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Based on document review and interview the facility failed to ensure all services, including those furnished by a contractor were included in the Quality Assessment and Performance Improvement (QAPI) program; and failed to measure, analyze, and track quality indicators for facility services including Laundry, and contracted services including Anesthesia, Biohazard Waste, Maintenance, and Radiology in the facility's QAPI program.

The cumulative effects of this systemic problem resulted in the facility's inability to ensure that it had an effective Quality Assurance program.

Based on document review and interview the Governing Board failed to ensure all services, including those furnished by a contractor were included in the Quality Assessment and Performance Improvement (QAPI) program.

Findings Include:

1. Facility document titled Quality/Patient Safety Committee Charter indicated under I. Purpose and Responsibilities, Hospital Quality/patient Safety Committee supports the Hospital Board of Directors in its commitment to assure that individuals receiving services from Hospital are provided safe, effective, and quality services. III. Authority and Responsibilities, A. The Committee will monitor the Hospital's quality improvement and performance improvement program, metrics and goals to determine congruence with the mission, vision and values of the Hospital.

2. Facility document titled Performance Improvement and Patient Safety Plan 2024, indicated facility leaders with authority and oversight by the Quality and Patient Safety Committee of the Board of Directors, establish the Quality and Safety standards, programs and monitoring process; Under Data Management Frequency, Additional annual reports will include a standardized quality review/report of clinical contracts to be submitted to the Quality and Patient Safety Committee of the Board of Directors, and the Board of Directors.

3. Review of Governing Board Meeting minutes from 9/2023 through 9/2024 lacked evidence of quality data collected for contracted services including, but not limited to Anesthesia, Maintenance, Radiology and Biohazard Waste; lacked evidence of quality data collected for facility services including Laundry.

4. In interview on 2/25/25 at approximately 1415 hours with A5 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Governing Board Meetings: Anesthesia, Biohazard Waste, Maintenance, and Radiology. A5 also confirmed the facility is not evaluating the following facility services in the Quality and Safety Meetings: Laundry.

Based on document review and interview, the facility failed to measure, analyze, and track quality indicators for 1 of 1 facility services (Laundry), and 4 of 4 contracted services (Anesthesia Service, Biohazard Waste, Maintenance and Radiology) in the facility's Quality Assessment and Performance Improvement (QAPI) program.

Findings include:

1. Facility document titled Quality/Patient Safety Committee Charter last approved 6/19 indicated under I. Purpose and Responsibilities, Hospital Quality/patient Safety Committee supports the Hospital Board of Directors in its commitment to assure that individuals receiving services from Hospital are provided safe, effective, and quality services. III. Authority and Responsibilities, A. The Committee will monitor the Hospital's quality improvement and performance improvement program, metrics and goals to determine congruence with the mission, vision and values of the Hospital.

2. Review of Quality and Patient Safety Committee meeting minutes from 12/2023 through 12/2024 lacked evidence of quality data collected for contracted services including, but not limited to Anesthesia, Biohazard Waste, Maintenance and Radiology and lacked evidence of quality data collected for facility services including, but not limited to, Laundry.

3. In interview on 2/25/25 at approximately 1415 hours with A5 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings: Anesthesia, Biohazard Waste Maintenance and Radiology. A5 also confirmed the facility is not evaluating the following facility services in the Quality and Safety Meetings: Laundry.