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Based on document review and interview, the facility failed to measure, analyze, and track quality indicators for facility services including Discharge Planning, Laundry, Security, Nursing Professionals, Pest Control and Housekeeping in the facility's Quality Assessment and Performance Improvement (QAPI) program.

The cumulative effects of this systemic problem resulted in the facility's inability to ensure that it had an effective Quality Assurance program.

Based on document review and interview, the facility failed to ensure all services, including those furnished by a contractor, were evaluated and reviewed through the Quality Assessment and Performance Improvement (QAPI) program for fiscal year 2024 and 2025 for 3 contracted services. (Pest Control, Nurse Professionals, Environmental Services.

Findings Include:

1. Facility document titled Quality Strategic Plan 2024, indicated facility leaders with authority and oversight by the Quality and Patient Safety Committee of the Board of Directors, establish the Quality and Safety standards, programs and monitoring process; Safety contract reviews will contain, at minimum, one performance indicator.

2. Review of Governing Board Meeting minutes from 12/2023 through 10/2024 lacked evidence of quality data collected for contracted services including Pest Control, Nurse Professionals, and Environmental Services.

3. In interview on 2/14/25 at approximately 1100 hours with A5 (Executive Assistant/Board Secretary), he/she confirmed preparing a Governing Board Meeting packet, but it does not include Quality data/tracking. A4 (Director of Pharmacy) also confirmed contracted services are not discussed at Quality Committee Meeting or Governing Board Meetings. Quality Committee Chair Physician picks one hot topic for quality to discuss such as Sepsis at a Governing Board Meeting, and that is all that is discussed or reviewed. A4 confirmed the Governing Board is not reviewing Quality data from every service the facility offers.

4. In interview on 2/14/25 at approximately 1315 hours with A1 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings: Pest Control, Nurse Professionals, and Environmental Services.

Based on document review and interview, the facility failed to measure, analyze, and track quality indicators for facility services including Discharge Planning, Laundry, Security, Nursing Professionals, Pest Control and Housekeeping in the facility's Quality Assessment and Performance Improvement (QAPI) program.

Findings include:

1. Facility document titled Quality/Patient Safety Committee Charter indicated under I. Purpose and Responsibilities, Hospital Quality/patient Safety Committee supports the Hospital Board of Directors in its commitment to assure that individuals receiving services from Hospital are provided safe, effective, and quality services. III. Authority and Responsibilities, A. The Committee will monitor the Hospital's quality improvement and performance improvement program, metrics and goals to determine congruence with the mission, vision and values of the Hospital.

2. Review of Quality and Patient Safety Committee meeting minutes from 1/2024 through 11/2024 lacked evidence of quality data collected for contracted services including Pest Control, Nurse Professionals and Environmental Services; lacked evidence of quality data collected for facility services including Laundry, Security and Discharge Planning.

3. In interview on 2/14/25 at approximately 1315 hours with A1 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings. Services included Pest Control, Nurse Professionals, and Environmental Services. A1 also confirmed the facility is not evaluating the following facility services in the Quality and Safety Meetings including but not limited to Laundry, Security and Discharge Planning.

Based on document review and interview the Governing Board failed to assure all services, including those furnished by a contractor were included in the Quality Assessment and Performance Improvement (QAPI) program.

Findings Include:

1. Facility document titled Quality/Patient Safety Committee Charter indicated under I. Purpose and Responsibilities, Hospital Quality/patient Safety Committee supports the Hospital Board of Directors in its commitment to assure that individuals receiving services from Hospital are provided safe, effective, and quality services. III. Authority and Responsibilities, A. The Committee will monitor the Hospital's quality improvement and performance improvement program, metrics and goals to determine congruence with the mission, vision and values of the Hospital.

2. Facility document titled Quality Strategic Plan 2024, indicated facility leaders with authority and oversight by the Quality and Patient Safety Committee of the Board of Directors, establish the Quality and Safety standards, programs and monitoring process; Safety contract reviews will contain, at minimum, one performance indicator.

3. Review of Governing Board Meeting minutes from 12/2023 through 10/2024 lacked evidence of quality data collected for contracted services including Pest Control, Nurse Professionals and Environmental Services; lacked evidence of quality data collected for facility services including Laundry, Security and Discharge Planning.

4. Review of Council on Clinical Exellence Meeting minutes from 11/2023 through 11/2024 lacked data collected for contracted services including Pest Control, Nurse Professionals and Environmental Services; lacked evidence of quality data collected for facility services including Laundry, Security and Discharge Planning.

5. In interview on 2/14/25 at approximately 1100 hours with A5 (Executive Assistant/Board Secretary), he/she confirmed preparing a Governing Board Meeting packet but it does not include Quality data/tracking. Packet includes but not limited to Quality and Operations meeting minutes, consent items, resolutions, last meeting minutes, then packet is downloaded into a portal for the governing Board to review. A4 (Director of Pharmacy) also confirmed contracted services are not discussed at Quality Committee Meeting or Governing Board Meetings. Quality Committee Chair Physician picks one hot topic for quality to discuss such as Sepsis at a Governing Board Meeting, and that is all that is discussed or reviewed.

6. In interview on 2/14/25 at approximately 1315 hours with A1 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings. Services included Pest Control, Nurse Professionals, and Environmental Services; confirmed facility is not evaluating the following hospital services in the Quality and Safety Meetings including Laundry, Security and Discharge Planning.