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Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure the contracted services, the Pharmacy Department and Discharge Planning were reviewed by the hospital's Quality Assessment and Performance Program (QAPI) by failing to ensure the contracted services were included in the QAPI (A083); by failing to ensure Pharmacy monitored all medication errors, antibiotic usage, drug-drug and drug-food interactions and Discharge Planning monitored timeliness of discharges and length of stay (A265); and by failing to ensure the QAPI program included tracking indicators from Pharmacy and Discharge Planning (A267).

Findings include:

Review on May 29, 2013, of the Board of Trustee Bylaws, dated reviewed March 21, 2013, revealed "... 8.1 Board Responsibility For The Quality Of Professional Services ... After considering the recommendations of the Medical Staff and the other health care professionals providing patient care services, the Board shall implement specific review and evaluation activities to assess, preserve, and improve the overall quality and efficiency of patient care in the Hospital. The Board, through the CEO [Chief Executive Officer], shall provide whatever administrative assistance is reasonably necessary to support and facilitate activities contributing to continuous quality assessment and improvement."

Review on May 29, 2013, of the Medical Staff Bylaws, dated revised May 2012, revealed "... Article XI: Functions and Committees of the Medical Staff ... Section 11.9 Quality Improvement/Patient Care Committee ... 11.9-2 Duties ... The duties of the Quality Improvement Committee shall be to: a) coordinate the objective and systematic monitoring and evaluation of the quality and appropriateness of patient care and respond appropriately to quality improvement findings; ... f) monitor and evaluated the quality, safety and appropriateness for patient care and patient services and assure that appropriate actions on findings are taken. ..."

Cross Reference:
482.12(e) Contracted Services
482.21(a)(1) QAPI Health Outcomes
482.21(a)(2) QAPI Quality Indicators

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure utilization review (UR) was performed as described in the hospital's Utilization Management Plan by failing to ensure the Utilization Review Committee met and medical necessity was reviewed for admission, duration of the stay, and the professional services furnished (A655); and by failing to ensure the Utilization Review Committee periodically reviewed current inpatient care for patients receiving hospital services during a continuous period of extended duration (A657).

Findings include:

Review on May 29, 2013, of facility "Medical Staff Bylaws" dated revised May 2012 revealed "... Section 11.9-Quality Improvement/Patient Care Committee, Composition: The Quality Improvement/Patient Care Committee shall consist of at least two (2) members of the Medical Staff. Other committee members are represented by Administration, Quality Improvement, Nursing, Medical Records, Pharmacy, Laboratory Infection Control and Utilization Review. Governing Body Representatives will be appointed by the Chairperson of the Governing Body. 11.9-2 Duties; to monitor and evaluate the quality, safety and appropriateness for patient care and patient care services and assure all appropriate actions on findings are taken. ... ff) develop a utilization review plan that is appropriate to the Hospital and that meets the requirements of the law; gg) provide for the review of the appropriateness and medical necessity of admissions, continued hospital stays and support services; hh) address overutilization and underutilization of services; ii) provide information to the Medical Staff regarding the utilization process; jj) conduct studies, where appropriate, regarding utilization review findings; kk) assure the maintenance of quality patient care and the appropriate allocation of the Hospital's resources in a cost effective manner."

Review on May 29, 2013, of the facility "Utilization Management Plan," dated February 24, 2012, revealed "Utilization Review Committee: The Utilization Review Committee meets monthly and is facilitated and scribed by the Case Manager/Discharge Planner. Members include: Medical Director, Medical Staff Physician, Chief Nursing Officer, Nurse Managers, Case Managers and Discharge Planners,"

Cross reference:
482.30(c) Scope and Frequency of Review
482.30(e) Extended Stay Review

Based on review of facility documents and interview with staff (EMP), it was determined the governing body failed to ensure the Quality Improvement program assessed the services provided under contract for nine of nine contracted services.

Findings include:

Review on June 10, 2013, of the listing of "Special Care Contracts," provided to the Department revealed the following services were provided thru contract: Laundry, Wound Expert EMR [electronic medical record] Software Licensing Agreement, Trash Disposal, Elevators, Software, Copiers, Badges, Pyxis [a medication dispensing system], Teleradiology Services, and Communications.

