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Based on interviews with hospital staff and the review of policies and procedures, and other hospital documentation, it was determined that the hospital failed to ensure that the governing body was responsible for all services furnished in the hospital whether or not they were furnished directly or under contract. The governing body failed to ensure an assessment of the quality and appropriateness of all aspects of clinical contracted services.

Findings include:

1. The following policy and procedure was reviewed: Tuality Healthcare Corporate Operational Policy 0-40 "PERFORMANCE IMPROVEMENT (PI) PLAN," dated 06/2011. This policy states that contracted services are a part of the quality management program. The policy reflects on page 3, PROCEDURE III. QUALITY MEASURES "Data is collected and analyzed on the following measures ...H. Services related to patient care, furnished by a contractor."

The "PERFORMANCE IMPROVEMENT (PI) PLAN" policy lacked provisions for a plan to assess the quality and appropriateness of clinical contracted services provided to patients under contract with an outside company.

2. A document titled "Clinical Contracted Services" was received on 10/12/2011 at 1113 hours listing 70 contracted services, which included for example: acute dialysis, anesthesia, EEG, and EKG interpretation services. There was no evidence of QAPI documentation which corresponded with these services.

3. The Director of Standards & Performance Improvement was interviewed at 1245 hours on 10/12/2011. He/she indicated that there was no written plan for a quality assessment of any clinical contracted services and that the hospital had not been monitoring and assessing these services as part of the QAPI program.

Failure to develop quality indicators and collect data related to contracted services resulted in a failure to monitor the effectiveness and safety of services and quality of care.

Based on interviews with hospital staff, review of policies and procedures and other hospital documentation, it was determined the governing body failed to ensure that the ongoing program for quality improvement was defined to include an assessment of all hospital services, including those services provided under contract, and failed to ensure that the ongoing program for quality improvement was implemented according to policy direction. Refer to the findings at tag A 083, CFR 482.12(e), Contracted Services.