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The Condition of Participation: Governing Body was out of compliance. The Hospital as an independent separately certified Hospital with a single Hospital Governing Body failed to ensure the Hospital Governing Body independently demonstrated compliance with the Conditions of Participation and was effective in carrying out its responsibilities for the conduct of the entire Hospital.

Findings included:

1.) The Hospital Governing Body failed to ensure they (the Hospital Governing Body) determined which categories of practitioners, Nurse Practitioners and Clinical Psychologists as Non-physician practitioners, were eligible candidates for appointment to the Medical Staff.

Refer to A-0045.

2.) The Hospital Governing Body failed to ensure the Hospital Medical Staff had Bylaws and the Hospital Medical Staff operated under current Bylaws, and that they (the Hospital Governing Body) approved the Medical Staff Bylaws, and they (the Governing Body) were responsible for the conduct of the Hospital and the conduct of the Hospital included the quality of care provided to patients.

Refer to A-0047.

3.) The Hospital Governing Hospital Body failed to consult directly with the individual assigned the responsibility for the organization and conduct of the Hospital's Medical Staff (the Medical Director) , to include discussion of matters related to the quality of medical care provided to patients of the Hospital. Refer to TAG: A-0053.

4.) The Hospital Governing Body failed to have a written documentation that identified the Chief Executive Officer (CEO) legally responsible for the conduct of the entire Hospital.

Refer to TAG: A-0057.

5.) The Hospital Governing Body failed to ensure the appointed Chief Executive Officer was responsible for managing the entire Hospital.

Refer to TAG: A-0057.

6.) The Hospital Governing Body failed to ensure a Doctor of Medicine or Doctor of Osteopathy was on duty or on call at all times to provide medical care and onsite supervision when necessary.

Refer to TAG: A-0067.

7.) The Hospital Governing Body failed to ensure a Hospital Institutional Plan and Budget that included an annual operating budget, anticipated income and expenses, capital expenditures for at least a 3-year period.

Refer to TAG: A-0073.

8.) The Governing Body failed to ensure the Hospital maintained a list of all Contracted Services to include the scope and nature of the services provided.

Refer to TAG: A-0085.

The Condition of Participation: Quality Assessment and Performance Improvement was out of compliance.

Findings included:

The Hospital Quality Assessment and Performance Improvement (QAPI) Program activities failed for one Patient (Patient #1) in a sample of ten patients to ensure actions aimed at performance improvement and, after implementing those actions, the Hospital must measure its success, and track performance to ensure that improvements were sustained.

Refer to TAG: 0283.

Based on records reviewed and interviews the Hospital Governing Body failed to ensure they (the Hospital Governing Body) determined which categories of practitioners, Nurse Practitioners and Clinical Psychologists as Non-physician practitioners, were eligible candidates for appointment to the Medical Staff.

Findings included:

The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated Governing Body responsibilities included authorizing a group of qualified Practitioners to establish a Medical Staff which was accountable to the Governing Body for the Quality of care provided. The Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton indicated no documentation to indicate that the Hospital Governing Body determined categories of Allied Health Professionals eligible for Clinical Privileges.

The document titled Bylaws of the Medical Staff of (undefined), dated 8/2020, indicated in the Categories of Allied Health Professionals that the Governing Body determined, upon recommendation and comment of the Medical Executive Committee categories of Allied Health Professionals eligible to exercise Clinical Privileges in the Hospital as outlined in the Allied Health Professional Policy. The Bylaws of the Medical Staff of (undefined), indicated no documentation to indicate that the Governing Body determined, upon recommendation and comment of the Medical Executive Committee categories of Allied Health Professionals eligible to exercise Clinical Privileges in the Hospital.

The policy titled Curahealth Hospitals Medical Staff General Rules and Regulations, dated 10/2021, indicated no categories of Practitioners, Nurse Practitioners and Clinical Psychologists as Non-physician practitioners, were eligible candidates for appointment to the Medical Staff.

Meeting Minutes for the Curahealth Stoughton Governing Body, dated 3/11/2021, indicated that the Hospital Governing Body approved the Medical Staff Bylaws - Stoughton. The Meeting Minutes indicated no clear indication which document of Bylaws was approved.

