HospitalInspections.org

Based on observation, record review and interview, the Governing Body failed to maintain the hospital ensuring the physician and nurses followed their own policies and procedures regarding; implementing an effective Quality Assurance program; and implementing a utilization review committee. These findings resulted in the Conditions for Participation for Quality Assurance (A0263); and Utilization Review (A0652) to not be met.

Findings:

1. Cross Reference A0057: Based on observations, interview and record review, the Governing Body failed to appoint a Chief Executive Officer (CEO) who effectively manages the hospital.

2. Cross Reference A0263: Based on facility documentation and interview, the facility failed to ensure the Governing Body was proactive in implementing and maintaining an effective and ongoing hospital-wide, data driven Quality Assurance and Performance Improvement (QAPI) program that involved all departments and services for 2017 and 2018.

3. Cross Reference A0652: Based on interview and facility documentation, it was confirmed the facility failed to ensure a Utilization Review (UR) plan that provides for review of services furnished by the facility and the members of the medical staff and patients was conducted for the years 2017 and 2018. Due to this failure the Condition for Participation for Utilization Review has not been met.

Base on facility documentation and interview, the facility failed to ensure the Governing Body implemented and maintained an effective and ongoing hospital-wide, data driven Quality Assurance and Performance Improvement(QAPI) program that involved all departments and services for 2017 and 2018. This failure resulted in the Condition of Participation for QAPI not to be met.

Findings:

Cross to A0283 Quality Assurance.
A review of the Quality Assurance Plan and subsequent program revealed no evidence of quality indicators or measures for improvement identified. The data lacked a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no documentation of an annual Quality Assurance/Improvement Plan for 2017 and 2018.

Cross to A0654.
A review of the data from Peer Review (Utilization Review), Pharmacy; Laboratory and Radiology revealed minimal information being gathered in these departments, however the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments to include Nutritional Services, Maintenance/Engineering and Medical Records was not available.

Review of the Quality Assurance Minutes for 2017 and 2018, revealed reports of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QAPI) program.

A review of Governing Body agendas and minutes for years 2017 and 2018 failed to identify acknowledgement of the Quality Assurance Program and reflects the lack of follow-through with the requirements specific to Quality Assurance and Performance Improvement activities within the facility.

Based on interview and facility documentation, it was confirmed the facility failed to ensure a Utilization Review (UR) plan that provides for review of services furnished by the facility and the members of the medical staff and patients was conducted for the years 2017 and 2018. Due to this failure the Condition for Participation for Utilization Review has not been met.

Findings:

Cross to A654: An interview with the facility Administrator and Risk Manager on 8/08/2018 at approximately 12:30 PM, during a review of the Administrative functions of the facility, it was confirmed there is no Utilization Review plan which is actively in place and functioning at this time.

A follow-up interview with the Risk Manager on 8/08/2018 at 1:30 PM reconfirmed through review of the Utilization Review notebook, the plan which was executed for the year 2016, was discontinued for the years 2017 and 2018 and had not been implemented and was not current.

Based on interview and facility documentation, it was confirmed the Chief Executive Officer appointed by the Governing Body and responsible for the facility, failed to ensure pertinent hospital programs were implemented and managed effectively to include Quality Assurance, Utilization Review, Nutritional Services, and Nursing Services.

Findings:

An interview with the facility Administrator and Risk Manager on 8/08/2018 at approximately 12:30 PM during a review of the Administrative functions of the facility, confirmed there is no Utilization Review (UR) plan which is actively in place and functioning at this time. A follow-up interview with the Risk Manager on 8/08/2018 at 1:30 PM it was reconfirmed through review of the UR notebook, the plan which was executed for the year 2016, was discontinued for the years 2017 and 2018, they had not been implemented and were not current.

A review of the Quality Assurance Plan and subsequent program revealed no evidence of quality indicators or measures for improvement identified. The data lacked a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no documentation of an annual Quality Assurance/Improvement Plan (QI) for 2017 and 2018.

Review of the data from Pharmacy; Laboratory and Radiology revealed minimal information being gathered in these departments, however the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments to include Nutritional Services, Maintenance/Engineering and Medical Records was not available.

Review of the Quality Assurance Minutes for 2017 and 2018, revealed report of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QAPI) program.

