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Based on review of the facility's Quality Assessment and Performance Improvement (QAPI) Program, review of facility emails, and interviews, the facility failed to monitor, measure, analyze, and track patient quality indicators as required by the QAPI program.

Refer to A-0273

Based on policy review, medical record review, and interviews, the facility failed to ensure dietary services was staffed by a full time Dietary Service Manager/Director and failed to have a Registered Dietitian.

Refer to A-0620 and A-0621.

Based on review of the facility's Quality Assessment and Performance Improvement (QAPI) Program, review of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) information, review of facility emails, and interviews, the facility failed to obtain and monitor all required customer data and patient quality indicators for 4 months (1/1/19-4/11/19) of the previous 6 months reviewed.

The findings included:

Review of the facility's "...Quality Assessment and Performance Improvement Program..." dated 11/19/18 revealed "...Goals...To utilize internal and external customer feedback...To organize data into useful information, including comparison to internal and external data sources...To utilize external information sources..." Further review revealed "...Quality Improvement Council...Council meetings are at minimum, ten per year...Review Customer Service Surveys...Comparison of hospital performance through reference databases..."

Review of HCAHPS Survey Factsheet posted online 11/2/17 revealed "...Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS)...must collect and submit HCAHPS data..."

Review of an email from the facility's HCAHPS vendor to the facility dated 2/8/19 revealed "...services will be placed on hold 2/13 [2019] due to invoice delinquency..."

Review of an email from the HCAHPS vendor to the facility dated 3/5/19 revealed "...URGENT - SERVICES ON HOLD...payment has not been received...Effective today, your account will be placed on hold until all delinquent charges have been paid..."

Review of an email from the HCAHPS vendor to the facility dated 4/4/19 revealed "....URGENT - SERVICES PENDING CANCELLATION...the October [2018] invoice is still over 100 days due. Once payment is received for October, services will be restored...online access is disabled at this time..."

Interview with the Human Resources (HR) Director on 4/9/19 at 9:00 AM, in the Administrative Conference Room, revealed the HR Director was responsible for gathering and monitoring the HCAHPS survey data monthly for the facility. Further interview revealed the facility had not obtained or reviewed HCAHPS data since December 2018. Continued interview revealed "...in 2019 we have not gotten any HCAHPS data..." Further interview revealed on 3/5/19 the facility was notified by the HCAHPS vendor the account was placed on hold and the account would be cancelled if payment was not made. Continued interview revealed the HR director notified the facility administration in February 2019, of the HCAHPS vendor's concern with overdue accounts and that access to the data was blocked by the vendor. Further interview revealed the facility was notified on 4/3/19 the HCAHPS vendor had cancelled the facility's account and the vendor would no longer perform patient surveys until paid. Continued interview confirmed the facility failed to obtain and monitor HCAHPS data since 12/2018.

Based on policy review and interviews, the facility failed to ensure Dietary Services was directed by a full time manager/director for the food and dietetic services for 1 of 1 dietary department.

The findings included:

Review of facility policy "Plan of Care Plan" dated 11/26/18 revealed "...Nutritional Services...STAFFING...Nutritional Services Director...The Dietary Manager will be either Certified [Certified Dietary Manager] or hold a certificate from the state on food safety and sanitation..."

Interview with the Director of Nurses on 4/8/19 at 2:00 PM, in the DON's office, revealed the dietary manager worked 8 hours per week in the facility. Further interview confirmed the facility did not have a full time dietary manager.

Interview with the Human Resources Director on 4/9/19 at 9:10 AM, in the Administration Conference Room, confirmed the facility did not have a full time dietary manager.

Based on policy review, medical record review, and interviews, the facility failed to ensure a dietitian assessed the nutritional needs of 3 patients (#5, #6, and #8) of 8 patients reviewed.

The findings included:

Review of facility policy "Plan of Care Plan" dated 11/26/18 revealed "...NUTRITIONAL SERVICES...SCOPE AND COMPLEXITY OF SERVICES...Evaluation and assessment of patient's nutritional needs...STAFFING...Registered Dietitian..."

Medical record review revealed Patient #5 was admitted to the facility on 4/1/19 with diagnosis of Heart Palpitations. Further review revealed the patient was discharged on 4/2/19.

Medical record review of a physician's order dated 4/1/19 at 11:55 AM revealed the physician ordered a dietary consult for Patient #5. Further review revealed no documentation a dietary consult was provided.

Medical record review revealed Patient #6 was admitted to the facility on 3/27/18 with diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease. Further review revealed the patient was discharged on 4/2/19.

Medical record review of a physician's order dated 3/27/19 at 12:58 PM revealed the physician ordered a dietary consult for Patient #6. Further review revealed no documentation a dietary consult was provided.

Medical record review revealed Patient #8 was admitted to the facility on 3/23/19 with diagnosis of Intractable Vomiting. Further review revealed the patient was discharged home on 3/26/19.

Medical record review of a physician's dated 3/24/19 at 1:46 AM revealed the physician ordered a dietary consult for Patient #8. Further review revealed no documentation a dietary consult was provided.

Interview with the Acute Care Director on 4/9/19 at 1:30 PM, in the Nurses' Station, confirmed the facility failed to provide a dietary consult for Patient #5, Patient #6, and Patient #8. Further interview confirmed the facility did not have a Dietitian on staff.

Interview with the Director of Nurses on 4/9/19 at 9:00 AM, in the DON's office, revealed the facility's contracted Dietitian resigned from the facility at the end of 2/2019 and the facility had been without a Dietitian since 2/2019.