HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined that the governing body failed to ensure that the services performed under a contract are provided in a safe and effective manner.

This is not met as evidenced by:

1) Review of the Facility's Governing Board and Committee Meetings dated July 2012 through June 2014 revealed no documentation of review of services performed under contract for DME (durable medical equipment) or staffing agencies.

During an interview on July 9, 2014, at approximately 2:00 PM, EMP1 indicated, "We don't review all of our contracts."

Based on review of medical records (MR) and staff interview (EMP), it was determined the facility staff failed to provide rehabilitation treatment upon the written prescription of the responsible physician in two of two medical records reviewed (MR31 and MR32).
Findings include:
1) Review of MR31 revealed a physician order for PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy), dated June 30, 2014, "eval and treat once." Further review of MR31 revealed no further orders for PT, OT, or ST after the initial evaluation, with documentation of treatment by PT, OT and ST on July 1, July 2, July 5, July 7, July 8, July 9 and July 10, 2014.
2) Review of MR32 revealed a physician order for PT and OT dated June 29, 2014, "eval and treat once." Further review of MR32 revealed no further orders for PT or OT after the initial evaluation, with documentation of treatment by PT and OT on June 30, July 1, July 2, and July 5, July, July 8, July 9, and July 10, 2014.
3) Interview with EMP5 on July 10, 2013, revealed, "You won't find any other orders for any of our inpatients."