HospitalInspections.org

Based on review of facility documents and staff interviews (EMP), it was determined the QAPI(Quality Assessment and Improvement Plan) committee failed to incorporate patient care data and other relevant data in the report submitted to the Organization Improvement Committee as evidenced by incomplete data.

Findings include:

Review of "Select Specialty Hospital - McKeesport Inc. Governing Board Bylaws" dated February 18, 2014, revealed, "3.8-21 Ensuring that there is an effective, hospital-wide Quality Improvement program to evaluate the provision of care and making decisions regarding quality of service to be made available at the Hospital, which includes establishing a mechanism for review of the quality of care services provided by individuals who are not subject to the Medical Staff privilege delineation process."

Review of the facility's "Quality Assessment and Performance Improvement Plan " dated January 20, 2013, revealed "The Hospital will incrementally improve patient outcomes and hospital operations by meeting and exceeding constituent expectations and needs through systematically measuring, assessing, and improving our performance....8. Collect data to monitor performance in areas targeted for further study...10. Ensure coordination and integration of all performance improvement activities by maintaining an Organization Improvement Committee (OIC) as the forum for information exchange, collaboration, prioritization and monitoring;.....The Governing Board shall ensure that there is an on-going systematic interdisciplinary mechanism to measure assess and improve the hospital's ability to do the right thing and to do it well for suspected or potential opportunities to improve patient care processes and outcomes and hospital operations.
Patient and system tracers will be consistently completed by QAPI Team members. Results of these tracers will be reported to OIC, MEC (medical executive committee) and Governing Board at least quarterly and utilized as a source for data collection, compliance status and improvement opportunities."

1) Review of the QAPI's meeting minutes of 2014 dated May 12, June 10, July 18, August 19, September 11, and October 7 failed to include all data as per the facility's "Quality Assessment and Performance Improvement Plan."

Interview with EMP2 on February 4 , 2015, at approximately 10:45 AM confirmed the above findings and indicated "I don't remember seeing it [documentation of the program activity for Rehabilitation and Dietary Services]. The information should go to QAPI then to OIC and Governing Board.

Based on review of facility documentation and staff interviews(EMP) it was determined the facility failed to measure the success and track the performance to ensure improvement of the program activity for Rehabilitation and Dietary Services.

Findings include:

1. Review of the QAPI's meeting minutes of 2014 dated May 12, June 10, July 18, August 19, September 11, and October 7 failed to include all data for Rehabilitation and Dietary Services.

2. Interview with EMP14 on February 2, 2015, at approximately 10:00 AM revealed, "We are looking at mobility to ensure the patients are out of bed, how long they are out of bed, things like that."

During an interview with EMP1 on February 2, 2015, at approximately 1:00 PM, EMP1 was asked if there was documentation of Mobility Indicator. EMP1 stated, "There is no documentation."

3. Interview with EMP13 on February 3, 2015 at approximately 10:30 AM revealed, "We have been looking at trends for weights. We've be having trouble with accuracy, I review the weight book, medical records, and labs." When asked how long EMP13 was looking at weights EMP13 replied, "We started looking at it about one and half years ago. I have no documentation, I had a verbal discussion with the CNO (Chief Nursing Officer) about the discrepancies.

Interview with EMP2 on February 4, 2015, at approximately 10:45 AM confirmed the above findings and indicated, "I don't remember seeing it [documentation of the program activity for Rehabilitation and Dietary Services]. The information should go to QAPI then to OIC and Governing Board."