HospitalInspections.org

Based upon review of Quality Assurance/Performance Improvement Program (QA/PI) and data for 2009 and 2010 and staff interview, the Governing Body failed to ensure all services performed under contract were evaluated through the hospital's quality assessment/performance improvement program as evidenced by failing to evaluate through the QA/PI Program the Intensive Outpatient Program (IOP) services provided by contract personnel. Findings:

Review of the QA/PI Program and associated data for 2009 and 2010 revealed there failed to be documented evidence the outpatient IOP was evaluated through the hospital's QA/PI Program. Interview with the Director of Quality Management, S5, on 06/24/10, 2:10 PM, revealed she thought the IOP was monitoring the patient's progress towards goals. After S5 spoke with the IOP personnel, she stated that they were reviewing each patient for program compliance and according to the IOP personnel, the monitoring data was submitted on a disk. At 2:30 PM, S5 provided for review performance improvement data from the IOP with Chart Compliance, Attendance Compliance, and Patient Satisfaction identified as the monitored categories; however, there failed to be evidence this information was included in the hospital wide QA/PI program.

Based upon review of the list of Contracted Services (maintained by the hospital), and Administrative interviews the hospital failed to ensure the list of Contracted Services: 1) included the contract the hospital had with a local Nursing School (Nursing School-A), and 2) were specific by including the nature/scope of the individual Contracted Services. Findings:

Review of the list of Contracted Services (the hospital maintained), revealed there lacked documented evidence of what each Contracted Service would provide to the hospital. Continued review of the list revealed the Contracted Services were listed alphabetically.

Interview, on 06/22/2010 at 10:30 am, with Chief Clinical Officer (CCO) S2 revealed he acted as the preceptor for nursing students from a local Nursing School, identified as Nursing School-A. CCO S2 was questioned if the hospital had a contract with Nursing School-A, as the surveyor did not see Nursing School-A listed on the contracted services list. CCO S2 did not answer the question.

Interview, on 06/22/2010 at 2:30 pm, with CCO S2 and Registered Nurse S5 confirmed the list of Contracted Services the hospital maintained was not complete as it did not document Nursing School-A as a Contracted Services; nor did any of the listed contracted services have their individual provisions of services listed.

Based upon reviews of 2 of 10 medical records (patient #2, #6), Health Information Management (HIM) policies and procedures, and Administrative interviews the hospital failed to ensure all entries in the patients medical records were 1) authenticated by the individual who documented the nursing progress note (patient #2); and 2) timed the group meetings and one to one sessions (patient #6). Findings:

Review of patient #2's medical revealed Registered Nurse (RN) S7 documented findings on a Nursing Progress Note, dated 06/17/2010; however, on the signature section the RN S7 placed her initials but had not documented her credentials.

Review of patient #6's medical record revealed documented group meeting notes and one to one sessions which occurred 05/21/2009 to 06/11/2010. Continued review of patient #6's record revealed various Licensed Professional Counselors had documented the dates the group sessions were conducted, as well as the one to one sessions; however the times the sessions (group and one to one) occurred were not documented.

Interview, on 06/23/10 at 10:00 am, with Chief Clinical Officer (CCO) S2 confirmed RN S7 had not placed her credentials behind her initials on the Nursing Progress Note dated 06/17/10.

Interview, on 06/24/10 at 2:00 pm, with Licensed Professional Counselor S6 confirmed (after she reviewed patient #6's medical record), all the group sessions and one to one sessions conducted with patient #6 did not have any times documented as to when the sessions occurred.

There lacked documented evidence all entries in the patient's medical records were authenticated (#2) and
had all entries timed (patient #6).