HospitalInspections.org

Based on the systemic nature of the standard level deficiencies related to Quality Assessment and Performance Improvement, the facility failed to substantially comply with this condition.

Findings include:

The following standards were cited and show a systemic nature of non-compliance with regards to Quality Assessment and Performance Improvement as follows:

§482.21(a) Standard: Program Scope
§482.21(d) Standard: Performance Improvement Projects.

Based on the systemic nature of the standard level deficiencies related to Respiratory Services, the facility failed to substantially comply with this condition.

Findings include:

The following standards were cited and show a systemic nature of non-compliance with regards to Respiratory Services as follows:

§482.57(a)(1) - There must be a director of respiratory care services who is a doctor
of medicine or osteopathy with the knowledge, experience and capabilities to
supervise and administer the service properly. The director may serve on either a
full-time or part-time basis.

§482.57(b) Standard: Delivery of Services

§482.57(b)(4)- All respiratory care services orders must be documented in the
patient ' s medical record in accordance with the requirements at §482.24.

Based on review of facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure the program measured, analyzed, and tracked quality indicators for contracted services.

Findings include:

Review on December 13, 2023, of the facility's "Performance Improvement Plan Qaulity Assessment & Performance Improvement (QAPI) plan" dated 2023, revealed "... Design & Scope ... 2. Scope: QAPI activities will be integrated across all the care and service areas of our organization ... 3. Objectives: ... All departments and services will be involved in Performance Improvement activities ... 4. Quality Assurance: We will have a committee that will review data from areas of the organization on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization ... Performance Improvement Projects (PIPs) 13. As part of our QAPI program, we will conduct Performance Improvement Projects ... We will document what projects are being conducted, the reason for conducting the projects and the measurable progress achieved on the projects ..."

A request was made to EMP1 on December 13, 2023, for the facility's contracted services quality indicators. None was provided.

Interview with EMP1 on Decmeber 13, 2023, at 11:40 AM, confirmed there is no measuring, analyzing, and tracking of quality indicators for the following contracted service areas: laboratory, radiology, dietary services, pharmaceutical services, envionmental services and dialysis services.

Based on review of facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure it conducted performance improvement projects related to its contracted services.

Findings include:

Review on December 13, 2023, of the facility's "Performance Improvement Plan Qaulity Assessment & Performance Improvement (QAPI) plan" dated 2023, revealed "... Design & Scope ... 2. Scope: QAPI activities will be integrated across all the care and service areas of our organization ... 3. Objectives: ... All departments and services will be involved in Performance Improvement activities ... 4. Quality Assurance: We will have a committee that will review data from areas of the organization on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization ... Performance Improvement Projects (PIPs) 13. As part of our QAPI program, we will conduct Performance Improvement Projects ... We will document what projects are being conducted, the reason for conducting the projects and the measurable progress achieved on the projects ..."

A request was made to EMP1 on December 13, 2023, for the facility's performance improvement projects related to its contracted services. None was provided.

Interview with EMP1 on Decmeber 13, 2023, at 11:40 AM, confirmed there were no performance improvement projects conducted for the following contracted service areas: laboratory, radiology, dietary services, pharmaceutical services, envionmental services and dialysis services.

Based on review of facility documents, and interviews with staff (EMP), it was determined the facility failed to designate a director of respiratory care services who is a Doctor of Medicine or osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly.
Review on December 13, 2023, of facility document "Good Shepherd Specialty Hospital Medical Staff Bylaws" revised June 22, 2021, revealed no designation of a director of respiratory care services.
A request was made on December 13, 2023, at 10:30 AM to EMP3 for the job description of director of respiratory care services. None provided.
Interview on December 13, 2023, at 11:36 AM with EMP3 confrimed the facility did not designate a director of respiratory services who is a Doctor of Medicine or osteopathy.

Based on review of medical records (MR), facility policy and procedures, and interviews with staff (EMP), it was determined the facility failed to adhere to its Respiratory Care Services established policies and procedures for two (2) out of five (5) respiratory medical records reviewed (MR12 and MR13).
Review of MR12 on December 12, 2023, revealed tracheostomy care was documented as completed one time, at 2:10 AM, over two shifts on September 2, 2023.
Review of MR13 on December 12, 2023, revealed tracheostomy care was documented as completed one time, at 3:20 AM, over two shifts on September 2, 2023.
Review on December 13, 2023, of facility policy, " Tracheostomy Care", dated December 2022, revealed, " ...C Changing Tracheostomy Tube Dressing...should be changed whenever soiled and/or every shift."
Interview on December 12, 2023, at 1:59 PM with EMP1 confirmed MR12 did not have progress note regarding omitted tracheostomy care on September 2, 2023.
Interview on December 12, 2023, at 2:07 PM with EMP1 confirmed MR13 did not have progress note regarding omitted tracheostomy care on September 2, 2023
Interview on December 13, 2023, at 12:34 PM with EMP1 confirmed the Respiratory department staff work 12-hour shifts. Further interview with EMP1 confirmed that tracheostomy care should be completed and documented twice per 24-hour period.

Based on review of medical records (MR), facility policy and procedures, and interviews with staff (EMP), it was determined the facility failed to document in the medical record of two (2) out of five (5) respiratory medical records reviewed. (MR12 and MR14)
Review of MR12 on December 12, 2023, revealed breathing treatments ordered by the physician on August 28, 2023, to be administered four times per 24-hour period. Further review revealed the breathing treatments were documented three times, at 7:07 AM, 10:55 AM, and 3:10 PM, over the 24-hour period of September 1, 2023.
Review of MR14 on December 12, 2023, revealed cough assist was ordered by physician on October 17, 2023, to be completed four times per 24-hour period and as needed every two hours. Further review revealed cough assist was documented as completed three times, at 7:15 AM, 11:55 AM, and 9:00 PM, over the 24-hour period of October 19, 2023.
Interview on December 12, 2023, at 1:59 PM with EMP1 confirmed when a treatment is not performed, there should be a progress note explaining why it was not performed. Further interview with EMP1 confirmed MR12 did not have a progress note regarding omitted breathing treatment for the 24-hour period of September 1, 2023.
Interview on December 12, 2023, at 2:11 PM with EMP1 confirmed MR14 did not have progress note regarding omitted cough assist for the 24-hour period of September 2, 2023.