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Based on record review and interview, the Governing Body failed to ensure the hospital conducted its responsibilities for contracted services in a safe manner. Contracted services refers to a service that is provided to the facility in exchange for compensation.

The Governing Body failed to ensure contracted services were performed as required for preventative maintenance on hospital patient care related electrical equipment. Refer to standard at A0083.

The Governing Body failed to ensure contracted services for patient care related electrical equipment were performed in a safe and effective manner. Refer to standard at A0084.

Based on record review and interview the hospital failed to implement an effective hospital-wide Quality Assessment and Performance Improvement (QAPI) program for contracted services for preventative maintenance on patient care related electrical equipment.

The hospital's QAPI program failed to accurately reflect services provided under contract or arrangement. The hospital's QAPI program was reporting inaccurate data to the Governing Body for patient care related electrical equipment management. Refer to standard at A-0308.

Based on record review and interview, the facility failed to maintain the physical plant to ensure patient's safety.

The hospital failed to maintain an effective preventative maintenance program for patient care related electrical equipment (PCREE) and failed to provide a generator capable of supporting safe internal environmental temperatures in the event of a power failure. These failures can result in unsafe electrical equipment and unsafe internal building temperatures in the event of a power failure. Refer to standard at A-0701.

The hospital failed to maintain patient care related electrical equipment (PCREE) to ensure safety availability and reliability. Refer to standard at A-0724.

Based on record review and interview, the Governing Body failed to ensure contracted services were performed as required for preventative maintenance on hospital equipment. Failure to perform preventative maintenance on equipment has the potential to result in harm or death to patients should the equipment malfunction. A contracted service is one that provides a service for compensation.

The findings included:

During an accrediting organization survey conducted 9/13/14 through 9/14/18, the hospital was found to have no preventative maintenance (PM) program for its patient care related electrical equipment (PCREE) including, but not limited to, intravenous pumps, cardiac monitors, and cardiac defibrillators.

A review of facility management records failed to produce evidence of any preventative maintenance being performed on PCREE.

On 9/26/18 at 1:30 p.m., the Facility Manager said the biomedical services provider had left the facility. The Facility Manager said the biomedical services provider had all the records related to progress of the preventative maintenance performed. He said the biomedical services provider would not provide records to the hospital at the time of the interview.

On 9/26/18 at 3:55 p.m., the Chief Compliance Officer acknowledged the biomedical services provider was not on the list of contracted services.

On 9/27/18 at 10:55 a.m., the Facility Manager said he believed the electrical safety testing performed on the PCREE was part of the PM. He said the biomedical service provider had been performing the electrical safety testing on the PCREE since 2015. There had not been any PM performed other than what may have been performed while the PCREE was under warranty.

There was no risk-based assessment to determine the facility's frequency for testing and maintaining PCREE. There was no documentation available to confirm when the last preventative maintenance was performed on the PCREE. The biomedical service provider left the hospital on 9/26/18 and was unwilling to return. No biomedical service provider records were available at the time of the survey.

Based on record review and interview, the hospital's Governing Body failed to ensure contracted services for preventative maintenance (PM) were performed in a safe and effective manner. A contracted service is one that provides a service for compensation. Failure to perform PM on equipment has the potential to result in harm or death to patients should the equipment malfunction.

The findings included:

During an accrediting organization survey conducted 9/13/14 through 9/14/18, the hospital was noted to have no PM program for its patient care related medical equipment (PCREE) such as IV pumps, monitors, and defibrillators.

A review of hospital records failed to produce evidence of any PM being performed on PCREE.

On 9/26/18 at 1:30 p.m., the Facility Manager said the biomedical services provider had left the facility. He said the biomedical services provider has all the records related to progress of the PM. He said the biomedical services provider would not provide records to the hospital at the time of the interview.

On 9/26/18 at 3:55 p.m., the Chief Compliance Officer acknowledged the biomedical services provider was not on the list of contracted services.

On 9/27/18 at 10:55 a.m., the Facility Manager said he believed the electrical safety testing performed on the PCREE was part of the preventative maintenance. He said the biomedical services provider had been performing the testing on the PCREE since 2015. There has been no preventative maintenance performed other than what may have been performed while the PCREE was under warranty. There was no documentation available to confirm when the last preventative maintenance was performed on the PCREE.
There was no risk-based assessment to determine the required frequency for testing and maintaining PCREE. The biomedical services provider left the facility on 9/26/18 and was unwilling to return. No biomedical services provider records had been provided to the hospital.

Based on record review and interview the hospital failed to maintain a complete list of contracted services. The hospital failed to identify contracted services and the scope of the service. Contracted services refers to a service that is provided to the facility in exchange for compensation.

