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Based on interviews, observations and record reviews, the governing body failed to ensure that the facility protects patient rights (see A 115), failed to ensure that the facility had an ongoing Quality Assessment Performance Improvement Program (see A 263), failed to ensure that the facility had a contract with an Organ Procurement Organization (see A 884), failed to ensure that the facility developed an Infection Prevention/Control Program (see A 747), failed to identify types of practitioners eligible to practice at the facility (see A 045), failed to provide documentation in the corporate by-laws regarding the process for appointment and privileging of physicians (see A 046), failed to draft bylaws that comply with the medicare conditions of participation (see A 047), failed to provide documentation of an Institutional Plan and Budget (see A 073)

Based on record reviews and interveiws the facility failed to ensure that patient rights were being protected. Findings include:
The facility failed to ensure that patient's receive the Important Message for Medicare letter within 48 hours of admission and within 48 hours of discharge (see A 117),
the facility failed to ensure that patients recieve care in a safe setting (see A 144), the facility failed to ensure that restraints are used according to policy (see A 154), the facility failed to ensure that physician orders for restraints are written according to policy (see A 165)

Based on interview with staff #M, it was determined the hospital failed to implement an organized QAPI (Quality Assurance Performance Improvement) program for 2009-2010 as evidenced by failure to comply with the following standards:

A-0265 Failure to ensure the QAPI program shows measurable improvement in indicators for which there is evidence that it will improve health outcomes
A-0266 Failure to ensure the QAPI program identified and reduce medical errors
A-0267 Failure to ensure the QAPI program measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services and operations
A-0274 Failure to ensure the QAPI program incorporate quality indicator data including patient care data, and other relevant data, and information submitted to or received from the hospital's Quality Improvement Director
A-0275 Failure to ensure the QAPI program monitor the effectiveness and safety of service and quality of care
A-0276 Failure to ensure the QAPI program identify opportunities for improvement and changes that will lead to improvement
A-0285 Failure to ensure the QAPI program focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care
A-0286 Failure to ensure the QAPI program tracked medical errors and adverse patient events
A-0289 Failure to ensure the QAPI program take actions aimed at performance improvement
A-0290 Failure to ensure the QAPI program take actions aimed at measuring its success
A-0291 Failure to ensure the QAPI program take actions aimed at tracking performance to ensure that improvements are sustained
A-0300 Failure to ensure the QAPI program take actions that document what quality improvement projects are being conducted
A-0301 Failure to ensure the QAPI program take actions that document what quality improvement projects are being conducted and the reasons for conducting these projects and
A-0302 Failure to ensure the QAPI program take actions that document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

The hospital failed to provide documentation of an organied Medical staff under the following standards:
-A-0339- Failure to ensure that all members of the Medical staff were appointed by the governing body
-A0341- Failure to ensure that credentials of all members of the medical staff were examined
A-0358- Failure to ensure that the Bylaws require completion of patient physicals withing 30 days or 24 hours of admission

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based on interview with the staff C on 11/10/2010 at 0900, he revealed that the facility failed to establish an infection control program and that there was no data available for 2009 or 2010.

Based on interview, it was determined that the facility failed to implement an organ, tissue and eye procurement program.

During interview with Staff C on 11/8/2010 at 1600, the Organ Procurement Organization [OPO] agreement documents and policies were requested. Staff C stated that the facility has no OPO agreement established.

Based on document review and interview, the governing body failed to identify which type practitioners are eligible for appointment to the medical staff. Findings include:
The document titled BY-LAWS of T & G CORPORATION, INC given to this surveyor on 11/09/2010 at 1230, lacked any information regarding eligible candidates for appointment to the medical staff.
Interview with Staff S on 11/09/2010 at 1430 revealed that there was no further documentation available regarding the corporations BY-LAWS and eligible medical staff.

Based on document review and interview, the governing body failed to appoint members of the medical staff. Findings include:
Document titled BY-LAWS OF T & G CORPORATION, INC did not contain documentation regarding privileging or appointing of the medical staff.
Interview with Staff T on 11/09/2010 at 1400, he confirmed that physicians are approved by the medical executive committee but not by the board. Per Staff T, the board is not involved in this process.

Based on document review and interview, the governing body failed to draft bylaws that comply with Medicare Conditions of Participation.
Documentation titled BY-LAWS OF T & G CORPORATION, INC did not contain any information or process for privileging and credentialing of physicians.
Interview with staff R on 11/09/2010 at 1200, he confirmed that the document provided as facility BY laws did not contain any information in regards to privileging or credentialing of physicians.

