HospitalInspections.org

Based on review of facility contracts, review of performance improvement data, review of provider's policy and procedures and staff interview, the governing body failed to ensure oversight of contracted services as evidenced by failing to monitor and enforce terms of the contractual terms for all contracted services.

The findings include:

Review of the Purchased Services Agreement on 09/01/2015 revealed an agreement with the following services: "Biomedical; Registered Dietician; Imaging; Laboratory; Laundry and Linen (Environmental Services); Outpatient; Sterile Processing; Food and Nutrition; Emergency; Information Technology; and Surgical Support." Further review of the Purchased Services Agreement revealed the agreement was signed on 06/29/2015 with a retroactive date of March 1, 2014 and "end at midnight three (3) years thereafter...Review of the general conditions of the agreement revealed the following:

IV. "COVENANTS OF PROVIDING PARTIES...
4.2 Quality of Services...Each party covenants, when acting as a Providing Party providing Services..., to use its reasonable efforts to provide Services consistent with (the hospital)Policies...provide...Services in such a manner as will ensure that all duties are performed....Services Provided...as may be required by, and in compliance with, the Conditions of Participation, and any standard, ruling, or regulation of DHHS (Department of Health and Human Services),...US Department of Health and Human Services, or any other federal, state, or local governmental agency...

4.2.2 Quality Improvement Program. Each Providing Party under this Agreement shall participate in the overall quality improvement program of (the hospital), in accordance with...Policies and the requirements of certifying agencies..."

Review on 09/01/2015 of the hospital's "Quality Assessment / Performance Improvement Program" effective 04/16/2015 revealed "B. Patient Focused Functions 1. The Director of Clinical Services shall ensure an on-going systematic process for monitoring, measuring, assessing and improving care delivery processes, clinical outcomes and appropriateness of care provided. 2. At a minimum the following services shall participate

· dialysis services;
· diagnostic services;
· dietary services;
· environmental services, housekeeping and maintenance;
· linen services;
· nursing services;
· rehabilitation services;
· respiratory services;
· pharmaceutical services
· Case management services

C. Organizational Functions and Essential Structural Components. Organizational leaders shall ensure an ongoing systematic process for monitoring, measuring, assessing, and improving functions that support delivery of quality care..."

Interview on 09/02/2015 at 0920 with the hospital's chief executive officer (CEO) revealed hospital leadership was aware of the need to evaluate contracted services as part of the Quality Assessment / Performance Improvement (QAPI) program and in compliance with hospital policy. Interview revealed "we don't have any QAPI on them but that's something we recognized we need to work on and we have plan in place." Interview revealed Organ Procurement; Telemedicine; Anesthesia, Nuclear Medicine, emergency, and rehabilitation services are also contracted services. Interview revealed the hospital's regional QAPI director "is coming to train us." The interview confirmed the hospital's QAPI program policy was not followed or the Purchase Services Agreement.

Based on review of the hospital's contracts, review of performance improvement data, policy and procedures and staff interview, the governing body failed to ensure oversight of contracted services.

The findings include:

Review of the Purchased Services Agreement on 09/01/2015 revealed an agreement with the following services: "Biomedical; Registered Dietician; Imaging; Laboratory; Laundry and Linen (Environmental Services); Outpatient; Sterile Processing; Food and Nutrition; Emergency; Information Technology; and Surgical Support." Further review of the Purchased Services Agreement revealed the agreement was signed on 06/29/2015 with a retroactive date of March 1, 2014 and "end at midnight three (3) years thereafter...Review of the general conditions of the agreement revealed the following:

IV. "COVENANTS OF PROVIDING PARTIES...
4.2 Quality of Services...Each party covenants, when acting as a Providing Party providing Services..., to use its reasonable efforts to provide Services consistent with (the hospital)Policies...provide...Services in such a manner as will ensure that all duties are performed....Services Provided...as may be required by, and in compliance with, the Conditions of Participation, and any standard, ruling, or regulation of DHHS (Department of Health and Human Services),...US Department of Health and Human Services, or any other federal, state, or local governmental agency...

4.2.2 Quality Improvement Program. Each Providing Party under this Agreement shall participate in the overall quality improvement program of (the hospital), in accordance with...Policies and the requirements of certifying agencies..."

Review on 09/01/2015 of the hospital's "Quality Assessment / Performance Improvement Program" effective 04/16/2015 revealed "B. Patient Focused Functions 1. The Director of Clinical Services shall ensure an on-going systematic process for monitoring, measuring, assessing and improving care delivery processes, clinical outcomes and appropriateness of care provided. 2. At a minimum the following services shall participate:

· dialysis services;
· diagnostic services;
· dietary services;
· environmental services, housekeeping and maintenance;
· linen services;
· nursing services;
· rehabilitation services;
· respiratory services;
· pharmaceutical services
· Case management services

C. Organizational Functions and Essential Structural Components 1. Organizational leaders shall ensure an ongoing systematic process for monitoring, measuring, assessing, and improving functions that support delivery of quality care..."

