not indicate discharge instructions regarding a psychiatric plan of care, only include follow-up for suture removal. The ED Disposition Summary, for Patient #1, dated 4/2/15 at 4:44 P.M., did not indicate psychiatric condition at or near the time of discharge or a psychiatric plan of care after discharge from the ED.

Review of Patient #2's Medical Record, ED Physician Note, dated 5/23/15 at 12:28 A.M., indicated that Patient #2, a 6-year-old, presented to the ED for psychiatric evaluation and the ED plan of care included, inpatient psychiatric hospitalization level of care. Review of Patients #2's Medical Record did not indicated a PES Treatment Recommendations Instruction Sheet (Discharge Instructions) with the psychiatric follow-up plan of care for Patient #2's discharge.

Based on records reviewed and interviews the Hospital failed to identify opportunities for improvement for the following Contracted Services; Psychiatric Emergency (PES), Newborn Audiology and the Illumination Services.

Findings include:

1.) Surveyor #1 interviewed the Executive Director of Behavioral Health (BH) at 1:20 P.M. on 6/23/15. The Executive Director of BH said PES monitored provider response time, patient disposition, and access to a psychiatrist, discussed data at a quarterly meeting, the Hospital did not record minutes as these meetings. The Executive Director of BH said the Hospital asked PES for reports of the QAPI data but the Hospital had not received reports.

2.) Surveyor #1 interviewed the Emergency Department (ED) Chairperson at 9:34 A.M. on 6/26/15. The ED Chairperson said ED quality monitoring of psychiatric occurred only if their medical condition fell well into the medical condition categories identified by the ED for monitoring and monitoring of psychiatric patient services was not formal.

3.) Surveyor #1 and Surveyor #2 interviewed the Chief Medical Officer (CMO) on 6/25/15 at 1:10 P.M. The CMO said that he had not seen any PES quality assessment and performance data.

4.) Review of the Hospital document titled Measure, dated January through April, did not indicate QAPI data regarding the Psychiatric Emergency Service, Neonatology Services for the Special Care Nursery, Newborn Audiology Services, or the Illuminate (patient callback service) Contracted Services.

5.) Perinatal Committee minutes, dated 11/10/14 1/12/15, and 3/9/15, did not indicate QAPI data regarding the Newborn Audiology contracted service.