During an interview, at 2:30 P.M. on 10/13/2021, the Corporate Compliance Officer said she was the Corporate Compliance Officer and (also served as) the Chair of the Governing Body for all Curahealth Hospitals. The Corporate Compliance Officer said the Medical Staff Bylaws were designed by the Corporation and standardized by outside (the Corporation) attorneys. The Corporate Compliance Officer said the Hospital Chief Executive Officer, Hospital Medical Staff and Hospital Governing Body had input into the Hospital Medical Staff Bylaws.

During an interview, at 8:30 A.M. on 10/14/2021, the Medical Director said the Medical Staff included Medical Doctors, Osteopathy Doctors, Nurse Practitioners and Psychologists. The Medical Director said he did not know if the Psychologist was an active (member of the Medical Staff) or if the Psychologist had left (resigned).

Based on observations, records reviewed and interviews the Hospital Governing Body failed to ensure:

A.) The Medical Staff had Bylaws and the Medical Staff operated under current Bylaws,
B.) They (the Governing Body) approved the Medical Staff Bylaws, and they (the Governing Body) were responsible for the conduct of the Hospital and the conduct of the Hospital included the quality of care provided to patients.

Findings included:

A.) Regarding two documents provided by the Hospital as the Medical Staff Bylaws:

The document titled Bylaws of the Medical Staff of (undefined), dated 8/2020 and provided during the Survey, indicated in the preamble, The Medical Staff of (undefined, with a line to identify the Hospital). The document titled Bylaws of the Medical Staff indicated it was a template for a Medical Staff Bylaws. The Bylaws indicated basic responsibilities of the Medical Staff Membership included participating in the Hospital's Emergency Service call schedule The Bylaws indicated Emergency Services coverage would be defined in contracts between the Physician(s) or Physician group and the Hospital. Emergency Services Physicians would be credentialed and privileged as prescribed in those contracts and consistent with these Bylaws. A physician providing Emergency Services may also apply for other staff membership in one of the aforementioned categories of Medical Staff membership. The document titled Bylaws of the Medical Staff did not indicate the document was the Bylaws of the Curahealth Medical Staff nor did the document indicate it was approved by the Governing Body.

The document titled Bylaws of the Medical Staff of Curahealth Stoughton, dated 8/2020 and provided after the Survey, indicated a different document for the Hospital's Medical Staff Bylaws.

During observations of the Hospital, dated 10/14/2021, the Survey observed that the Hospital did not have an Emergency Service (Emergency Department).

During an interview, at 8:30 A.M. on 10/14/2021, the Medical Director said he covered Medicine in the Hospital. The Medical Director said the Hospital did not have an Emergency Service and did not know why Emergency Services were included in the Medical Staff Bylaws. The Medical Director said he did not know what Allied Health Professionals were and did not think that Physician Associates (Assistants) practiced in the Hospital. The Medical Director said he did not know what was in the Medical Staff Bylaws regarding Allied Health Professionals. The Medical Director said the Medical Staff Bylaws were approved by the Corporation.

Meeting Minutes for the Curahealth Stoughton Governing Body, dated 3/11/2021, indicated that the Hospital Governing Body approved the Medical Staff Bylaws - Stoughton. The Meeting Minutes indicated no clear indication which document of Bylaws was approved.

The Hospital provided no one clear document that indicated the Hospital's Medical Staff operated under current Bylaws.

B.) Regarding the Hospital Governing Body:

The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated the Governing Body would consist of at least five voting members, which would include the Corporate (the business, not the Hospital) Chief Compliance Officer, the Corporate Vice President of Operations, the Hospital's Medical Director, the Hospital's Nurse Executive, and the Hospital's Chief Executive Officer.

Organization Chart #1 titled Curahealth Stoughton Governing Board, undated, indicated three positions for the Hospital's Governing Body with two individuals named to the Hospital's Governing Body; President of the Medical Staff, and the Chief Executive Officer, and the Chief Clinical Officer (Nurse Executive) position as vacant.

Organization Chart #2 titled Curahealth Stoughton Organization Chart, undated, indicated the Medical Director, President of the Medical Staff, Chief Executive Officer, Director of Pulmonary Services, Medical Director NRU (undefined), Director of Psychiatric Services NRU were members of the Governing Board (Body).

During an interview, at 9:15 A.M. on 10/13/2021, the Medical Staffing Coordinator said the Hospital Governing Body included the Chief Executive Officer, the Medical Director, and Corporate (Chief Compliance Officer). The Medical Staff Coordinator said Corporate represented the Corporation. The Medical Staffing Coordinator said the Chief Medical Officer was the Medical Director. The Medical Staffing Coordinator said the Chief Clinical Officer (Nurse Executive) position was vacant.

