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PUSHMATAHA COUNTY TOWN OF ANTLERS HOSPITAL
CONTRACTED SERVICES
Tag No.: A0083
Based on interviews, and document review, the hospital failed to ensure that all contracted services were provided according to acceptable standards of practice.
Findings:
On 12/20/2016 at 1:42 pm, the surveyors requested a list of contracted services, and none was provided. Chief Executive Officer (CEO) and Staff A stated the hospital contracted for the following services: Teleradiology, and Laboratory Director and the Pharmacist. The CEO failed to identify other services that were evident during the survey, such as equipment preventative maintenance, generator testing services etc.
On 12/20/2016 am, the "Board of Trustee Meeting Minutes 08/15/2016, 09/28/2016 and 10/10/2016" were reviewed. No contract evaluations were documented within those minutes.
The CEO stated the hospital had no current evaluation of contract services, and planned to review the contracts "at the first of the year."
FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Tag No.: A0724
Based on observation, staff interview, and record review, the hospital failed to perform inspections and preventive maintenance for the following medical and environmental equipment: facility's 3 transfer switches, a power strip and a sterilizer located in the surgical department.
See Tag K-0147.
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on interview and document review, the hospital failed to:
a. Define the position responsibilites for the Infection Control Preventionist (ICP),
b. Appoint the selected staff for the ICP through the Governing Body, and
c. Ensure the ICP was qualified and trained for the position.
Findings:
On 12/20/2016 at 10:22 am, Staff A was identified as the Infection Control Preventionist. Staff A stated had fulfilled the role since 08/2016.
On 12/20/2016 12:00 am, the "Board of Trustee Meeting Minutes 08/15/2016, 09/28/2016 and 10/10/2016" were reviewed. No appointment of the ICP was documented within those minutes. Staff A stated she had never been appointed by the Governing Body as ICP.
On 12/20/2016 at 2:30 pm, the personnell file for Staff A was reviewed. No ICP job description or specialized training for infection control was found within the file. Staff A stated no specialized training had been provided for the ICP role other than orientation from the prior ICP.