HospitalInspections.org

Based on records reviewed and interviews, the Condition Participation for Governing Body Condition was not met as evidenced by the failure to ensure the quality of patient care determination by Emergency Department (ED) Physicians were based on complete and accurate medical record information provided by a crisis agency completing emergency crisis evaluations for 4 of 6 sampled patient records (Patient Record #2A, 3A, 3B, and 3D). In addition, evidence that indicated the Governing Body failed to ensure a system was in place to verify services from crisis agencies were furnished by qualified individuals for two crisis agencies (Crisis Agency #1 and #2), that these agencies' performances were discussed and reported to the Quality Assurance and Performance Improvement Committee (QAPI), and the Governing Body approved the overall 2018 QAPI program.

Findings:

1. Standard: §482.12(a)(5) Medical Staff Accountability also known as A0049 - The Governing Body failed to ensure the quality of patient care determination by Emergency Department (ED) Physicians, were based on complete and accurate medical record information provided by a crisis agency completing emergency crisis evaluations for 4 of 6 sampled patient records whose records indicated crisis evaluations were conducted (Patient Record #2A, 3A, 3B, and 3D). See A0049 for details.

2. Standard: §482.12(e) Contracted Services also known as A0083 - The Governing Body failed to ensure a system was in place to verify services from crisis agencies were furnished by qualified individuals for two crisis agencies (Crisis Agency #1 and #2) and that these agencies' performances were discussed and reported to the Quality Assurance and Performance Improvement Committee (QAPI). See A0083 for details.

3. The Governing Body has an overall responsibility for the services furnished at the hospital which includes the review and approval of the hospital's Performance and Patient Safety Improvement Plans (QAPI program).

Documentation provided to the surveyors indicated that the Board of Directors approved the 2017 St. Mary's Regional Medical Center Performance and Patient Safety Improvement Plan at a meeting on 3/29/17.

On 5/22/18 at 10:25 AM, the Risk Manager provided documentation that hospital's 2018 Performance Improvement and Patient Safety Plan was scheduled to be reviewed in June 2018 by the System Quality Committed and was scheduled to be brought to the full board for approval in September 2018.

Based on the fact that the 2018 Performance Improvement and Patient Safety Plan was not scheduled for full board review until September 2018, eight months after the plan would be in effect, the Governing Body has failed to provide oversight of the QAPI programs within the hospital.


The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.

Based on record reviews and interview, it was determined that the Governing Body failed to ensure the quality of patient care determination by Emergency Department (ED) Physicians were based on complete and accurate medical record information provided by a crisis agency completing emergency crisis evaluations for 4 of 6 sampled patient records that indicated a Crisis Agency evaluated the patient in the ED. (Patient Record #2A, 3A, 3B, and 3D).

Findings:

During record reviews, it was noted that four records (Patient Record #2A, 3A, 3B, and 3D) indicated the patient had been evaluated by Crisis Agency #1. However, the records failed to contain documentation of the referenced evaluation of the patient performed by Crisis Agency #1.

On 5/16/18 between 1:48 PM and 2:09 PM and on 5/17/18 at 12:07 PM and 1:30 PM, interviews were conducted with the Vice President of Emergency Services/Physician A, the Director of Emergency Service, and the Risk Manager. The following information was obtained during these interviews: the crisis agencies provide further evaluation of the patients which may involve extensive interviews with the patients and community members if needed; the agencies would make recommendations of what they think should happen with the patient; and treatment decisions were made in conjunction with the crisis agencies.

On 5/18/18 at 9:35 AM, the surveyors interviewed the Vice President of Emergency Services/Physician A and the Director of Emergency Services regarding Patient Record #2A. The Director of Emergency Services looked in their electronic medical record and confirmed that the crisis agency report had not been scanned and attached to Patient Record #2A.

On 5/21/18 at 11:26 AM, surveyors discussed with the Director of Emergency Services that the evaluation by Crisis Agency #1 was not in Patient Records #3A, #3B, and #3D.

On 5/21/18 at 11:19 AM, the Risk Manager verified that they did not have any crisis agency reports and she had reports faxed to her today.

On 5/21/18 at 12:15 PM, the Vice President of Emergency Services/Physician A indicated that the crisis workers discuss with the ED staff and a consultation report should go into the medical record.

Based on record reviews and interviews, the Governing Body failed to ensure a system was in place to verify services from crisis agencies were furnished by qualified individuals for two crisis agencies (Crisis Agency #1 and #2) and that these agencies performances were discussed and reported to the Quality Assurance and Performance Improvement Committee (QAPI).

Findings:

The governing body's responsibilities in relation to the furnishing of services would include ensuring any individuals furnishing services through an agency are qualified and credentialed to provide a safe and effective care.

The hospital has utilized Agency #1 through 3/31/18 and Agency #2 since 4/1/18, to furnish mental health crisis services to patients that present to the Emergency Department (ED).

During an interview on 5/17/18 at 12:07 PM, conducted with the Vice President of Emergency Services, Director of Emergency Service and Risk Manager, it was stated that the purpose of Agency #1 and Agency #2 was for bed management, resources in the community, and evaluation. These evaluations may involve extensive interviews in the hospital and out in the community. The crisis workers would discuss with the medical providers their evaluations, would offer what they think may be appropriate for the patient, and would discuss plans for the patient.

The involvement of the agencies with the patients in the ED indicates an integration of services furnished between the hospital and the two separate agencies.

On 5/21/18 at 2:37 PM, the Risk Manager indicated to the surveyor that the hospital did not have a contract with the agencies that have been and continue to furnish crisis services to patients in their ED, but they did have a Memorandum of Understanding (MOU) with each agency. She also indicated that the hospital had not credentialed the individuals from Agency #1 and #2.

A review of the MOU with Agency #1, dated February 20, 2015, and the MOU with Agency #2, dated April 2, 2018, did not include any language related to ensuring qualified and credentialed individuals would be provided by the agencies.

On May 21, 2018 at 2:48 PM, the Director of the Emergency Department was asked how it was determined that staff from Agency #1 were qualified and he stated he "does not know the qualifications of crisis workers". He also indicated that there was no discussions or reporting to the QAPI Committee regarding these agencies.

Record reviews determined that services were provided at the hospital or services were recommended upon discharge from Crisis Agency #1 or #2, for 13 ED patient records reviewed (Patient Record #1B, #1C, #1D, #2A, #2C, #3A, #3B, #3D, #4A, #4B, #8, #9, and #11).