During an interview, at 2:30 P.M. on 10/13/2021, the Corporate Compliance Officer said she was the Corporate Compliance Officer and the Chair of the Governing Body for all Curahealth Hospitals. The Corporate Compliance Officer said originally the Hospital had five members of the Governing Body that included the Corporate Compliance Officer, Corporate Vice President of Operations, the Hospital Chief Executive Officer, the Hospital Chief Clinical Officer and the Hospital Chief Medical Officer, however the Corporate Vice President of Operations was eliminated from the Hospital Governing Body and the Hospital Chief Clinical Officer position was vacant. The Corporate Compliance Officer said the Hospital was pending a merger and that the Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton would be updated after the merger and there was no planned date.

During an interview, at 8:30 A.M. on 10/14/2021, the Medical Director said he was not a member of the Governing Body.

Based on records reviewed and interview the Hospital Governing Body failed to consult directly with the individual assigned the responsibility for the organization and conduct of the Hospital's Medical Staff (Medical Director).

Findings included:

The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated Medical Director, means the physician selected by the Hospital Governing Body to serve as the Medical Director of the Hospital. The Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, indicated Governing Body responsibilities included ensuring regular communication with the Medical Staff leadership as documented in written minutes or reports and distributed to the Governing Body and Medical Staff leadership. The Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, indicated no number of consultations (communications, that occurred at least twice during either a calendar or fiscal year) needed based on various factors specific to the Hospital including quality of care that a hospital's Quality Assessment and Performance Improvement program.

Meeting Minutes of the Medical Executive Committee, dated 1/19/2021, indicated the (Medical) Chief of Staff had resigned.

During an interview, at 8:30 A.M. on 10/14/2021, the Medical Director said the Medical Executive Committee discussed patient care and the Chief Executive Officer was present.

The Hospital provided no lists of attendees present at the Curahealth Stoughton Governing Body Meetings, dated 3/11/2021 and 6/10/2021, nor the Medical Executive Committee Meetings, dated 1/19/2021, 2/16/2021, 3/23/2021, 4/20/2021, 5/18/2021.

The Hospital provided no documentation to indicated that the Governing Body implemented periodic, direct consultation with the Medical Director for discussion of matters related to the quality of medical care provided to patients and an awareness of the concerns and views of members of the medical staff; it was unclear if the Medical Director had direct and documented twice yearly consultation a member of the Governing body for discussion of matters related to the quality of medical care provided to patients of the Hospital.

Based on records reviewed and interview the Hospital Governing Body failed to ensure the appointed Chief Executive Officer (CEO) was responsible for managing the entire Hospital.

Findings included:

A.) The Hospital Governing Body failed to have a written documentation that identified the Chief Executive Officer legally responsible for the conduct of the Hospital.

The letter titled Curahealth Hospitals, dated 11/17/2017, indicated, Congratulation on your promotion to the Chief Executive Officer role. This letter served as a notification of formal appointment to the Chief Executive Officer of the Curahealth Stoughton Hospital effective 11/17/2017. The letter indicated authentication (signature) by the Hospital System (Corporate) Chief Financial Officer. The letter did not indicate the Hospital Governing Body appointed the Chief Executive Officer as the individual legally responsible for the conduct of the entire Hospital.

B.) Regarding CEO Responsibilities for managing the entire Hospital.

1.) The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated the definition of the Chief Executive Officer as meaning the individual appointed by the Governing Body to provide for the day-to-day management of the Hospital. The Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton did not define the Chief Executive Officer as meaning the individual appointed by the Hospital Governing Body to be responsible for managing the entire Hospital.

The document titled Chief Executive Officer Job Description, dated 8/24/2021, indicated the Chief Executive Officer was ultimately accountable for the overall leadership, patient outcomes, relationships, regulatory compliance, operations and financial performance of the Hospital. The Chief Executive would work closely with the Governing Body, Medical Staff, and facility leadership and management teams to successfully achieve the mission, values and desired outcomes of the organization.

During an interview, at 9:15 A.M. on 10/13/2021, the Chief Executive Officer said he was the designated representative and the Chief Executive Officer for the Hospital. The Chief Executive Officer said Corporate Hospitals (Curahealth Hospitals) out of Texas, ran each Hospital. The Chief Executive Officer said the Governing Board (Governing Body) comes from Hospitals (Corporate, Curahealth Hospitals) in Texas. The Chief Executive Officer said the Hospital Governing Body members came from Corporate and there were three members that include me as the Hospital Chief Executive Officer. The Chief Executive Officer said there were seventeen Curahealth Hospitals.

