HospitalInspections.org
Bringing transparency to federal inspections
FIRST HOSPITAL OF WYOMING VALLEY
QAPI GOVERNING BODY, STANDARD TAG
Tag No.: A0308
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure quality improvement was completed on all contracted services provided to the facility.
Findings include:
Review on May 14, 2018, of the facility's "First Hospital Organization-wide Quality Assessment and Performance Improvement Program 2018," revealed " ...First Hospital s [sic] dedicated to meeting the needs of our patients in a manner which is consistent with our mission, vision and belief statements. The Organizational Quality Assessment and Performance Improvement plan is designed to provide a systematic and organized program for the promotion of safe, quality patient care and services. ...The Governing Board shall be responsible to ensure the provision of optimal quality care, safety, and organization-wide performance. ... The Board shall facilitate Quality Improvement by: ... 9) Require a process designed to assure that all individuals responsible for the treatment and/or care of patients, whether provided through internal mechanisms or contracted services, are competent. ...Senior leadership supports the maintenance of the QAPI process through allocation of staff and resources necessary to fulfill the requirements of the program. Leaders also: ... Perform evaluations of clinically contracted services in collaboration with the respective department director and reporting the results of the evaluation to the Quality Improvement Council, Medical Executive Committee and the Board. ... "
Review on May 14, 2018, of the contractor list provided by EMP1 revealed a list of six contractors. The services included: environmental, dietary, pharmacy, release of information, transcription and security. There was no documentation the facility completed quality on the environmental, dietary, pharmacy and security contracted services.
Interview on May 14, 2018, with EMP1 at approximately 1:30 PM confirmed the facility did not complete quality on the environmental, dietary, pharmacy and security contracted services.