HospitalInspections.org

Based on contract review, quality data review and staff interviews; the hospital governing body failed to ensure services provided by a contractual agency was provided in a safe and effective manner.
The findings include:
Review of the contract conducted October 28, 2015 revealed on March 4, 2015, the hospital entered into an agreement/contract with {Company A}. Review revealed services provided by {Company A} included housekeeping.
Review of quality data from quarter one to quarter four of 2014, {Company A} was evaluated in the areas of cleanliness and food services.
Review of the terminal cleaning report forms revealed 5 of 5 operating rooms and 1 of 1 cystoscopy room were terminally cleaned from September 1, 2015 to September 30, 2015 (22 days). Review of the terminal cleaning report forms revealed 5 of 5 operating rooms and 1 of 1 cystoscopy room were terminally cleaned from October 1, 2015 to October 27, 2015 (19 days).
Interview conducted October 29, 0215 at 1000 with the Director of Surgical Services and the Charge Nurse of Surgical Services revealed the operating rooms and the cystoscopy room were terminally cleaned by {Company A}. Interview revealed previously data was collected and submitted to performance improvement for analysis of the service provided in the surgical service area. Further interview revealed currently, the terminal cleaning report forms were reviewed daily by surgical services leadership. Further interview revealed the daily review of the data was not submitted to the hospital performance improvement committee for overall analysis of the services provided by {Company A}. Interview revealed the hospital performance improvement committee failed to analyze data collected to monitor the effectiveness of services provided by a contracted agency.
Interview conducted October 29, 2015 at 1545 with Hospital Leadership team revealed the quality data evaluated {Company A} in the areas of "nutrition, EOC (Environment of Care), patient satisfaction and hazard waste." Further interview revealed the data did not include an analysis of the terminal cleaning of the operating and cystoscopy rooms. Interview revealed the hospital governing body failed to ensure a contracted agency provided services in a safe and effective manner.

NC00111361