During an interview, at 2:30 P.M. on 10/13/2021, the Corporate Compliance Officer said she was the Corporate Compliance Officer and (also served as) the Chair of the Governing Body for all Curahealth Hospitals. The Chair of the Hospital Governing Body said the Hospital Governing Body appointed Chief Executive and the Chief Executive Officer was delegated to do the day-to-day operations of the facility (the Hospital).

2.) The Hospital Governing Body failed to ensure a Hospital Institutional Plan and Budget that included an annual operating budget, anticipated income and expenses, capital expenditures for at least a 3-year period.

Refer to TAG: A-0073.

3.) The Hospital Governing Body failed to ensure policies and procedures of the Hospital System (Corporation) were clearly approved by the Hospital (Curahealth Stoughton) Governing Body.

The Corporate Compliance Officer said she was the Corporate Compliance Officer and (also served as) the Chair of the Governing Body for all Curahealth Hospitals. The Corporate Compliance Officer said policies and procedures were established by the Corporation, reviewed by the Hospital, Quality (staff), Medical Executive Committee(s) and rolled out (disseminated) to the Hospitals. The Corporate Compliance Officer said if the Hospital required a (revised or) different policy, the Hospital would not approve the Corporate policy. The Corporate Compliance Officer said Hospital approval of Corporate policies would be found in the Governing Body Meeting Minutes.

The policies titled:

a.) Curahealth Hospitals Rapid Response Team, dated 4/2020,
b.) Curahealth Hospitals Patient Transfer, dated 10/2020,
c.) Curahealth Hospitals Resuscitative Services Plan, 3/2021,
d.) Curahealth Hospitals Quality Assurance Performance Improvement (QAPI) Plan, dated 8/2021, and
e.) Curahealth Hospitals Medical Staff General Rules and Regulations, dated 10/2021,

indicated the policies were approved (authenticated, signed) by the Corporate (business not Hospital) Chief Compliance Office (and this was inconsistent with Condition of Participation Hospital Governing Body regulation).

Meeting Minutes for the Curahealth Stoughton Governing Body, dated 3/11/2021 and 6/10/2021 indicated no documentation of policy approval.

Meeting Minutes of the Medical Executive Committee, dated 1/19/2021, 2/16/2021, 3/23/2021, 4/20/2021, 5/18/2021, indicated no documentation of Hospital policy approvals.

The Hospital provided no clear process nor documentation that the policies were approved by the Hospital.

4.) During an interview, at 11:00 on 10/12/2021, the Chief Executive Officer said that the Chief Clinical Officer and the Chief Qualify Officer positions were vacant, he had conversations with the Corporation, the positions were re-posted and that he wished he could make the decisions about an interim Contracted Service for the vacant positions. The Chief Executive Officer said that he (regarding the vacant positions) had no checkbook, this comes out of Corporate, the Corporate Chief Financial Officer, not a Chief Financial Officer for this Hospital, there was centralized money and paid through the Corporation. The Chief Executive Officer said he did not know what the Corporation would do if he (the Chief Executive Officer) hired a Contracted Service for the vacant Chief Clinical Officer (Nurse Executive) and or a Chief Quality Officer. The Chief Corporate Officer said that anything the Hospital needs goes through Corporate. The Chief Executive Officer said the Corporate Chief Compliance Officer did (generated) the Hospital Quality Assessment and Performance Plan (QAPI) and does all our policies, not the Hospital; the final QAPI plan was signed by the Corporate Compliance Officer. The Chief Executive Officer said the Corporate Team ran all Hospitals.

The Corporate Compliance Officer said she was finding (searching) for the Hospital Chief Executive Officer a Chief Clinical Officer and Chief Quality Officer with Corporate Human Resources and I am helping the Hospital with posting the positions. The Corporate Compliance Officer said Human Resources resides with the Corporation. The Corporate Compliance Officer said she had never used a Contracted Service for a Chief Clinical Officer interim position before, and was meeting with Human Resources that afternoon and would ask that day.