Based on document review and interview, the governing body failed to present an institutional plan. Findings include:
The facility failed to provide item #26 of the survey material list presented to staff C at the time of the entrance conference on 11/08/2010. Item #26 request an Institutional Plan and Budget-3years (beginning of fiscal year and foward).
Further request were made to staff R and S on 11/09/2010 but no documentation was presented to this surveyor.

Based on document review and interview the governing body failed to produce a document regarding an institutional budget plan. Findings include:The facility failed to produce a document in regards to their institutional budget plan. Therefore this surveyor was unable to confirm if the hospital has submitted a plan to any other agency for review.

Based on interview the governing body failed to produce documentation of an institutional plan and budget that involved the medical staff. Findings include:
Interview with staff R and staff S on 11/09/2010 at 1430 failed to produce a document in regards to an institutional plan and budget.

Based on record review and interview, the facility failed to ensure that medicare patients receive the Important Medicare Message (IMM) letter within 48 hours of admission and again within 48 hours of discharge for 2 of 5 patients (#1, #6). Findings include:
During review of the medical record for patient #1 on 11/08/2010, per the documentation the patient had been admitted on 10/30/2010. Unable to locate IMM document in the medical record reflecting the 48 hour time frame.
Interview with Staff P on 11/09/2010 at 0915, she could not locate the IMM given to the patient at the time of admission. She stated that this is "Something we are working on."

Based on observation, interview and record review the facility failed to ensure that 1 of 1 patients with a diagnosis of Aids received medications as ordered 4 of 4 patients received nutritional supplements as ordered These occurrences were not reported to the Director or Nursing (DON) or identified as medication errors. Findings include:

On 11/10/10 at 1000 patient #39's clinical record was reviewed. The patient was admitted 10/28/10 with diagnoses that included Aids. A physician's verbal order dated 10/28/10 lists Truvada, Reyataz and Norvir with a note stating "patient group home to provide Aids meds." No documentation of staff contracts to secure these medications was noted until a 10/29/10 nursing note stating: "Spoke with ("caretaker") about patient's private medications, Norvir, Reyataz and Truvada. She stated they are at AFC (Adult Foster Care) home in Saginaw and she will phone them and phone us back 10/30/10. There is no documentation of any further effort to secure these medications until a nursing note on 11/1/10, stating: "guardian stated she would come on 11/2/10 to bring medication." Review of the Medication Administration Record revealed that patient #39 received the first doses of Truvada, Reyataz and Norvir on 11/2/10, 4 days after admission.

On 11/10/10 at 1115 the Director of Nursing (DON) was asked to explain why the facility did not provide the patient's Aids as ordered for 4 days. The DON stated that the facility relies on the family or caregiver for these kinds of mediations, even if the physician has ordered them. The DON also stated that the delay in administering the patient's medications should have been reported to him and the physician should have been notified. The DON stated that this was not reported to him and confirmed record review that produced no documentation of the physician being notified..

On 11/8/10 from 1420-1505 patients #38 ,41 and 42 told staff A that they were hungry and had not received their Boost supplements all day. The nurse stated that they were out of Boost on the unit and that she could get more from the pharmacy. On 11/9/10 at approximately 0900 review of the MAR revealed that patients # 38, #41 and #42 missed Boost supplements that were ordered for 1000 on 11/8/10. Patient #40, also on the first floor, did not receive her Boost supplement ordered for 1000 on 11/8/10. Omissions were marked as "NA" (not available) in the MAR.

ON 11/10/10 at approximately 1115 the Director of Nursing was asked to explain why these patients did not receive their supplements. He stated that the nurse should have had Pharmacy deliver it. Asked if these omissions constituted an error that should have been reported to him he replied "yes, it should have been but it wasn't."

Based on record review, policy review and interview, the facility failed to ensure that restraints are only utilized for the immediate safety of the patient, staff or others for 1 of 3 (#43) restraint records reviewed. Findings include:
During review of the medical record for patient #43 on 11/10/2010, it was noted that a physician ' s telephone order written on 10/22/2010 at 0730 read " Apply 2 point leather restraints prior court for patient ' s safety and others safety. "
Review of the document titled Restraints policy # MH-2.6 revised 09/2010 reads on page 3 paragraph 2 " The patient has the right to be free from restraints of any form that are not medically necessary. Restraint is not to be imposed as a means of coercion, discipline, convenience, or retaliation by staff. "
During discussion with staff C and R on 11/10/2010 at 1130, both confirmed that the restraints were used inappropriately on the patient.

