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Based on document review and staff interviews, it was determined that the Governing Body did not provide adequate oversight of contracted services to ensure that services are provided in a safe manner and in accordance with the terms of the contract. Findings noted in 3 of 4 contracts reviewed.

Findings include:

At interview with the Deputy Executive Director Network Regulatory Affairs/QM and the Deputy Executive Director of Operations on 5/16/11 it was stated that the hospital has over 200 non clinical contracts most of which are corporate contracts. The facility was unable to provide a comprehensive list of the non clinical contracts until the morning of 5/18/11. The list provided by the Corporate Headquarters noted 219 vendors; 22 local contracts, 11 state contracts and 186 corporate contracts.

At interviews with several staff members during the review of four contracts selected for review (Sedexho, Citistorage, Quadramed and Siemens), it was noted that non clinical contracts are not subjected to the same quality assessment and performance improvement as clinical contracts. The Deputy Executive director of Operations stated that each contact is monitored according to the terms of the contact. The non clinical contracts are reported in the hospital wide Quality Assessment and Performance Improvement only when there are violations in the terms of the contract. Deputy Executive Director, Network Regulatory Affairs/QM stated that non clinical contacts unlike clinical contracts are reported to the Governing Body by exclusion therefore contract review by Governing Body is incident driven. She explained that Material Management and Contract Management review incidents and make recommendation to the New York City Health and Hospital Corporation who determines whether to keep or terminate a contract. The review of January 2010 to December 2010 minutes of the New York City Health and Hospital Corporation Board of Director revealed no periodic discussion of non clinical contracts.

In the minutes of the Governing Body quarterly meeting held on 4/21/11, it notes the method of review of contracts services; " Patient Care Contracts are evaluated by relevant Chief of Service, the Medical Director and the Executive Director and reports are presented to the Medical executive Committee for recommendation for contract renewal. However, for the non-patient care contracts services, evaluation of contracts is an ongoing process. As complaints are received from administrative, supervisory or line staff, feedback is provided to vendors and corrective actions with expected performance are discussed. Depending on the severity of the problem, required action may include immediate removal of product or equivalent from service, replacement or substitution of product, change in procedures and others as deemed appropriate by the facility. In the absence of an appropriate and timely response from vendor, or should the severity of the failure warrant, the contract is terminated. "The facility report to the Governing Body stated that in 2010, no contracted services was terminated due to poor performance.

The facility was unable to provide documents to assure that all non clinical contracts are subject to the same hospital-wide quality assessment and performance improvement evaluation as other services provided by the hospital. There was no evidence the hospital developed a coordinated system for monitoring of non- clinical contracts and agreements. 3 of 4 contracts reviewed (Citistorage, Quadramed and Siemens) lacked detailed monitoring and qualitative review of the contracts.

1. For example, Siemens Medical Solution USA, Inc. was contracted by the New York City Health and Hospital Corporation on 12/27/07 to provide a revenue cycle management system for its acute, ambulatory and long-term care facilities. To register and manage patients and services provided in its facilities, optimize patient and third party collections, and for billing and accounting purposes, and to continually maintain and update its revenue cycle management system. In a document submitted by the facility on 5/17/11, titled Quality Indicators, Siemens (Utility) and Siemens (Document imaging) were tracked monthly for System Down-time which was reported in minutes. The report showed 100% compliance with system availability; however, there was no indication that that the hospital changed indicators to assess potential new problem areas.

Under article 6.21 of the agreement with Siemens, the contractor agrees that all the reports, information, or data furnished or prepared, assembled or used by the contractor are to be held confidential. The facility did not ensure that Siemens operating protocol for the handling of CDs meets acceptable standards and maintain confidentiality of Personal Health Information.

At interview with the Deputy Executive Director Network Regulatory Affairs/QM and the Deputy Executive Director of Operations on 5/16 and 5/17 they reported that CDs containing Protected Health Information created by Siemens Medical Solutions USA, Inc, were missing in March 2010 while in the custody of Fedex. The CDs contained protected health information that includes names, addresses, medical record numbers; health plan information, date of birth, and social security number, dates of admission and discharge, diagnostic and procedural codes and descriptions.
Although the missing CDs were password protected they were not encrypted to ensure the content was unreadable.

2. Similarly, there were no indication of qualitative reviews of contracts with Citistorage and Quadramed. At interview with the Deputy Executive Director of Operations on 5/18/11, he stated that only significant issues are reported up to the Governing Body.
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16790

Based on tour of inpatient units, interviews with staff, patients/patients' representatives and the review of records, it was determined that the facility did not consistently ensure that the notice of rights requirement was met. This deficiency was noted in 10 of 15 applicable medical records reviewed (MR #s 1-7 and 11-13).

Findings include:

The facility demonstrated lack of compliance with Medicare requirements for provision of either the initial Medicare admission notice titles "An Important Message From Medicare About Your Rights" (IM) or delivery of the discharge appeals notice within regulatory time frames. The regulations mandate IM issuance within two days of admission and require delivery of a follow up IM discharge appeals notice no longer than two days prior to discharge or no less than four hours prior to discharge. Also, the facility did not provide patients with a copy of the IM as required.

MR #1
This 78 year old patient was admitted and arrived on the unit on 5/14/11 at 7:25 AM. A signed copy of the IM form acknowledging that the patient was aware of her rights as a Medicare patient was not in the patient's record. The Nursing Admission form, dated 5/14/11 at 1042, noted a question mark under the section "Advance Directive" and indicated "No advance Directive"; under "Action taken" it notes that "Additional information on advance directives provided on request." This documentation did not include if there was a discussion with the patient regarding Advance Directives and the outcome of the discussion.

