HospitalInspections.org

Based on interview and document review, the Critical Access Hospital (CAH) had not compiled a complete listing of all contracted services utilized in the CAH, with which the CAH could track the performances of contracted service providers. The available partial list did not describe the nature, scope or any quality-performance indicators with which the CAH could evaluate the quality, safety or effectiveness of the services or products provided. This failure could potentially expose staff or patients to harmful effects from poor quality, unsafe or inefficient products or services supplied by contracted vendors or providers.

Findings:

On 4/1/2015 the facility's Executive Assistant (EA-1) was asked to provide the CAH's list of all services or products utilized under agreement with outside vendors; and to provide the Quality or Performance Indicators (QI, PI or Q-PI) that had been selected for each written contract. "A 'Quality or Performance Indicator' is a description of a quantitative or qualitative measurement, or any other criterion, by which the performance, efficiency, achievement, etc. of a person or organization can be assessed, often by comparison with an agreed standard or target." On 4/1/2015 a two page list of 69 contracts, which ranged from physician and other practitioners that cared for patient to banking services or office supply vendors. The list did not contain any descriptions of the nature, scope or Q-PIs used to evaluate the contracted providers.

On 4/1/15 at 1:50 p.m. during an interview the Chief Executive Officer (CEO) stated he had only recently taken the CEO position and acknowledged the current list of contracted services was incomplete. It did not contain all of the services utilized at the CAH and the list did not contain all of the elements required by regulation (scope and nature). He stated he was in the process of personally reviewing each contract, but his current focus was not on individual contract specific Quality Indicators (QIs) or Performance Indicators (PIs) which would insure quality, safety and effectiveness. His focus was on the cost aspects of the contracts. The CEO was receptive to the idea of developing and tracking QIs or PIs for quality, safety and effectiveness, specifically tailored for each contract individually. He was also receptive to the concept of ranking the contracts in order of priority for the frequency and rigor of review. He acknowledged the CAH still had considerable improvements to make before being compliant with this section of CMS regulations.

On 4/2/15 during an interview beginning at 9:45 a.m., the EA-1 stated the list of contracted services was incomplete and did not have the required data, and the list had no performance indicators which the CAH could use to evaluate the services provided. She state the Plan of Correction (PoC) for contracts was her assignment and she did not completed her PoC tasks.

Based on interview and document review, the Critical Access Hospital (CAH) failed to consider and take needed corrective action related to the findings of the "2015 Annual Quality Assurance and Credentialing Review" conducted by a Quality Improvement Organization (QIO-1) from 2/24/2015 to 2/26/2015. On 3/10/2015 the findings of this evaluation, included the findings and recommendations for achieving regulatory compliance were reported to the CAH's Chief Executive Officer (CEO). The CEO presented this report to the Medical Executive Committee (MEC) and the Governing Body (GB), but neither took any corrective action. This failure permitted the continuation of multiple quality assessment and credentialing deficiencies which dated back to early 2014; and left in place the possibility that staff or patients could be exposed to harmful effects from poor quality, unsafe or inefficient staff, products or services.

Findings:

On 4/1/15 the CAH's Executive Assistant (EA-1) provided the 3/10/15 report from QIO-1 detailing the findings and recommendations for needed action from its 2/24-2/26/15 Annual Quality Assurance and Credentialing Review (2015 QIO Review). During an interview, 4/1/15 at 1:40 p.m. the CEO acknowledged receipt of the 2015 QIO Review report on 3/10/15. He stated he had presented the report informally to the MEC members and formally to the GB at their most recent meeting. He provided the GB meeting packet outlining the report. He stated the CAH had not yet initiated any corrective action, and specifically stated neither the MEC nor the GB had called for corrective action to begin.