Review on May 30, 2013, of 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 EMP2 on May 29, 2013, at approximately 11:30 AM confirmed there was no documentation the contracted services provided to the hospital were included in the hospital Quality Improvement Program.

Interview with EMP1 on May 31, 2013, at approximately 11:00 AM 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 documents and interview with staff, the facility pharmacist failed to ensure Pharmacy tracking indicators and data were provided to the Quality Improvement program.

Findings include:

Review on May 31, 2013, of Chief Pharmacist's Job Description revealed "Position Summary: Directs pharmacy services at Special Care Hospital. Provides pharmaceutical care to the patients. Essential Duties and Responsibilities ... Improves quality: ... 16. Oversees quality control of pharmacy products. 17. Develops, participates in and evaluates quality improvement programs in the pharmacy and in related departments. 18. Assures compliance with current Department of Health standards. 19. Appropriately related to pharmacy 'customers' [sic]. 20. Actively participates in hospital committees. ..."

Review of the 2012 Quality Meeting Minutes revealed Pharmacy tracking indicators were submitted for the first, second, and third quarters of 2012. There was no documentation Pharmacy tracking indicators were submitted to Quality Improvement for the last quarter of 2012.

Interview with EMP3 on May 29, 2013, confirmed the Pharmacy submitted tracking indicators for the first, second, and third quarters of 2012. EMP3 confirmed there was no documentation the Pharmacy submitted tracking indicators for the fourth quarter of 2012.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure the medical necessity was reviewed for admission, duration of the stay, and the professional services furnished.

Findings include:

Review on May 29, 2013, of facility "Medical Staff Bylaws" dated revised May 2012 revealed "... Section 11.9-Quality Improvement/Patient Care Committee, Composition: The Quality Improvement/Patient Care Committee shall consist of at least two (2) members of the Medical Staff. Other committee members are represented by Administration, Quality Improvement, Nursing, Medical Records, Pharmacy, Laboratory Infection Control and Utilization Review. Governing Body Representatives will be appointed by the Chairperson of the Governing Body. 11.9-2 Duties; to monitor and evaluate the quality, safety and appropriateness for patient care and patient care services and assure all appropriate actions on findings are taken. ... ff) develop a utilization review plan that is appropriate to the Hospital and that meets the requirements of the law; gg) provide for the review of the appropriateness and medical necessity of admissions, continued hospital stays and support services; hh) address overutilization and underutilization of services; ii) provide information to the Medical Staff regarding the utilization process; jj) conduct studies, where appropriate, regarding utilization review findings; kk) assure the maintenance of quality patient care and the appropriate allocation of the Hospital's resources in a cost effective manner."

Review on May 29, 2013, of the facility "Utilization Management Plan," dated February 24, 2012, revealed "Utilization Review Committee: The Utilization Review Committee meets monthly and is facilitated and scribed by the Case Manager/Discharge Planner. Members include: Medical Director, Medical Staff Physician, Chief Nursing Officer, Nurse Managers, Case Managers and Discharge Planners."

Review on May 29, 2013, of the meeting minutes for Utilization Review Committee for 2012 revealed documentation of a meeting for the first quarter of 2012. There was no documentation the Utilization Review Committee meet for the second, third and fourth quarters of 2012.

There was no documentation of Utilization Review Committee meetings from February 2012 through May 2013.

Review on May 29, 2013, revealed no documentation the facility reviewed the medical necessity for admission, duration of the stay, and the professional services furnished from February 2012 thru May 2013.

Interview on May 31, 2013, at approximately 1:00 PM with EMP4 confirmed there was no documentation of Utilization Review Committee meetings from February 2012 through May 2013.

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure the Utilization Review Committee periodically reviewed current inpatient care for patients receiving hospital services during a continuous period of extended duration for one of one applicable medical records reviewed (MR9).

