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24 HOSPITAL AVE

DANBURY, CT 06810

CONTRACTED SERVICES

Tag No.: A0083

Based on interview and review of facility documentation the facility failed to ensure that the quality improvement activities completed by a contracted service were comprehensive and integrated into the hospital QI program. The findings include the following:

Review of the Quality Improvement activities for the dietary department with the QI coordinator identified that the quality indicators reviewed for dietary are selected by the dietary department (contracted service) and not selected by the hospital, based on the hospitals needs. Interview with the QI coordinator on 8/30/12 at 1:30 PM identified that the contracted service provides the listing of QI indicators to be reviewed. The QI coordinator indicated that the information is sent to the corporate office and to the onsite Dietary Director, however the data is not funneled to the hospital QI committee. The QI coordinator stated that the Dietary Director is a member of the hospital QI committee however review of the meeting minutes for the period of 1/2011 to 8/2012 failed to identify his/her presence at the committee meetings.

Review of the hospital QI plan indicated that the QI program is designed to continually improve organizational performance and safety by evaluating and enhancing systems and processes identified by the leadership.

DATA COLLECTION & ANALYSIS

Tag No.: A0273

Based on interview and review of facility documentation the facility failed to ensure that the quality improvement activities were comprehensive and /or evidence based. the findings include the following:

Review of the Quality Improvement activities for the dietary department with the QI coordinator on 8/30/12 at 1:30 PM identified that the quality indicators reviewed for dietary are selected by the dietary department (contracted service) and not selected by the hospital based on the hospitals needs. Review of the program failed to identify that the hospital instituted the interventions based on areas requiring improvement and/or the frequency of the monitoring and/or the number of charts to be reviewed.

In addition the quality indicators failed to be specific and clear regarding what was being monitored.

QAPI PERFORMANCE IMPROVEMENT PROJECTS

Tag No.: A0297

Based on interview and review of facility documentation the facility failed to ensure that the quality improvement activities were selected based on an assessment of the needs of the facility. The findings include the following:

Review of the Quality Improvement activities for the dietary department with the QI coordinator on 8/30/12 at 1:30 PM identified that the quality indicators reviewed for dietary are selected by the dietary department (contracted service) and not selected based on the hospitals needs. Review of the program failed to identify that the hospital selected indicators based on areas requiring improvement.

Review of the hospital QI plan indicated that the QI program is designed to continually improve organizational performance and safety by evaluating and enhancing systems and processes identified by the leadership.

QAPI GOVERNING BODY, STANDARD TAG

Tag No.: A0308

Based on interview and review of facility documentation the facility failed to ensure that the quality improvement activities completed by a contracted service were comprehensive and integrated into the hospital QI program. The findings include the following:

Review of the Quality Improvement activities for the dietary department with the QI coordinator on 8/30/12 at 1:30 PM identified that the quality indicators reviewed for dietary are selected by the dietary department (contracted service) and not selected by the hospital based on the hospitals needs. Interview with the QI coordinator on 8/30/12 at 1:30 PM identified that the contracted service provides the listing of QI indicators to be reviewed. The PI coordinator indicated that the information is sent to the corporate office and to the onsite Dietary Director, however the data is not funneled to the hospital QI committee. The QI coordinator stated that the Dietary Director is a member of the hospital QI committee however review of the meeting minutes for the period of 1/2011 to 8/2012 failed to identify his/her presence on the committee.