Interview on 09/02/2015 at 0920 with the hospital's chief executive officer (CEO) revealed hospital leadership was aware of the need to evaluate contracted services as part of the Quality Assessment / Performance Improvement (QAPI) program and in compliance with hospital policy. Interview revealed "we don't have any QAPI on them." Interview revealed Organ Procurement; Telemedicine; Anesthesia, Nuclear Medicine, emergency, and rehabilitation services are also contracted services. Interview confirmed the hospital's QAPI program policy was not followed nor the Purchase Services Agreement.

Based on review of hospital medical staff bylaws, governing bylaws, and interview, the hospital staff failed to periodically review, update the medical staff bylaws, and obtain signatures as evidence of review and approval.
The findings include:

Review of the hospital's Medical Staff By-Laws, Medical Staff Rules and Regulations on 09/01/2015 revealed a revision date of September 2010. Review revealed the bylaws signature page confirming review and approval was blank. Review revealed the bylaws lacked signatures of the hospital's Medical Director, Chairman of the Board of Director's, and Secretary as witness thereof.

Review on 09/02/2015 of the hospital's Governing Body (GB) Bylaws amended and restated effective August 28, 2015 revealed, "C. General Functions 1. Policies and Strategy...The Board of Directors shall develop and approve...Medical Staff's bylaws, rules, and regulations. 3. Relationship with Medical Staff. The Board of Directors shall periodically review the Medical Staff bylaws, rule, and regulations... IX. Medical Staff D. 2. Bylaws and Related Documents The Board of Directors shall approve the Medical Staff bylaws..."

Interview on 09/02/2015 at 1015 with the hospital's CEO revealed, Medical Staff bylaws are developed by the hospital's Medical Director, reviewed and approved by the Governing Body, and witnessed by the secretary. Interview revealed an addendum was made to the bylaws in August 2015 adding Telemedicine staff requirements. Interview revealed the hospital Medical Staff bylaws were not reviewed at that time and the addition of Telemedicine staff requirements were not dated and signed as being approved by the required disciplines. Interview revealed there has been no periodic review(s) of the Medical Staff bylaws since the establishment in 2010.

Based on policy review, observation and interview, the facility failed to ensure unauthorized personnel from accessing to locked areas where drugs and biologicals were stored.
The findings include:
Review on 09/01/2015 of the facility's policy entitled "DRUG INVENTORY CONTROL, last revised January 2013, " revealed ... Storage: ... Medications are stored in a secure manner... Medication rooms on patient care units used for storage of floor stock medications will remain locked. Access is limited to licensed nursing staff."
Observation on 09/01/2015 of the clean utility room revealed the doors were locked and a code was needed for entry. Bags of patient labeled, ready to use IV (intravenous) antibiotics hung on hooks from a pegged wall.
Interview on 09/01/2015 at 1230 with the Charge Nurse revealed departments with access to the clean utility room included Rehabilitation staff, CNAs (Certified Nursing Assistants) and environmental services. The Charge Nurse further stated the IV bags of antibiotics used to be kept in the medication room which "was too small... we just didn't have enough room."
Interview on 09/03/2015 with the Director of Pharmacy revealed the IV antibiotics in the clean utility room was "not an ideal situation" and was due to space constraints. The facility is looking at getting a locked cabinet to keep in the clean utility room "so only nurses have access."

Based on policy review, observation and interview, the facility failed to ensure a patient bed was safe for use for 1 of 1 bariatric rental bed.
The findings include:
Review on 09/01/2015 of the facility policy entitled "Medical Equipment Management Defective Equipment," last revised in June 2013, revealed "...PROCEDURE 1. When any piece of equipment that is used or may come into contact with a patient, visitor, or employee is deemed not to be operating properly or has been broken or damaged, it should be removed immediately from service..."
Observation on 09/01/2015 at 1145 revealed a rental bariatric bed in an empty patient room recently occupied by a patient. When in the lowered position, 4 of 4 bedrails had broken, sharp edges of plastic protruding outward at the points where the elbows bent to move the rails up and down.
Interview on 09/01/2015 with the interim Charge Nurse revealed the rental bed was provided by a company with whom the facility contracted for bariatric beds. Staff helped to bring the rental beds in and set them up. "I think the staff would have said something if they had noticed... I can see that if someone put their leg over the side it could cause a scratch or injury of some kind..." The charge nurse further stated she would start looking at the rental beds "more closely."