Findings include:

Review on May 29, 2013 of the facility policy "Utilization Management," dated reviewed February 24, 2012, revealed "The Plan of Care is established prior to admission to include admitting diagnosis, care and disciplines required, potential length of stay, and discharge plan. Utilization of Medicare time is done by assigning each patient a 'working' Diagnosis Related Group/Length of Stay (DRG/LOS). The Case Manager/Discharge Planner completes a 'Discharge Planning Pathway' with the patient's diagnosis, DRG/LOS, the earliest possible discharge date, and the Rehabilitation Services proposed discharge date. The earliest discharge date is calculated by computing the length of stay from the patient's admission date to one day more than the lowest DRG/LOS day. To reach the maximum reimbursement potential, patients should be discharged between the DRG/LOS days. Early discharges or 'short stay outliers' will be reimbursed at a lesser rate. Patients with extended length of stays will also have their reimbursement rate adjusted. The Case Manager/Discharge Planner is responsible to insure that the physicians are aware of the LOS and that appropriate discharge plans are instituted in a timely manner."

Review on May 29, 2013, of MR9 revealed the patient was admitted to the Special Care Long Term Acute Care satellite unit on December 20, 2012, and discharged to the facility's hospice unit on May 29, 2013. There was no documentation of utilization review of MR9 during the patient's LOS. The unit's maximum LOS is 28 days. The last day for LOS compliance was January 18, 2013.

Interview on May 29, 2013, at approximately 1:30 PM with EMP4 confirmed there was no documentation of Utilization Review Committee meetings or utilization review for MR9. Further interview with EMP4 confirmed the utilization review for MR9 was 131 days out of compliance.

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure Pharmacy monitored all medication errors, antibiotic usage, drug-drug and drug-food interactions and Discharge Planning monitored timeliness of discharges and length of stay.

Findings include:

Review on May 29, 2013, of facility document "Quality Improvement/Infection Control Plan," dated approved February 28, 2013, and February 24, 2012, revealed "Introduction ... While core measures are mostly facility-wide; each SCH [Special Care Hospital] department also has unique requirements and regulatory standards that must be monitored to ensure a safe, healthy environment for patients, visitors and staff. Each department is responsible for their own monitoring and follow-up; providing updates to the Quality Officer on monthly or quarterly schedule. Reports of these individual departments will be reviewed and discussed at the Quality Improvement meetings. Copies of all initiatives and reports are maintained by the Quality Officer for review for regulatory surveys. ... IV. Department Initiatives ... Pharmacy ... Monitor all medication errors; antibiotic usage; drug-drug and drug-food interactions ... D/C [Discharge] Planning ... Timeliness of discharges within the DRG/LOS [Diagnosis Relate Groups-a system to classify hospital cases into one of approximately 500 groups, also referred to as DRG's, expected to have similar hospital resource use/Length of Stay].

1) Review on May 29, 2013, of the Quality Meeting Minutes for 2012 revealed Pharmacy submitted outcomes data to the Quality Officer for the first, second, and third quarters of 2012. There was no documentation Pharmacy submitted outcomes data to the Quality Officer for the fourth quarter of 2012.

Interview with EMP2 on May 29, 2013, at approximately 11:00 AM confirmed Pharmacy outcomes data was submitted to the Quality Officer for the first, second, and the third quarters of 2012. EMP2 confirmed there was no Pharmacy outcomes data submitted to the Quality Officer for the fourth quarter of 2012.

2) Review on May 31, 2013, of the Quality Meeting Minutes revealed Discharge Planning outcomes data was submitted for the first quarter of 2012. There was no documentation of outcomes data for DRG/LOS submitted to the Quality Officer for discussion for the second, third, and fourth quarters of 2012, and no DRG/LOS outcomes data submitted for the first quarter of 2013.

Interview with EMP2 on May 31, 2013, at approximately 2:30 PM confirmed DRG/LOS data was submitted for the first quarter of 2012. EMP2 confirmed there was no DRG/LOS data submitted for the second, third, and fourth quarters of 2012 and the first quarter of 2013.

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure the Quality Assurance/Performance Improvement (QAPI) program included tracking indicators from Pharmacy and Discharge Planning.

