The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|MILTON S HERSHEY MEDICAL CENTER||500 UNIVERSITY DRIVE HERSHEY, PA 17033||June 9, 2015|
|VIOLATION: CONTRACTED SERVICES||Tag No: A0084|
|Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.
A review on June 8, 2015, of facility policy "Purchase Contract Management Policy" last revised November 2013, revealed "...7. All contracts must meet business requirements for licensure, background checks, other HR needs, Department Safety, Department Process and Joint Commission Performance Expectations. ..." The facility then provided Joint Commission Performance Expectations which revealed, "...Leaders are expected to select the best methods for their hospital to oversee the quality and safety of services provided through contractual agreement. Examples of sources of information that may be used for evaluating contracted services include the following: Review of information about the contractor's Joint Commission accreditation or certification status - Direct observation of the provision of care - Audit of documentation, including medical records - Review of incident reports - Review of periodic reports submitted by the individual or hospital providing services under contractual agreement - Collection of data that addresses the efficacy of the contracted service - Review of performance based reports based on indicators required in the contractual agreement - Input from staff and patients - Review of patient satisfaction studies - Review of results of risk management activities. In the event that contracted services do not meet expectations, leaders take steps to improve care, treatment, or services. ..."
An interview conducted on June 8, 2015, at 1:00 PM with EMP1 revealed the facility has over 300 contracted services. Further interview with EMP1 confirmed the facility could not show that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.