Based on record review, policy review and interview the facility failed to ensure that a physician ' s order for restraints states the type of restraints being applied to the patient in 2 of 3 (#44, #45) records reviewed. Findings include:
During review of the medical records for patient #44 on 11/10/2010 it revealed a physician ' s order dated 10/09/2010 at 1553 for " Physical restraint. " The order did not contain information regarding the type of restraint used or duration for the restraints. Patient #45 ' s record contained a physician telephone order written on 10/10/2010 at 2115 that did not contain information regarding the type of restraint to be used or duration for the restraints.
Review of the document titled Restraints policy # MH-2.6 revised 09/2010 reads on page
5 under #10 " The physician ' s order for restraint will include: Time/Date, Rationale for use (specific behavior described), Time limit (i.e. up to four hours), Clothing to be removed(to be specific in the order if any removed), Type of restraint to be used and placement of the restraint on the patient. '
During discussion with staff C and R on 11/10/2010 at 1130, both confirmed that the orders for restraints were incomplete.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that tracked medical errors and adverse patient events. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data or report from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented QAPI data submitted to this surveyor for review that demonstrate this facility had an active QAPI program for the year 2009 to 2010 which tracked medical errors and adverse patient events. The facility failed to meet this requirement.

Based on interview and policy review, the facility failed to ensure that the governing body approved all medical staff practitioners. Findings include:

On 11/9/10 at approximately 0930 the Medical Staff Constitution and Bylaws were reviewed. On 11/9/10 at approximately 1100 the Medical Director was asked to provide documentation that the governing body had approved individual members of the medical staff. The Medical Director stated that he was not a member of the Board (governing body) and didn't know whether the Board had approved all members of the Medical Staff. On 11/9/10 at approximately 1600 review of Board Minutes provided reveal lacking documentation that the Board had approved all current members of the Medical Staff. A Physician's Assistant, staff x, performed a History and Physical on 3 patients (#34 and #36 on 4/10/11 and #35 on 4/11/10, with no credentials on file. On 11/15/10 at approximately 1250 the Chief Executive Officer verified that he was unable to produce verification that the Board had approved all members of the Medical Staff.

Based on record review and interview the Medical Staff failed to examine the credentials of all candidates for membership. Findings include:

On 11/9/10 at approximately 0930 the Medical Staff Constitution and Bylaws were reviewed. On 11/9/10 at approximately 1100 the Medical Director was asked why his application for Medical Staff membership "Application Procedure" check list was blank, except for his dated signature (4/3/09.) He stated that it wasn't done. His request for privileges was undated. His most recent medical Staff Approval was dated April 2007, beyond the 2 year reappointment date specified in the bylaws. Staff Y, a physician, had no privilege request form on file. these findings were confirmed in an interview with the Medical Director.

On 11/ 9/10 at approximately 0930 the Medical Staff Constitution and Bylaws were reviewed with the Medical Director. The Medical Director was unable to identify a bylaw requirement that physician's ensure that each patient receives a History and Physical with 30 days of admission or 24 hours of admission.

Based on observation and staff interview conducted on 11/9/10, it was determined the hospital failed to maintain the confidentiality of the patients' medical records. Findings include:

During the clinical record review and xeroxing of items from the patients' clinical records on 11/9/10 at approximately 8:30 am, this surveyor noted several xeroxed forms with patient personal information that had been left on this xerox machine. It was noted, during the xeroxing process on 11/9/10, personal patient information was being xeroxed by the Medical Record's staff on this same xerox machine, and not always immediately removed. It was also noted, there was patient's personal information that had been xeroxed and left unattended on the xerox machine. This was an open area were people walked through to get to other offices, preparing coffee, talking, looking at documents that had been xeroxed on this xerox machine etc. There was no staff present to monitor the items that was being xeroxed and/or removed from the xerox machine.

During an interview on 11/9/10 at approximately 9:20 am, staff #N stated, "the Medical Records department do not have their own xerox machine, we share this machine with other staff members of the hospital and as you can see sometimes our documents are removed and can be reviewed by anyone coming into this area, it is hard to maintain confidentiality of the medical records.

During review of medical records on 11/08/2010 it was determined that patient #4 had telephone orders written on 11/4/2010 that had not been signed by the physician. Patient 5 had orders written on 11/04/2010 that were not dated when signed by the physician. Patient #38 had orders written on 8/9/10 that were not signed by a physician. During interview with the Director of Nursing (staff C) on 11/10/10 at 1130, it was confirmed that telephone orders for these patients weren't signed and dated.



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Based on record review and interview, the facility failed to ensure that telephone orders are authenticated by the physician within 48 hours for 7 of 8 records (#1, #2, #4, #5, #13, #30, #37).
Findings include:
During review of medical records on 11/08/2010 it was determined that patient #1 had telephone orders written on 10/30/2010 and 11/01/2010 that had not been signed by the physician. Patient #2 had two telephone orders written on 11/02/2010 that were not signed by the physician.
During interview with staff C on 11/08/2010 at 1525, he confirmed that telephone orders are supposed to be signed by a physician within 48 hours.