The Hospital provided no documentation to indicate the Chief Executive Officer was responsible for hiring into vacant positions as responsible and accountable for the entire Hospital. The Hospital provided no clear and consistent role (definition) for the Chief Executive Officer as responsible and accountable for managing the entire Hospital

Based on records reviewed and interview the Governing Body failed to ensure a Doctor of Medicine or Doctor of Osteopathy was on duty or on-call at all times to provide medical care and onsite supervision when necessary.

Findings included:

During an interview, at 8:30 A.M. on 10/14/2021, the Medical Director said a Nurse Practitioner was:

-on duty Monday through Friday onsite from 10:00 A.M. through 5:00 P.M.,
-on-call Monday through Friday from 6:00 P.M. through 10:A.M.,

-duty onsite on weekends 10:00 A.M. through 5:00 P.M.,
-on-call on weekends from 6:00 P.M. through 10:00 A.M.

The Medical Director said he started patient care rounds at 8:00 A.M. each day and there was no Provider over-night. The Medical Director said that there was no Provider (Doctor of Medicine or Doctor of Osteopathy) on duty or on-call Monday through Friday from 10:00 P.M. through 8:00 A.M. and no Provider on duty or on-call 6:00 P.M. through 8:00 A.M. on weekends. The Medical Director said that if the was a patient care emergency over-night the nurses called the on-call Nurse Practitioner who provided verbal orders or transfer orders, and called 911 (Emergency Medical Services).

The Hospital provided no documentation that a Doctor of Medicine or Doctor of Osteopathy was on duty or on-call at all times; the Hospital provided no documentation of a Provider schedule; the Hospital provided no documentation of a Doctor of Medicine or Doctor of Osteopathy on-call policy.

Base on records reviewed and interview the Hospital Governing Body failed to ensure a Hospital Institutional Plan and Budget that included an annual operating budget, anticipated income and expenses, capital expenditures for at least a 3-year period.

Findings included:

The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated Governing Body responsibilities included preparing capital and annual operating Budgets, reviewing and approving the Hospital's annual operating budget and long-term capital expenditures plan, and monitoring the implementation of approved plans. The Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton did not indicate that the Hospital's Governing Body was responsible for the Hospital's annual operating budget development and long-term capital expenditures plan.

The document titled Curahealth Hospitals Curahealth Stoughton Budget, dated FY 2021, indicated annual operating budget, anticipated income and expenses. The Curahealth Hospitals Curahealth Stoughton Budget indicated no documentation of capital expenditures for at least a 3-year period or sources of financing for, each anticipated capital expenditure in excess of $600,000.

During an interview, at 2:30 P.M. on 10/13/2021, the Corporate Compliance Officer said she was the Corporate Compliance Officer and (also served as) the Chair of the Governing Body for all Curahealth Hospitals. The Chair of the Governing Body said she was not involved with the budget process. The Chair of the Governing Body said the Hospital annual budget (Hospital Institutional Plan and Budget) was generated at the Corporate level with data provided by the Hospital Chief Executive Officer. The Chair of the Governing Body said the budget process was between the Corporate Chief Financial Officer and the Hospital Chief Executive Officer.

The Hospital provided no document to verify that an institutional plan and budget existed, that the plan and budget were reviewed and updated annually, nor the plan was prepared under the direction of the Hospital Governing Body.

Based on records reviewed and interview the Governing Body failed to ensure the Hospital maintained a list of all Contracted Services to include the scope and nature of services provided.

Findings included:

The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated Governing Body responsibilities included ensuring a list of all contractors, and contractors of services to the Hospital's Patients furnish services in a safe manner.

The document titled Curahealth Stoughton Clinical Contracted Services included seven contracted services. The Curahealth Stoughton Clinical Contracted Services list included no documentation of the scope and nature of the services provided. The Curahealth Stoughton Clinical Contracted Services list included no documentation that the list included:

1.) The ESP Personnel Services Agreement, dated 2/27/2019,

2.) The Hospital-Health Care Facility Transfer Agreement, dated 5/23/2019, nor

3.) The Favorite Healthcare Staffing Supplemental Staffing Agreement, dated 2/2/2018.

During an interview, at 4:00 P.M. on 10/13/2021, the Administrative Assistant said that the Hospital also had Contracted Services for ambulance services (ambulance service was not included on the list of Contracted Services).

Based on records reviewed and interview the Hospital Quality Assessment and Performance Improvement (QAPI) Program activities failed for one Patient (Patient #1) in a sample of ten patients to ensure actions aimed at performance improvement and, after implementing those actions, the Hospital must measure its success, and track performance to ensure that improvements were sustained.