An interview with the Director of Risk Management on 8/08/2018 at approximately 10:50 AM revealed she was not aware of any current QI activity in which all departments were actively involved. When asked, she confirmed there was no data being actively collected for Quality purposes in the Nutritional Services Department.

An interview with the Consultant Dietitian on 8/07/2018 at approximately 2:00 PM confirmed she was not actively involved in any committees within the hospital and no data collection could be provided specific to Quality Assurance programs or activities for the department.

Based on documentation and interview, it was confirmed the facility Administration failed to ensure a Quality Assurance Performance Improvement program was initiated which identified and focused on priorities based on all departments' data collection which affect patient safety, quality of life and care though tracking and trending through collected data.

Findings:

A review of the Quality Assurance Plan and subsequent program revealed no evidence of quality indicators or measures for improvement identified. The data lacked a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no documentation of an annual Quality Assurance/Improvement Plan for 2017 and 2018.

Review of the data from Peer Review, Pharmacy; Laboratory and Radiology revealed minimal information being gathered in these departments, however the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments to include Nutritional Services, Maintenance/Engineering and Medical Records was not available.

Review of the Quality Assurance Minutes for 2017 and 2018, revealed reports of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QAPI) program.

A review of Governing Body agendas and minutes for years 2017 and 2018 failed to identify their acknowledgement of the Quality Assurance Program and reflects the lack of follow-through with the requirements specific to Quality Assurance and Performance Improvement activities within the facility.

An interview with the Director of Risk Management on 8/08/2018 at approximately 10:50 AM confirmed she was not aware of any current QAPI activity in which all departments within the hospital were actively involved. When asked, she confirmed there was no data being actively collected for Quality purposes in the Nutritional Services Department.

An interview with the Consultant Dietitian on 8/07/2018 at approximately 2:00 PM confirmed she was not actively involved in any committees within the hospital and no data collection could be provided specific to Quality Assurance programs or activities for the department.

Based on interview, policy and procedure review, and medical record review the facility failed to ensure care plans were completed on admission for 1 of 17 sampled patients, Patient #12.

Findings:

Patient #12 was admitted on 08/06/18 for alcohol withdrawal. During a review of the medical record with Staff B, RN (Registered Nurse), a request was made to review the care plan for Patient #12, review of the medical chart showed there was no care plan documented.

During an interview on 08/08/18 at 10:35 AM, with Staff B, RN it was stated that even with a patient with alcohol withdrawal diagnosis, there should be an initial care plan. The admitting RN should have documented the initial care plan. Care plans should be started on admission and updated every shift

During an interview on 08/08/18 at 12:30 PM, with Staff A, RN it was stated the expectation is that all RN staff will do a care plan on initial admission and update each shift. Staff A, RN confirmed there was no care plan completed or updated for Patient #12.

Review of the facility's policy titled "Documentation- Care Plan" revised 10/19/17 showed the plan of care provides a mechanism to document review/update the plan of care and to provide ongoing documentation for patient problems. The care plan section completed once every shift, indicating time, updated/reviewed discipline and initials. The documentation is to be done each shift in the computer.

Review of the facility's policy titled "Documentation-Nursing" revised 10/19/17 showed that the initial plan of care for the patient would be charted on the Interdisciplinary Plan of Care (IDR) form. The plan of care must include a list of patient's problems. The patient should have an assessment done on every shift.

Based on interview and facility documentation, it was confirmed the facility failed to ensure a Utilization Review (UR) Committee of at least two (2) practitioners had reviewed the services furnished by the facility and the members of the medical staff and patients was conducted for the years 2017 and 2018.

Findings:

An interview with the facility Administrator and Risk Manager on 8/08/2018 at approximately 12:30 PM during a review of the Administrative functions of the facility, confirmed there is no Utilization Review committee or process in place by which to actively review patient's medical records. It was confirmed through previous documentation, the facility has three (3) physicians on staff. It confirmed there is no committee which is actively in place and functioning at this time.

A follow-up interview with the Risk Manager on 8/08/2018 at 1:30 PM reconfirmed through review of the UR notebook, the committee and activity which was executed for the year 2016, was discontinued for the years 2017 and 2018, and which had not been implemented and was not currently active in the hospital. She confirmed there is no mechanism utilized by the medical staff for the reviewing of the medical records of other physicians. There was no indication of the Governing Body identifying the lack of Peer Review or Utilization review.