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Based on staff interview, medical record review, and review of hospital documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program was comprehensive and effective in identifying and resolving problems in the hospital. The hospital failed to ensure the QAPI program scope was comprehensive (refer to A 264); failed to ensure adequate monitoring of professional services and drug utilization review in order to show measurable improvement, implement change, and to identify opportunities to reduce medical error (refer to A 265, A 266, A 267, A 273, A 274, A 275 and A 276); failed to ensure all program activities were met (refer to A 283); and failed to ensure that improvements were sustained (refer to A 291). The UR Condition of Participation was also cited during the previous recertification survey in October 2008. The cumulative effect of these systematic problems resulted in a determination that the Condition of Participation for QAPI was not met.

Based on staff interview and review of the most current (September 2011) utilization review (UR) documents, the hospital failed to ensure there was an effective UR program. Interview on 5/15/12 at 3:30 PM with the medical director and medical records director who provided joint oversight for the UR program revealed the hospital did not have a contract with the QIO (Quality Improvement Organizations) for UR. The hospital failed to ensure professional services including drugs and biological were reviewed (refer to A 655 and A 658). The cumulative effect of this failure resulted in a determination that the Condition of Participation for Utilization Review was not met. This Condition of Participation was also cited during the last recertification survey in October 2008.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program included collection of data on professional services, including review of drugs and biologicals. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services or drug utilization was collected and analyzed. For example, there was no evidence emergency services, radiology services, physician services, and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for appropriateness. Interview with the medical director and the medical records director who oversee and coordinate the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services had been performed for at least two years.

Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program showed all program activities were met. The findings were:

Review of the hospital quality assurance program plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services was collected and analyzed. For example, there was no evidence emergency services, radiology services, physician services, and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for quality and appropriateness. Also there was no evidence drug utilization review was performed. Interview with the medical director and the medical records director who oversee and coordinate the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services or drug utilization had been performed for at least two years.

Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on observation, medical record review, and staff interview, the hospital failed to ensure all necessary assessments, monitoring, and nursing measures were implemented for pain management for 1 of 2 sample patients (#10) who experienced pain. The findings were:

Review of the medical record showed patient #10 had diagnoses including headaches, right hand injury, and major depression with psychotic features. Review of the physician's orders showed Ibuprofen 600 milligrams (mg) three times daily as needed for pain in addition to Tylenol 500 mg four times daily as needed for pain. Review of the nursing notes and pain management documentation revealed the following concerns with pain management:
a. On 1/13/12 at 5:40 PM the patient complained of left shoulder pain and right hand pain rated 6 on a pain scale of 0 to 10 with 10 being the worst (6/10). The patient was administered Tylenol 500 mg at this time. There was no evidence the patient's pain was re-assessed to determine the effectiveness of the medication in relieving the pain. The next assessment was at 11 AM (approximately18 hours later). At that time, 11 AM, the patient rated his/her pain at 8/10.
b. On 1/25/12 at 3 AM the patient complaint of pain in the right hand of 6/10 and received Tylenol 500 mg. There was no evidence the patient's pain was re-assessed to determine the effectiveness of the medication in relieving the pain. The next assessment was at 6:45 PM (approximately16 hours later). At that time, 6:45 PM, the patient was resting.
c. On 4/8/12 at 2:58 PM the patient complained of bilateral hip pain rated 7/10 in the and was administered Tylenol 500 mg. There was no evidence the patient's pain was re-assessed to determine the effectiveness of the medication in relieving the pain.
d. On 5/7/12 at 6:05 PM the patient complained of a headache rated 3/10 and received Tylenol 600 mg. There was no evidence the patient's pain was re-assessed to determine the effectiveness of the medication in relieving the pain.

Interview with the unit manager on 5/17/12 at 9 AM revealed the hospital had made some strides in pain management but that pain management continued to be a problem.

Based on staff interview and review of hospital utilization review documents, the hospital failed to ensure professional services including drugs and biologicals were reviewed. The findings were:

Review of utilization review documents showed no evidence professional services were reviewed for medical necessity. For example, there was no evidence drugs or biologicals, emergency services, radiology services, physician services, and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for appropriateness. Interview with the medical director and the medical records director who oversee and coordinate the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services had been performed for at least two years.

Based on staff interview and review of hospital utilization review documents, the hospital failed to ensure professional services including drugs and biologicals were reviewed. The findings were:

Review of utilization review documents showed no evidence professional services were reviewed for medical necessity or appropriateness. For example, there was no evidence drugs or biologicals, emergency services, radiology services, physician services, outside health facilities and services were assessed and reviewed for scheduling, overutilization or underutilization. Interview with the medical director and the medical records director who oversee the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services had been performed for at least two years.

