HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the nutritional Quality Improvement projects for 2016 were presented the Quality Improvement Committee, and the facility failed to ensure Quality Assessment and Performance Improvement (QAPI) monitoring was performed for all services under contract with an outside company.

Findings include:

Review on November 29, 2016, of the facility's "Organization - wide Quality Improvement Program," last reviewed July 12, 2016, revealed "... II. Introduction/Philosophy: A. Purpose Sunbury Community Hospital is an institution dedicated to meeting the needs of our patients in a manner which is consistent with our mission, vision and belief statements. The Organizational Quality Improvement plan is designed to provide a systematic and organized program for the promotion of safe, quality patient care and services. The plan outlines the philosophy of improvement principles, organizational structure and approach to be utilized in fulfilling our purpose which is to continually strive toward (a) doing the right things, (2) doing the right things well, and (3) continually improving. Activities are interdisciplinary and collaborative in order to respond to the needs of the customer, patient, physician, employee and community. Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optimal achievements, with appropriate accountability assumed by the Governing Board, Medical Staff, Administration, and support personnel. ... Quality and Regulatory Compliance The Quality and Regulatory Compliance department shall be responsible to support the organization's Quality Improvement principles, strategies, approach, and methodologies, which includes be is not limited to the following tasks: ... 6) Conducts an annual departmental and organization-wide evaluation of the Quality Program. ... F. Scope of Activities The scope of the Organizational Quality Improvement Program encompasses measurement and assessment activities of the Medical Staff, Nursing and Ancillary or support services. ... III. Organization and Responsibilities of Leaders A. Responsibilities Quality Improvement activities are the responsibility of everyone employed by, on the medical staff of, or contracted with Sunbury Community Hospital.

1) Review on November 29, 2016, of the facility's contracted services revealed radiology, nutrition, housekeeping and maintenance services, the Emergency Department physicians and the Hospitalist group were provided to the facility under contract with an outside company.

Review on November 29, 2016, of the nutritional quality improvement monitoring revealed the facility completed Quality Improvement projects for 2016.

Review of the facility's Quality Improvement Committee meetings for January through November 2016 revealed no documentation that nutritional services reported the Quality Improvement projects to the facility's Quality Improvement committee during 2016.

Interview with EMP2 on November 29, 2016, at approximately 4:10 PM confirmed nutritional services were under contract; nutritional services completed Quality Improvement projects during 2016; and there was no documentation nutritional services reported the Quality Improvement projects to the Quality Improvement committee during 2016.

2) A request was made of EMP2 on November 29, 2016, for the housekeeping and maintenance services, the Emergency Department physicians and Hospitalist group Quality Improvement projects for 2016.

Interview with EMP2 on November 29, 2016, at approximately 4:15 PM confirmed the housekeeping and maintenance services, the Emergency Department physicians and the Hospitalist group were contracted services. EMP2 revealed there were no Quality Improvement projects for the housekeeping and maintenance services, the Emergency Department physicians or the Hospitalist group for 2016.