Findings include:

Review on May 29, 2013, of the facility document "Quality Improvement/ Infection Control Plan," dated approved February 28, 2013, and February 24, 2012, revealed "Introduction ... While core measures are mostly facility-wide; each SCH (Special Care Hospital) department also has unique requirements and regulatory standards that must be monitored to ensure a safe, healthy environment for patients, visitors and staff. Each department is responsible for their own monitoring and follow-up; providing updates to the Quality Officer on monthly or quarterly schedule. Reports of these individual departments will be reviewed and discussed at the Quality Improvement meetings. Copies of all initiatives and reports are maintained by the Quality Officer for review for regulatory surveys ... IV. Department Initiatives ... Admissions ... Accuracy of patient registration of information ... Behavioral Medicine ... Compliance with education with diabetic patients and follow-up with diet instructions provided at D/C [Discharge] Planning ... Timeliness of discharges within the DRG/LOS [Diagnosis Related Groups-a system to classify hospital cases into one of approximately 500 groups, also referred to as DRG's, expected to have similar hospital resource use/Length of Stay). ... Facilities/Maintenance ... Monitor usage of all hand hygiene products, timely completion of work orders. ... HBO/Wound Center ... Monitor accuracy of Initial Risk Assessment regarding pain, nutrition status, fall risks, and educational needs. ... Infection Control ... Monitor all Hospital Acquired Infections. ... Lab ... Monitor Blood Bank transfusions and specimen rejections. ... Medical Records ... Monitor Releases of Information; delinquency rate for physician charts; and transcription accuracy. ... Nursing ... Monitor restraint usage, CLABSI [Central Line-Associated Blood Stream Infections], CAUTI [Catheter Associated Urinary Tract Infections]; fall risk assessments; wound care; and patient education. ...Pastoral Care ...Monitor completion of Advanced Directives and Spiritual Assessment. ... Pharmacy ... Monitor all medication errors; antibiotic usage; drug-drug and drug-food interactions. ... D/C [Discharge] Planning ... Timeliness of discharges within the DRG/LOS. ... Radiology ... Patient wait time; timeliness of film analysis and out-patient files. ... Rehab ... Completion of documentation of family education and timeliness of completion of out-patient records for payment. ... Respiratory ... Compliance of ventilator protocols; bipap/cpap [Bilevel Positive Airway Pressure/Continuous Positive Airway Pressure] patient compliance; home oxygen referrals; monitoring of high oxygen flow patients. ..."

1) Review on May 29, 2013, of the 2012 and 2013 Quality Improvement/Infection Control meeting minutes revealed documentation of tracking indicators trackers for Admissions, Behavioral Medicine, Dietary/Nutrition, Facilities/Maintenance, HBO/Wound Center, Infection Control, Lab, Medical Records, Nursing, Pastoral Care, Radiology, Rehab, Respiratory Departments. Further review of meeting minutes revealed documentation Pharmacy reported tracking indicators for the first, second, and third quarters of 2012. There was no documentation of a tracking indicators submitted for the fourth quarter of 2012.

2) Review on May 31, 2013, of the 2012 and 2013 Quality Improvement/Infection Control meeting minutes revealed documentation of Utilization Review (Discharge Planning) tracking indicators for the first quarter of 2012. There was no documentation of Utilization Review tracking indicators for the second, third, and fourth quarters of 2012 and for the first quarter of 2013.

3) Interview with EMP3 on May 29, 2013, at approximately 10:30 AM confirmed there was no data submitted in the last quarter of 2012 for the Pharmacy Department. EMP3 further confirmed Utilization Review data was submitted for the first quarter of 2012. EMP3 confirmed no Utilization Review data was received for the second, third, and fourth quarters of 2012 or for the first quarter of 2013. EMP3 confirmed they distributed the Quality Department initiatives and trackers to department managers in the first quarter of 2013.

Based on review of facility policy, observation, and interview with facility staff (EMP), it was determined the facility failed to ensure security of physical therapy records from unauthorized individuals.

Findings include:

Review of the facility's "Confidentiality of Medical Records," dated approved December 13, 2011, revealed "The medical record is the property of the hospital and is maintained for the benefit of the patient, the medical staff, and the hospital. It is the hospital's responsibility to safeguard both the record and its informational content against loss, defacement, and tampering and from use by unauthorized personnel."

Observation tour of the physical therapy department on May 29, 2013, at approximately 1:00 PM revealed an unlocked supply closet containing an unlocked filing cabinet with five drawers. Each drawer was filled with physical therapy records containing patient information dating back to 2006. This closet was accessible to housekeeping staff.

Interview with EMP7 at the time of the tour confirmed these records were not in a locked cabinet or locked room preventing access from unauthorized personnel.