HospitalInspections.org

Based on review of policy and procedures, facility documents, and staff interview (EMP), it was determined that the governing body failed to ensure the contracted services for clinical laboratory testing services, patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services were provided in an effective manner.
On April 5, 2023, at approximately 11:15 AM a request was made to EMP1 for the facility's policy regarding evaluation of contacted services. None was provided.
On April 5, 2023, at approximately 11:30 AM a request was made to EMP1 for documentation of governing body's review and evaluations of the contracted services: clinical laboratory testing services, patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services. None was provided.
On April 5, 2023, at approximately 11:35 AM a request was made to EMP1 for documentation of the quality assessment and performance improvement (QAPI) committee's review and evaluation of the following contracts: clinical laboratory testing services, patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services. None was provided.
Interview with EMP1 on April 5, 2023, at approximately 2:30 PM confirmed the governing body or QAPI committee does not review and evaluate the contracted services of patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services.

Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to maintain a safe environment for patients by failing to conduct an annual comprehensive environmental risk assessment.

Findings include:

Review on April 6, 2023 of facility policy "Building Safety Tour", approved January 7, 2020 revealed "I. Policy Statement: Building Safety Tours shall be conducted in KidsPeace buildings and all necessary corrective actions shall be promptly performed..."

Review on April 6, 2023 of facility documents revealed there was no documented evidence a environmental risk assessment was conducted for the year 2022.

Interview conducted on April 5, 2023, with EMP2 at 10:45 AM confirmed an enviironmental risk assessment for 2022 was not conducted.

Based on review of facility documents, facility policy and staff interviews (EMP), it was determined the facility failed to create and maintain a therapeutic diet manual approved by the dietitian and medical staff and make it readily available to all medical, nursing, and food service personnel.


Review of facility policy on April 4, 2023 "Menu Planning, approved August 4, 2004 revealed "I. It is the policy of KidsPeace that all clients shall be provided with meals that are nutritionally adequate, properly prepared, and served in pleasant surrounds...C. Special Diets 1. Therapeutic diets shall never be offered as a reward or punishment, but shall be provided to clients only under the following conditions: a) When prescribed by appropriate medical or dental staff; b) As directed or approved by a registered dietitian; and c) As a complete meal service and not as a supplement to or choice between dietary meals and regular meals..."

Request was made to EMP7 for the facility's Therapeutic Diet Manual on April 4, 2023. None was provided.

Interview with EMP7 on April 4, 2023, at 1:45 PM confirmed "We do not have a therapeutic diet manual"