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Based on review of the minutes of the Quality Assurance Committee, policy and procedure review, Quality Assurance Program review, and staff interview, the facility:
1. failed to have a Quality Assessment and Performance Improvement (QAPI) program that includes, but is not limited to, an ongoing program that shows measureable improvement in indicators for which there is evidence that it will improve health outcomes or measure, analyze, and track quality indicators and other aspects of performance that asses processes of care hospital services and operations, and
2. failed to incorporate quality indicator data including patient care data, and other relevant data, submitted to, or received from, the hospital's Quality Improvement Organization.

Findings Include:

Cross Refer to A263 / 482.21 for the facility's failure to have a QAPI program that includes an ongoing program that shows measureable improvement in indicators for which there is evidence that it will improve health outcomes or measure, analyze, and track quality indicators and other aspects of performance that asses processes of care hospital services and operations, and failure to incorporate quality indicator data including patient care data, and other relevant data, submitted to, or received from, the hospital's Quality Improvement Organization.

Based on review of the minutes of the Quality Assurance Committee, Quality Assurance Program review, policy and procedure review, and staff interview, the facility failed to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas.

Findings include:

Cross Refer to A263 / 482.21 for the facility's failure to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas.

Based on review of the minutes of the Quality Assurance Committee, Quality Assurance Program review, policy and procedure review, and staff interview, the facility failed to have performance improvement activities that track medical errors and adverse patients events analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital


Findings include:


Cross Refer to A263 / 482.21 for the facility's failure to have performance improvement activities that track medical errors and adverse patients events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Based on review of the minutes of the Quality Assurance Committee, Quality Assurance Program review, policy and procedure review, and staff interview, the facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable process achieved on these projects.


Findings include:


Cross Refer to A263 / 482.21 for the facility's failure to document what quality improvements projects are being conducted, the reason for conducting these projects and the measureable progress achieved on these projects.

Based on document review, Quality Assurance Program review, and staff interview, the facility failed to ensure the reassessment of their discharge planning on an on-going basis.


Findings Include:


Review of the facility's Quality Assurance program revealed no documented evidence of their discharge planning being reviewed on an ongoing basis.


During an interview on 3/17/16 at 5:30 p.m. the Director of Nurses confirmed there was no documented evidence of discharge planning in the Quality Assurance and Performance Improvement (QAPI) program.