The findings included:

A review of the facility's facilities management documentation revealed correspondence from biomedical service provider. The correspondence dated 9/16/15, 8/8/17, 6/27/18, and 8/1/18 revealed the biomedical service provider was providing electrical safety testing on patient care related electrical equipment (PCREE) on 9/16/15, 8/8/17, and 6/27/18. The correspondence dated 10/1/18 was for equipment calibration and testing.

A review of the hospital's List of Contracted Services revealed the biomedical service company was not listed.

On 9/27/18 at 10:55 a.m., the Facility Manager said he believed the electrical safety testing performed on the PCREE was part of the PM. He said the biomedical service provider had been performing the electrical safety testing on the PCREE since 2015.

On 9/26/18 at 3:55 p.m., the Chief Compliance Officer acknowledged the biomedical service provider was not on the list of contracted services.

Based on record review and interview, the hospital's Quality Assessment and Performance Improvement (QAPI) program failed to accurately reflect services provided under contract or arrangement. There was no record of preventative maintenance performed on patient care related electrical equipment (PCREE) by the contracted biomedical services provider.

The findings included:

1. A review of the QAPI Committee Report dated March 2018 revealed a performance measure "PM's [Preventative Maintenance] completed on a 6 month rotation" had a 98% compliance rate.

On 9/14/18, an accrediting organization survey revealed the hospital had not performed preventative maintenance on 325 pieces of PCREE for over a year.

On 9/26/18 a request was made to review the preventative maintenance documentation for the hospital's PCREE. No records were available to review. It was uncertain what information the QAPI committee was referring to in the quarterly report.

On 9/27/18 at 10:55 a.m., the Facility Manager said he believed the electrical safety testing performed on the PCREE was part of the preventative maintenance. He said the biomedical services provider had been performing the electrical safety testing on the PCREE since 2015. There has been no preventative maintenance performed other than what may have been performed while the PCREE was under warranty. There was no documentation available to confirm when the last preventative maintenance was performed on the PCREE. The was no risk-based assessment to determine the frequency for testing and maintaining PCREE. The biomedical services provider had left the hospital on 9/26/18 and was unwilling to return. No biomedical services provider records had been provided to the hospital.

On 9/27/18 at 12:43 p.m., the Chief Compliance Office said prior QAPI data was based on the belief the PCREE was receiving preventative maintenance rather than just electrical safety tests.

Based on record review and interview, the hospital failed to maintain the physical plant to assure patient safety and well-being. The hospital failed to maintain an effective preventative maintenance program for patient care related electrical equipment (PCREE) and failed to provide a generator capable of supporting safe internal environmental temperatures in the event of a power failure.

The findings included:

1. On 9/14/18, an accrediting organization survey revealed the hospital had not performed preventative maintenance on 325 pieces of PCREE for over a year.

On 9/26/18 a request was made to review the preventative maintenance of the hospital's PCREE. No records were available to review to determine compliance.

On 9/27/18 at 10:55 a.m., the Facility Manager said he believed the electrical safety testing performed on the PCREE was part of the preventative maintenance. He said the biomedical services provider had been performing the testing on the PCREE since 2015. There had been no additional preventative maintenance performed other than what may have been performed while the PCREE was under warranty.

There was no documentation available to confirm when the last preventative maintenance was performed on the PCREE. There was no risk-based assessment to determine the necessary frequency for testing and maintaining PCREE. No biomedical services provider records had been provided to the hospital. The biomedical services provider left the hospital on 9/26/18 and was unwilling to return.

2. In an interview on 9/27/18 at 10:55 a.m., the Facility Manager said, in the event of a municipal power failure, the hospital generator did not have sufficient output to run the cooling system. He said the fans would run, but not cool the air.

Based on record review and interview, the hospital failed to maintain patient care related electrical equipment (PCREE) to ensure safety availability and reliability.

The findings included:

1. 1. On 9/14/18, an accrediting organization survey revealed the hospital had not performed preventative maintenance on 325 pieces of PCREE for over a year.

On 9/26/18 a request was made to review the preventative maintenance of the hospital's PCREE. No records were available to review to determine compliance.

On 9/27/18 at 10:55 a.m., the Facility Manager said he believed the electrical safety testing performed on the PCREE was part of the preventative maintenance. He said the biomedical services provider had been performing the testing on the PCREE since 2015. There had been no preventative maintenance performed other than what may have been performed while the PCREE was under warranty.
There was no risk-based assessment to determine the hospital's frequency for testing and maintaining PCREE. There was no documentation available to confirm when the last preventative maintenance was performed on the PCREE.

The biomedical services provider left the hospital on 9/26/18 and was unwilling to return. No biomedical services provider records had been provided to the hospital.