HospitalInspections.org

Based on interview and record review, the hospital did not have a written contract with the off campus laboratory that performed their laboratory services. In addition, there was not a list of services provided by the off campus laboratory.

Findings included:
Interview with Hospital administrator (S7) during the entrance conference revealed the hospital utilized an off campus laboratory recommended by one of the hospital physicians for laboratory services. Continued interview with the hospital administrator (S7) at 2:45 PM on June 10, 2013 in the administration conference room confirmed she was unable to produce a written contract with the off campus laboratory that described the services provided to the hospital by the laboratory.
Record review of the hospital Evaluation of Contract Service Criteria 2012 for the local laboratory and signed by the facility administrator (S7) on February 4, 2012, revealed that "no" was checked under "#9. There is a written contract that is signed.".

Based on review of Quality Assurance Meeting minutes and personnel interview the facility failed to measure, analyze, and track quality indicators from their contracted dialysis services in their quality assurance program.

The findings include:

a. Review of quality assurance meeting minutes for January -June 2013, on 7/10/13 in the facility conference room, revealed there was no data presented in regard to the contracted dialysis services for quality indicators from March 2013 (when it was started) to present.
b. In an interview with (S7) on 7/10/13 at 2:00 p.m. in the facility conference room she stated the representative for the contracted dialysis services had not provided her with any quality assurance data that had been requested.
c. In an interview with (S10), on 7/10/13 at 3:50 p.m. in the dialysis storage room area, he stated he had not provided the facility with quality indicators for their quality assurance meeting. He presented to the surveyor paperwork that he stated was quality assurance data for the facility. At the top of the forms was the name of a different hospital. (S10) stated he must not have changed the name at the top of the forms before he printed them; this was on all data for March-June 2013.

Based on interview and record review, the hospital did not have a written contract with the laboratory that performed their laboratory services.
Findings included:
Interview with Hospital administrator (S7) at 2:45 PM on June 10, 2013 in the administration conference room confirmed the facility utilized a local laboratory recommended by one of the hospital physicians but she was unable to produce a written contract with the local laboratory.
Record review of the hospital Evaluation of Contract Service Criteria 2012 for the local laboratory and signed by the facility administrator (S7) on February 4, 2012, revealed that "no" was checked under "#9. There is a written contract that is signed.".