During the tour of 9B, (medical services unit) on 5/16/11 at approximately 10:30 AM, the patient and her daughter were interviewed in the patient's room (RM 110A). The patient reported that she was given a patient rights package on admission. Upon review of the package given to the patient, it was noted that all the documents in the package, including a copy of "Your Rights as a Hospital Patient" , were written in Spanish. The patient reported that she did not speak, read or write in Spanish. It was noted that a copy of an Important Message from Medicare (IM) form was not in the package. The patient reported she was not given an IM form or signed such a form.

At interview with the Head Nurse on 5/16/11, she reported that the Patients' Rights package is given in the Emergency Room; however, the nurse in the unit is required to go over rights information with the patient on admission.

MR #2
This 91 year old patient was admitted on 5/13/11 at 8:34 with diagnosis of pneumonia. It was noted that a copy of the IM form was in the chart; however, the form was not signed.

The patient reported on interview conducted in her room (RM 105B) on 5/16/11 that she was just informed by the staff that she would be discharged today. There was a discussion with the patient regarding patient rights. The patient admitted she was given the patients' rights package; however, she did not recall being given the IM form or having a copy in her possession.

MR #3
This 79 year-old male was admitted from home on 4/22/11 and discharged to a Skilled Nursing Facility (SNF) on 5/16/11. At interview with the nursing staff at 1:30PM on 5/16/11, it was stated that the patient would be leaving at 5:00PM to the SNF. The review of the patient's record revealed he was confused and sometimes agitated. The record did not contain the initial Medicare admission (IM) notice and a follow up IM discharge appeals notice as required. There was no evidence the information contained in the IM was made available to an appropriate person on the patient's behalf if the patient was deemed not competent to receive the information.

Review of MR #s 11, 12 and 13 on 5/16/11 noted the lack IM provision within 48 hours of admission. The records contained blank IM forms for patients that were admitted on 5/9/11, 5/12/11 and 5/13/11 respectively.

MR #4
This 67 year-old patient was admitted on 4/10/11. It was noted that the patient's daughter signed an informed consent for treatment on 4/12/11. However, an IM form was not signed by the patient's daughter until 5/5/11. The regulatory requirement mandates the provision IM to Medicare beneficiaries within two days of admission.

During tour of 8C (medicine services unit) on 5/18/11, a list of possible discharge for was requested and three medical records of Medicare beneficiaries were reviewed.

In MR #5, the patient, a 68 year old male was admitted on 5/13/11. It was noted that the patient signed the acknowledgment Privacy of "NYCH Corporation " form dated 5/13/11. The patient also consented to a Diagnostic Test on a form dated 5/13/11. However, a copy of the IM form located in the chart was not signed. It was documented on the IM form that the patient was unable to sign. There was no documentation why the patient was unable to sign at the time of presentation. There was no evidence that nursing staff followed up with the patient who was still in the unit on 5/18/11.

MR #6 is a 67 year old who was admitted on 5/17/11 for evaluation of chest pain rule out ACS. It was noted that the original IM form dated 5/17/11 was signed by the patient. There was no evidence that the patient was given a copy of this form, as required.

MR #7 is a 91 year old patient who was admitted on 5/17/11. It was noted that an IM form was signed by the patient's daughter but not dated. There was no evidence that a copy of the IM was provided to the patient.

Review of MR #s 11, 12 and 13 on 5/16/11 noted IM notices were not provided within 48 hours of admission. The records contained blank IM forms for patients that were admitted on 5/9/11, 5/12/11 and 5/13/11 respectively.
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Based on record review, it was determined that the facility did not afford patients or their representative the right to make informed consent regarding their care. This finding was noted in 1 of 25 records reviewed.

Findings include:
Review of MR#4 noted a consent form for anesthesia signed by the anesthesiologist, dated 5/2/11 and witnessed by a staff member. It was documented on this form that the risks and benefits were explained to the patient/representative; however, the name of the patient/ patient's representative was not noted in the form.
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Based on tour of the unit, interviews with staff, patients and family members and the review of patients' complaint files, it was determine that the facility did not consistently ensure that patients ' care needs were met in a timely manner. In addition, staff did not ensure a clean and sanitary environment for all patients. This finding was noted in 4 of 12 applicable records.

3 of the Findings include:

MR #8
During the tour of 9B on 5/16/11 at approximately 10:55 AM, the patient's daughter upon interview was irate; she reported that the staff had not changed her father's diaper since last night. This family member also stated that she spoke to the nursing staff at around 10:00 AM and no one came to assist with his care. While in the room, the RN assigned to the patient ' s care walked into the room. This staff stated "they haven't changed him as yet " . The surveyor remained in this room for approximately 10 minutes and the nursing staff still did not change the patient's diaper. The complaint was brought to the attention of the head nurse who later informed the surveyor that based on the patient's record he was changed last night.

MR #9
During observation tour on 5/16/11, the patient in 108 B reported that housekeeping staff picks up dirt on the floor routinely but the room has not been mopped since he arrived on the unit on 5/12/11. The surveyor observed that the bathroom was dirty and needed mopping.

MR#10
The review of this patient's complaint file (#10-017) on 5/17/11, noted a family member filed a complaint regarding unsanitary condition in the patient ' s room; the room had feces and vomit. The hospital investigation found that nursing staff failed to timely notify housekeeping of the unsanitary condition in the patient's room.
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