20987

During the medical records review of 11/8/10 and 11/10/10, it was noted that Patient #13 had a verbal order dated 11/3/10 and a telephone order dated 11/2/10 and 11/6/10, both orders were taken from staff T (physician) and had not been signed or dated within the 48 hour timeframe for authenticating verbal orders. Also, Patient #30 had a verbal order dated 10/27/10 taken from staff T (physician) which had not been signed or dated.

Based on record review, policy and interview, it was determined the hospital failed to obtain a signed informed consent for 1 of 1 patient (Patient #29) with a guardian. Findings include:

Hospital Policy #MH-02 dated 4/2008 stated, "Informed consent will be obtained from the patient (or guardian, if indicated) at the time of admission, treatment or medication use in order to authorize these activities services."

Patient #29: This patient was admitted to the hospital on 6/22/10. During the record review on 11/9/10, the Social Work history dated 6/22/10 documented this patient has a guardian. This patient's Individual Plan of Service dated 6/22/10 was blank in the area to document the "Patient's/Guardian's involvement in individual Plan of Service." Also, the "Chart Summary" form which documented, "Status Check in [date] 9/28/10," documented, "No Guardianship papers in chart." During an interview on 11/9/10 at approximately 10 AM, staff #N stated, "after this patient's discharge on 6/23/10, this record was sent to us (Medical Records) for review, it was noted the chart states this patient has a guardian, however there was no Guardianship letter in this record." This surveyor reviewed this patient's record with staff #N on 11/9/10 and was unable to locate a Guardianship letter.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on November 8-10, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated November 10, 2010, for Life Safety Code.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes for 2010. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a Quality Improvement program for this hospital. I have not been able to find any QAPI data from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented QAPI data submitted to this surveyor for review which demonstrated this facility had an active QAPI program for the year 2010 that showed measureable improvement in health care outcomes. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program to identify and reduce medical errors for 2010. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any QAPI data from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented QAPI data submitted to this surveyor for review, which demonstrated this facility had an active QAPI program for the year 2010 which identified and reduced medical errors. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for this standard for a QAPI (Quality Assurance Performance Improvement) program that measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services and operations for 2010. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any QAPI data from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented QAPI data or report for 2010 submitted to this surveyor for review that assessed and analyzed the processes of care, hospital services and operations. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that incorporate quality indicator data including patient care data, and other relevant data, and information submitted to or received from the hospital's Quality Improvement Director for 2009-2010. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data submitted to this surveyor for review that included patient care and other relevant data and information that was submitted to or received from the hospital's Quality Improvement Director, for this surveyor to review. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that monitor the effectiveness and safety of service and quality of care for 2010. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any QAPI data from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data submitted to this surveyor for review that monitored the effectiveness and safety of service and quality of care provided by this facility. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that identify opportunities for improvement and changes that will lead to improvement for 2010. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any QAPI data from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data/report submitted to this surveyor for review that identified opportunities for improvement and changes that will lead to improvement. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any QAPI data or report from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data or report submitted to this surveyor that demonstrate this facility had an active QAPI program for the year 2009 to 2010 which focused on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that take actions aimed at performance improvement. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any QAPI data or report from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data or report submitted to this surveyor for review that demonstrate this facility had an active QAPI program for the year 2009 to 2010 which take actions aimed at performance improvement. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data or reports from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data/report submitted to this surveyor for review which demonstrated the hospital took actions aimed at performance improvement, and after implementing those actions the hospital measured it's success. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data or reports from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data/report submitted to this surveyor for review that demonstrated this facility take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that document what quality improvement projects are being conducted. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data or report from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data/report that document what quality improvement projects are being conducted for 2010. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that document what quality improvement projects are being conducted and the reasons for conducting these projects. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data or report from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data/report, submitted to this surveyor for review that documented what quality improvement projects are being conducted and the reasons for conducting these projects. The facility failed to meet this requirement.

Based on interview, the hospital failed to meet the requirements for a QAPI (Quality Assurance Performance Improvement) program that document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Findings include:

During an interview on 11/09/2010 at approximately 8:45 AM, Staff M stated she was hired on 10/16/10 as the hospital's Quality Assurance & Quality Improvement Director (QA/QI). She stated, "I have been reviewing policy and procedures and trying to develop a program for the hospital. I have not been able to find any 2010 QAPI data or report from the person who was in this position before me, it appears the processes were disconnected and there was a block to reporting the findings." At the time of the interview, there was no documented 2010 QAPI data/report submitted to this surveyor for review that demonstrate this facility document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. The facility failed to meet this requirement.