HospitalInspections.org

Based on observation, interview and record review the Governing Body:


1) Failed to ensure the off-site out-patient emergency room and wound care center were integrated into the hospital's quality assessment /performance improvement (QAPI) program as required for provider based entities. (Refer to Federal tag 0263 QAPI Condition 282.21)

2) Failed to ensure that Billing / Collection Services and Laboratory Contracts for the out-patient emergency room department were valid and signed by a Hospital representative.

(Offsite out-patient emergency department: "Elite Care Emergence Center, 2500 Rice Boulevard, Houston, Texas")

(Offsite out-patient wound care department: "Center for Wounds and Hyperbarics, 5314 Dashwood Drive, Houston, Texas")


Findings include:


Interview 4/12/11 at 9:30 a.m. with the Chief Operating Officer (COO ID# 53) revealed the hospital has two off-site out-patient departments, an emergency room and a wound care center. Elite Care Emergency Center began services as a provider-based entity of the hospital October, 2010 and the Center for Wounds and Hyperbarics began services as a provider-based entity May, 2010.

The COO further stated that Elite Care Emergency Center is operated by a Management Agreement with another company and that all the billing for the emergency center is done by a contracted company.

Observation 4/12/11 at 1 p.m. at Elite Care Emergency Center revealed a sign on the front door that read "A Department of University General Hospital."

Record review of a Governing Body Committee meeting dated February 16, 2011 stated "We have signed a new contract with Elite ER, a free standing ER, as an Outpatient Department of University General Hospital, effective November 1, 2010."

Record review of Contract titled "Office Services Agreement" dated January 1, 2010 between Elite Care Emergency Center and Enfina Healthcare Solutions, stated "Enfina shall have the responsibility and commensurate authority to provide or cause to be provided all off-site business, office, and related services for company, including, without limitation,..........financial record keeping and reporting, preparation of financial statements and income tax returns, cash management, contract administration, billing and collection services, independent third party coding services, payroll administration, and other customary business office services."

The billing / collection Contract was initiated on January 1, 2010 with Elite Care Emergency Center and not University General Hospital. Elite Care Emergency Center did not become an outpatient department of the Hospital until October 2010 (ten months later).


Record review of a Contract titled "Laboratory Services Agreement" dated June 18th, 2010 between Elite Clinical laboratory and Elite Care Emergency Center stated "Elite Lab and participant desire to enter into a Laboratory Services Agreement...." The Laboratory Contract was never updated once University General Hospital began operating Elite Emergency Center as an outpatient department in October 2010. The nurse manager (ID# 57) at Elite Care Emergency room acknowledged 4/12/11 at 1 p.m. that the ER utilizes some laboratory services of Elite Clinical Laboratory. The nurse manager further stated that there is no relationship between Elite Care ER and Elite Clinical Laboratory other than the same name.


"Center for Wounds and Hyperbarics"
Observation 4/12/11 at 3 p.m. at the "Center for Wounds and Hyperbarics" revealed a sign posted behind the receptionist desk that read "Welcome to University General Hospital for Wounds and Hyperbarics."

Record review of a Contract titled "Wound Care Center Occupancy Agreement" dated May 1st, 2010 stated "The purpose of this agreement is to state the terms and conditions under which the Provider will occupy space to provide wound care services as a "provider-based" (under Medicare) department of Provider under the administration of Provider and its medical staff at 5314 Dashwood Drive, Houston, Texas." The Agreement was between University General Hospital and Cornerstone Hospital to lease space from Cornerstone Hospital.

Record review of the Hospital's "Performance Improvement Plan" dated January 2011 stated "Purpose: The organization-wide performance improvement program is primarily designed to improve patient care through quality patient outcomes and medical error reduction." The Plan further stated "Policy: The scope of the Performance Improvement Plan encompasses's all services provided at University General Hospital including inpatient, outpatient, and clinical contract services."

Record review of the Hospital's "Performance Improvement Committee Meetings" for 2010 revealed no integration of services regarding the outpatient Emergency Department or the Wound Care Center. (Refer to Federal tag 0263 QAPI Condition 282.21)

Based on interview and record review the Hospital failed to implement a Hospital-wide quality assessment and performance improvement (QAPI) program in 2010. The QAPI program did not include all hospital departments (the primary emergency department, an off-site out-patient emergency department and a off-site wound care center).

Findings include:

Record review of "Hospital Performance Improvement / Patient Safety Committee Meetings" dated 2/2/10, 4/4/10, 10/5/10, 1/26/11 revealed no information / monitoring regarding the primary emergency department, the offsite outpatient emergency department (Elite Care ER) or the offsite outpatient wound care center.

A Performance Improvement meeting dated February, 2011 revealed Quality Indicators were established for the primary emergency department, the outpatient ER (Elite Care) and the Wound Care Center.
Elite Care ER outpatient department had been operating since November 2010 (three months) and the Wound Care department had been operating since May 2010 (nine months) before quality indicators were established.

The Quality Assurance Director (ID# 55) acknowledged 4/13/11 at 10:20 a.m. that prior to February 2011 the primary emergency room, the offsite emergency department and the Wound Care center were not represented in the Performance Improvement meetings in 2010. The Director further stated that the Management company of the offsite emergency department (Elite Care) has not attended any Performance Improvement Meetings.

The Medical Director (ID# 54) of the Emergency Department acknowledged 4/13/11 at 1:10 p.m. that he does not oversee the offsite outpatient emergency department (Elite Care).

Record review of the "Performance Improvement Plan" dated 1/20/11 stated "Purpose: The organization-wide performance improvement program is primarily designed to improve patient care through quality patient outcomes and medical error reduction.......Policy: the scope of the Performance Improvement Plan encompasses all services provided at University General Hospital including inpatient, outpatient, and clinical contract services. The hospital-wide program will monitor the performance of medical staff and hospital department indicators."

Record review of a management agreement between Elite Care Emergency Center and University General Hospital dated October 1, 2010 stated "Quality Improvement: Manager shall participate in the Hospital's Quality Improvement and Utilization Review programs designed to ensure regulatory compliance and enhance the quality of patient care."

Environment of Care safety rounds were made 3/16/11 at the off-site emergency center (Elite Care) and it was noted that none of the electrical equipment had biomedical stickers /checks identifying that the equipment was safe for use according to a "Patient Safety Tool" dated 3/16/11.

Observation 4/12/11 at 1 p.m. at Elite Care Emergency center revealed the following equipment without biomedical stickers: Room 4 had a cardiac monitor and an infusion pump; Room 5 had a cardiac monitor; Room 6 had a cardiac monitor; the crash cart had a defibrillator, and an Ultrasound machine behind the nurses station.

The Safety nurse (ID# 73) acknowledged 4/13/11 at 1:15 p.m. that the electrical equipment at Elite Care emergency center has not had their electrical equipment checked for safety to date. The Safety Nurse stated the Hospital has requested the management company of Elite Care provide a list of all electrical equipment that needs testing but the management company has not provided a list to date.