HospitalInspections.org

Based on a review of facility documents and staff interview (EMP), it was determined that the governing body failed to bear responsibility for contracted services.

Findings include:

Review of the facility document " Quality Assessment and Performance Improvement Plan (QAPI) " indicated, " The Governing Board bears ultimate responsibility for assuring the quality and appropriateness of patient care and hospital operations provided by its leaders, physicians and other clinicians and support staff. 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 Focused Functions ... 3. At a minimum the following services, either hospital-owned or contracted, shall participate. ..."

1. Review of the facility document " Lease Agreement " indicated, " This Lease Agreement ... is made and entered into as of the 27th day of April, 2015, ...between UPMC Presbyterian Shadyside .....and Select Specialty Hospital - Pittsburgh. ... Quality Indicators ... Dietary 1) Timely and accurate deliver of dietary items as ordered; and 2) Hospital will sample ten (10) trays per month for ensure the food temperatures meet the following: Cold food temperatures between 40 and 60 degrees and hot food temperatures between 90 and 110 degrees. "

2. Review of the facility document " Annual Contract Services Review: 2015 SSH (Select Specialty Hospital) Pittsburgh " revealed one tray temperature that was completed on November 30, 2015 and one tray temperature that was completed on December 16, 2015. Further review revealed that the facility failed to sample ten trays per month to ensure the food temperatures met the following: Cold food temperatures between 40 and 60 degrees and hot food temperatures between 90 and 110 degrees.

3. An interview with EMP2 on January 26, 2016, at approximately 12:30 PM confirmed the above findings. Additionally, when asked for the third quarter of data from the Annual Contract Services Review to show food temperatures on ten sample trays per month, EMP2 stated, "I don't have the supporting documentation."

Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.

Findings include:

Review of the facility document " Quality Assessment and Performance Improvement Plan (QAPI) " indicated, " The Governing Board bears ultimate responsibility for assuring the quality and appropriateness of patient care and hospital operations provided by its leaders, physicians and other clinicians and support staff. 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 Focused Functions ... 3. At a minimum the following services, either hospital-owned or contracted, shall participate. ..."

1. Review of the facility document " Lease Agreement " indicated, " This Lease Agreement ... is made and entered into as of the 27th day of April, 2015, ...between UPMC Presbyterian Shadyside .....and Select Specialty Hospital - Pittsburgh. ... Quality Indicators ... Dietary 1) Timely and accurate deliver of dietary items as ordered; and 2) Hospital will sample ten (10) trays per month for ensure the food temperatures meet the following: Cold food temperatures between 40 and 60 degrees and hot food temperatures between 90 and 110 degrees. "

2. Review of the facility document " Annual Contract Services Review: 2015 SSH (Select Specialty Hospital) Pittsburgh " revealed one tray temperature that was completed on November 30, 2015 and one tray temperature that was completed on December 16, 2015. Further review revealed that the facility failed to sample ten trays per month to ensure the food temperatures met the following: Cold food temperatures between 40 and 60 degrees and hot food temperatures between 90 and 110 degrees.

3. An interview with EMP2 on January 26, 2016, at approximately 12:30 PM confirmed the above findings. Additionally, when asked for the third quarter of data from the Annual Contract Services Review to show food temperatures on ten sample trays per month, EMP2 stated, "I don't have the supporting documentation."