Based on staff interview, and policy and procedure review the facility failed to ensure designated requestors were chosen for donor requests. The findings were:

During an interview with the chief financial officer and assistant director of nursing on 5/16/12 at 3:30 PM, they stated the facility did not have staff designated as designated requestors for organ and tissue procurement. They stated that any nurse could make that request. Review of the facility policy and procedure titled, "Death of a Patient Section 1.H.-Health and Safety" showed the following: "L. The nurse is to notify the following: 10. Intermountain Donor Services at 1-800-833-6667 regarding organ/tissue donation."

Based on staff education documentation and staff interview, the facility failed to ensure that staff were educated regarding how to work with the organ and tissue donor organizations. The findings were:

Review of staff education documentation revealed there was no education of staff concerning organ and tissue donation. An interview with the chief financial officer and assistant director of nursing on 5/16/12 at 3:30 PM confirmed staff was not educated concerning organ and tissue donation.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program scope was comprehensive. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence professional services or utilization of drugs or biologicals were reviewed for opportunities to improve processes and outcomes. Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program. For example, there was no evidence utilization of emergency services, radiology services, physician services, and outside healthcare facility services were reviewed for quality and appropriateness.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program showed measurable improvement in professional services, including drugs and biologicals. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence professional services or utilization of drugs and biologicals were reviewed. As a result the hospital was unable to show measurable improvement in professional services and outcomes. Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services or drug utilization review was currently being performed as part of the QAPI program.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program showed review and analysis of professional services, including drugs and biologicals in order to identify and reduce medical errors. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services or utilization of drugs and biologicals was collected and analyzed to identify and reduce medical errors. For example, there was no evidence emergency services, radiology services, physician services, and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for quality and appropriateness. Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program showed review and analysis of professional services, including review of drugs and biologicals. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services or utilization of drugs or biologicals was collected for analysis. Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on staff interview, medical record review, and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program incorporated data regarding professional services in their review and analysis. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services was collected and analyzed to identify opportunities for improvement in patient care. For example, there was no evidence drugs or biologicals, emergency services, radiology services, physician services, and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for quality and appropriateness. Interview with the medical director and the medical records director who oversee and coordinate the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services had been performed for at least two years.

Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program monitored the effectiveness of quality of care in regard to professional services and drug utilization. The findings were:

Review of the hospital quality assurance program plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services was collected and monitored to determine the effectiveness and quality of care provided. For example, there was no evidence drugs or biologicals, emergency services, radiology services, physician services, and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for appropriateness. Interview with the medical director and the medical records director who oversee and coordinate the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services had been performed for at least two years.

Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on staff interview and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program identified opportunities for improvement and changes in regard to professional services and drug utilization review. The findings were:

Review of the hospital QAPI plan, dated September 2011, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director on 5/15/12 at 3:30 PM revealed no evidence data on professional services was collected and analyzed to identify opportunities for improvement. For example, there was no evidence drugs or biologicals, emergency services, radiology services, physician services and outside health facilities and services were assessed and reviewed for overutilization, underutilization, or for appropriateness. Interview with the medical director and the medical records director who oversee and coordinate the utilization review program on 5/15/12 at 3:30 PM revealed no review of professional services had been performed for at least two years.

Interview with the director of QAPI on 5/16/12 at 10 AM verified no review of professional services was currently being performed as part of the QAPI program.

Based on staff interview, medical record review, and review of facility documents, the hospital failed to ensure the quality assurance performance improvement (QAPI) program sustained improvements. The findings were:

1. Review of the previous recertification survey findings dated 10/9/08 revealed the hospital was cited for not having an effective utilization review (UR) program. Review of the October 2008 plan of correction revealed the UR program would be monitored for compliance with the regulations. Review of the hospital quality assurance performance improvement program plan, dated August 2008, revealed one of the goals included "To utilize results from ....., Utilization Review, and ...... to improve processes and outcomes." However, interview with the medical director and medical records director who provide coordination of the UR program on 5/15/12 at 3:30 PM revealed no review of professional services, including review of drugs and biologicals, had been performed for at least two years. Interview with QAPI director on 5/16/12 at 10 AM verified no review of professional services or drug utilization review was currently a part of the QAPI program.

2. Review of the previous recertification survey findings dated 10/9/08 revealed the hospital was cited for not having an effective organ, tissue, and eye procurement program. During the May 17, 2012 recertification the hospital failed to ensure designated requestors were chosen for donor requests (A889). Also cited was the hospital's failure to provide education to the designated requestors on how to work with the organ and tissue donor organizations (A891).

3. Review of the previous recertification survey findings dated 10/9/08 revealed the hospital was cited for nursing services. During the 5/17/12 recertification, nursing services was again cited (A395) in regard to inadequate pain management for patient #10 who had significant pain, who received pain medications for the pain, but who was at times not re-assessed to determine the effectiveness of the medication in relieving the pain.