HospitalInspections.org

Based on review of facility documents, observations and staff interview (EMP), it was determined the facility failed to ensure there was an effective system for monitoring and evaluating the quality of patient care and services provided under contract.

Findings include:

Review on June 27, 2013, of the facility policy "Organizational Performance Improvement Plan and Risk Management Plan," dated reviewed April 2013, revealed "Purpose: The purpose of the Organizational Performance Improvement Plan is to ensure that the Governing Body, Medical Staff and Professional Service Staff demonstrates a consistent endeavor to deliver optimal care in an environment of minimal risk. In keeping with the hospital's mission, to foster, nurture and perpetrate the concept of a family centered quality conscious and cost-effectiveness, the Organizational Performance Improvement Plan allows for a systematic, coordinated and continuous approach to improving performance focusing upon the processes and mechanisms that address these values. Objectives: Mid-Valley is committed to a patient-centered approach in designing and delivering care with the unique needs and evaluations of the patient in mind. Maintain a comprehensive, effective system for monitoring and evaluating the quality of patient care and services provided throughout the hospital in a cost effective manner. Providing care that is respectful of and responsible to the individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Assure that the patient care is provided and maintained at an optimal level consistent with the professional standards held in the medical community. Improvement of existing processes and functions through a systematic approach that includes identifying a potential improvement, testing the strategy for change, assessing data from the test to determine if the to determine if the change produced improved performance, and implementing the improvement strategy system wide. Provide for a collaborative approach to review the healthcare practices at the facility for their quality, cost effectiveness and positive outcome of the patients to improve patient satisfaction."

Review on June 27, 2013, of the listing of "Contracted Services" provided by the facility revealed the following services were provided thru contract: Laundry, Wound Care, Trash Disposal, Elevators, Copiers, Pyxis (a medication dispensing system), Teleradiology Services and Communications, Water Testing, and Pest Control.

Review on June 27, 2013, of the Quality Improvement/Infection Control Meeting Minutes for 2012 and 2013 revealed no documentation the contracted services for services furnished to the hospital were included in the Quality Improvement Program.

Interview with EMP1 on June 27, 2013 at approximately 1:00 PM confirmed there was no documentation the contracted services provided to the hospital were included in the hospital Quality Improvement Program.

Interview with EMP2 on June 27, 2013 at approximately 1:30 PM confirmed there was no documentation the contracted services provided to the hospital were included to the Quality Improvement Program and brought forward to the Board of Trustees for review.

Based on review of facility policy and procedures, personnel files (PF), and interview with staff (EMP), it was determined the facility failed to provide the employee with a competency review in order to maintain their skills and learn new developments in health care for three of 19 personnel files reviewed (PF7, PF15, and PF18).

Findings include:

Review on June 27, 2013, of the facility Human Resources policy and procedure "Policy A.8 Personnel Files," dated effective February 12, 2013, revealed "1.0 Purpose To ensure consistency in the contents and handling of employee personnel files and to recognize the individual employee's right to privacy. 2.0 Content of files The facility shall follow the requirements of equal employment opportunity laws and other federal regulations regarding the collection of information from job applicants and employees. ... 4th Section-Job Description/Performance ... Annual Performance Evaluations ... Competencies/Skill Checklists (validated)."

A random sample of personnel files was reviewed on June 27, 2013. This included staff from nursing (registered nurses, licensed practical nurses and certified nursing assistants), speech therapy, physical therapy, occupational therapy, dietary, respiratory therapy, laboratory and radiology. The personnel files from nursing, speech therapy, physical therapy, occupational therapy, dietary, respiratory therapy, and laboratory all contained documentation of annual compentency/skills checklists.

Review on June 27, 2013, of PF7, PF15, and PF18 (all radiology staff) revealed no documentation of annual competency/skills checklists. The last competency evaluations were performed in 2010.

Interview with EMP1 on June 27, 2013, at approximately 3:00 PM confirmed the last competency evaluations for PF7, PF15 and PF18 were performed in 2010.