Findings included:

1.) The Hospital failed to ensure completion of a Hospital identified corrective action following a Complaint regarding the quality of care provided to Patient #1.

The Report, dated 7/9/2021, indicated a Complaint that alleged the Hospital did not meet the needs of the Patient) and this was elder abuse and neglect. The Report indicated the Patient a stroke. The Report alleged that the Hospital did not meet the needs of the Patient's personal hygiene needs, as the Patient remained covered in feces on more than one occasion resulting in urinary tract infections.

The letter, dated 7/19/2021, indicated it was the Hospital's follow-up letter in response to the Complainant. The letter indicated the Hospital proposed to improve patient care, and the patient's family experience in the future with a process including Certified Nurse Assistants (CNA) and Nursing staff education regarding improvements providing patient care and ensuring patient safety, through patient care modules and real time observations.

The document titled Primary Care Bathing Patient, undated, a training module where seven of twelve (more that half) of the CNAs assigned to the training, on 7/26/2021, were overdue (incomplete) on the due date of 8/1/2021.

During an interview, at 2:20 on 10/8/2021, the Chief Executive Officer said that Hospital had no documented monitoring, (that is, the Hospital failed to ensure improvements in providing patient care through patient care modules and real time observations).

2.) The Hospital failed to ensure responsibility for Contracted Services, to ensure actions through the Hospital's Quality Assessment and Performance Improvement Program to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

The document titled Curahealth Hospitals Governing Body Bylaws of Curahealth Stoughton, undated, indicated the Chief Executive Officer responsibilities included negotiating service contracts.

The document titled ESP Personnel Services Agreement, dated 2/27/2019 indicated a Contracted Service agreement between the Medical Referral Network International (ESP Personnel) and Curahealth Hospital Stoughton. The ESP Personnel Services Agreement was authenticated (approved, signed) by the Hospital System (Corporation) President. The ESP Personnel Services Agreement indicated not documentation that the ESP Personnel Services Agreement was approved by the Hospital Chief Executive Officer. The Hospital provided no documentation to indicate the Hospital evaluated the ESP Personnel Services for the quality of care to Hospital patients.

The document titled Hospital-Health Care Facility Transfer Agreement, dated 5/23/2019, indicated a Contracted Service between Curahealth Stoughton and Sturdy Memorial Hospital for patient transfer to an acute care hospital. The Hospital-Health Care Facility Transfer Agreement indicated the agreement was authenticated by Sturdy Memorial Hospital on 5/23/2019 and unsigned by Curahealth Stoughton Hospital. The Hospital provided no documentation to indicate the Contracted Service was approved by the Hospital Chief Executive Officer. The Hospital provided no documentation to indicate the Hospital evaluated the Hospital-Health Care Facility Transfer Agreement for the quality of care to Hospital patients requiring transfer to an acute care hospital.

The document titled Favorite Healthcare Staffing Supplemental Staffing Agreement, dated 2/2/2018, indicated a Contracted Service for supplemental staffing between Curahealth Corporate Offices and Favorite Health Care Staffing, Inc. The Favorite Healthcare Staffing Agreement indicated Curahealth Corporate Offices and Favorite Healthcare Staffing authenticated the Agreement on 2/2/2018. The Hospital provided no documentation to indicate the Contracted Service was approved by the Hospital Chief Executive Officer. The Hospital provided no documentation to indicate the Hospital evaluated the Favorite Healthcare Staffing Supplemental Staffing Agreement for the quality of care to Hospital patients.

Meeting Minutes for the Curahealth Stoughton Governing Body, dated 3/11/2021, indicated a Contracted Service Update that included that the Hospital Governing Body requested and received some data and that the Hospital Governing Body needed to be more specific on what data the Hospital Governing Body needed to receive. The Meeting Minutes indicated no clarity as to who the request was referring to (that is to the Contracted Service or Hospital Quality Assessment and Performance Improvement activities required to evaluate Contracted Services).

During an interview, at 4:00 P.M. on 10/13/2021, the Administrative Assistant said the Hospital did not monitor the travel nursing Contracted Services.

The Hospital provided no documentation through its Hospital Quality Assessment and Performance Improvement (QAPI) program, that ensured every Contracted Service was evaluated (that is the Hospital evaluated the Contracted Service provided to patients).