Orlando Health Melbourne Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 13640 Based on interviews and review of facility documentation the hospital’s Governing Body failed to oversee the status and ensure contracts were provided in a safe and effective manner when contracted Fire Monitoring and Detection services for the facility’s fire alarm system was found to be expired as of 01/31/2023, due to non-payment. Services were not provided for regulatory testing outlined in the contract from 04/29/2024 through 05/23/2024, which was the initial time of administrations’ knowledge of the expired contract. The facility failed to take action to renew or secure services elsewhere after contract expiration date of 01/31/2023. It was not until 05/20/24 that the Administration became aware the fire alarms were not being monitored. Refer to A0084.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 13640 Based on interviews and review of facility documentation, facility failed to ensure an effective, ongoing, hospital-wide Quality Assessment and Performance Improvement program (QAPI) was maintained and addressed priorities in patient safety regarding fire monitoring and detection when services furnished under a contract for Fire Alarm Monitoring and Detection expired on 01/31/2023. No attempts were made to renew and/or seek out other monitoring services subsequently posing a risk of there being a fire incident without timely and proper response by emergency officials due to facility’s non-payment for services placing patients in a compromised safety position. Refer to A0309.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 13640 Based on interview and a review of facility documentation, the facility’s governing body failed to ensure that services performed under a contract were provided in a safe and effective manner, causing the facilities fire alarm system to be potentially unmonitored and posing a risk of their being a fire incident without timely and proper response by emergency officials placing patients in a compromised safety position. Findings: A review of a contract for remote fire alarm monitoring between the facility (formerly named Wuesthoff Medical Center - Melbourne) and the company Tyco SimplexGrinnell of 11/07/2017 revealed it had a contract term of “01-FEB-18 to 31-JAN-23.” During an interview of the Chief of Quality on 05/23/2024 at 1:35 PM, she stated that at the present time this contract had not been extended. Among the services that were included in the agreement was: “Alarm & Detection - monitoring Silent Knight Programmable Fire Alarm sys. and Fire alarm monitoring basic service (up to 100 devices).” Per the contract this service had an annual cost of $420. The contract elaborated upon what was involved in the monitoring including “Alarm signal initiated by a fire alarm control panel. Central Station will endeavor to notify the fire department and Customer when an alarm or trouble signal is received. This service includes 1-800 toll-free signal transmission, 24-hour auto dialer test, and notification of Customer-provided Emergency Call List.” The contract noted a “Payment term” which indicated the fee was to be paid “annual in advance.” The contract also contained a “Default” clause indicating “An event of default shall include . . . failure of the customer to pay any amount within ten (ten) days after the amount is due and payable. . . Upon the occurrence of an Event of Default, Company may pursue one or more of the following remedies, 1) discontinue furnishing services, 2) by written notice to Customer declare the balance of unpaid amounts due and to become due under the agreement to be immediately due and payable . . . “ Upon request on 05/23/2024, the facility produced documentation of their last testing of the system with verification of contractor notification on 04/29/2024. This was the last date for which the facility had evidence that the system was in operation, even with the expired contract. During an interview of the Chief of Quality on 5/23/24 at approximately 2:00 PM, she confirmed that after the contract had expired, there was no renewed contract for monitoring and no payments had been sent to the contractor. Review of facility’s policy “Approval and Monitoring of Contracted Services / External Services” read “The Governing Body is ultimately responsible for ensuring that contracts / externally provided service agreements between the Hospital and third parties permit the Hospital to comply, and that such contracts do comply, with applicable Medicare Conditions of Participation and other applicable legal and accreditation standards, and that such contracts are performed in a safe and effective manner.” Also “The Hospital Board of Directors (another term for Governing Body) is ultimately responsible for the monitoring of all contracted/external provider-services activities.” Review of the document “Contracted Services Quality Indicator”, dated 12/21/2023, indicated the contracted Service for “Johnson Controls (Fire Testing and Inspections) . . . At this time, the vendor is not able to provide the regulatory testing that is outlined in the contract due to financial constraints. Normal test and inspection services have been delinquent due to a credit hold status.” Continued review of this form did not reflect any contract expiration information and per interview with the Chief Quality Officer and review of facility documentation, this was the first mention of any financial concern with the monitoring system. The Chief Quality Officer produced a document which she stated was a review of contracts performed by the Regional Facilities Director on 01/18/2023 and included Johnson Controls, which had purchased Tyco Simplex Grinnell at some point after the creation of the contract in February of 2018. This document noted that the services provided under this contract were performed on time 100% of time and was noted with a Medical Executive Committee Annual Approval Date of 01/18/2023 and a Board of Directors Annual Approval Date of 01/24/2023 with notation to continue with Contracted Service and confirmation of this decision was found in Governing Body (Board of Directors) meeting minutes of 01/24/2023 under “Annual Contracted Services Review”. However, this document did not have any information regarding the contract’s upcoming expiration date of 01/31/2023, and an interview with Chief Quality Officer confirmed the Governing Body (Board of Directors) were unaware. The surveyor reviewed a series of emails beginning on 01/02/2024 with the subject heading of “Monitoring Renewal Multiple Sites Direct Billing.” An email, from the facility’s Financial Analyst to an individual at Johnson Controls on 01/11/2024 discussed the expired contract, acknowledging their awareness of the Hospital’s expired contract and being made aware by the contractor that with the nonpayment for services rendered (even during the expiration of contract) “will most likely have to terminate the current monitoring”, making facility aware of contractor’s plan to terminate their services for current monitoring. Therefore, the facility was aware of the likelihood for services to be terminated soon. This correspondence took place prior to 01/23/24, the date of the Government Body (Board of Directors) meeting where contracts were discussed. During an interview of the Chief of Quality on 05/23/2024 at 2:15 PM and 3:50 PM, she stated there was no evidence that anyone in the facility brought information regarding the expired contracts to the Board of Directors (Governing Body) from the date it had expired to the date of the annual contract review by the Board of Directors (Governing Body) on 1/23/24. The legally responsible Governing Body (Board of Directors) failed to recognize the contract for Fire Alarm and Detection monitoring for the Hospital had expired in January of 2023 for non-payment of services and without attempts to renew and/or seek out other monitoring services subsequently posing a risk of their being a fire incident without timely and proper response by emergency officials placing patients in a compromised safety position. An interview with the Chief of Quality on 05/23/2024 at 4:10 PM, confirmed that administration became aware of a problem in the monitoring system a weekend after the last drill (04/29/2024), on 05/18/2024. She stated that phones had gone out during a storm. When they re-initialized the phone system, they noticed on 05/20/2024 that the fire alarm panel was still in test mode. At that point, the Regional Director of Facilities contacted Johnson Controls and learned that they were no longer monitoring the facility. She stated that until 5/22/24, after the arrival of an AHCA Life Safety surveyor, they had not instituted a fire watch.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 13640 Based on interviews and a review of facility documentation, the facility failed to ensure there was an effective ongoing program for quality improvement and patient safety to address priorities in patient safety when Fire Monitoring and Detection services provided by a service contract was allowed to expire due to non-payment of their services. Findings: A review of a contract for remote fire alarm monitoring between the facility (formerly named Wuesthoff Medical Center - Melbourne) and the company Tyco SimplexGrinnell of 11/07/2017 revealed it had a contract term of “01-FEB-18 to 31-JAN-23.” During an interview of the Chief of Quality on 05/23/2024 at 1:35 PM, she stated that at the present time this contract had not been extended. Among the services that were included in the agreement was: “Alarm & Detection - monitoring Silent Knight Programmable Fire Alarm sys. and Fire alarm monitoring basic service (up to 100 devices).” Per the contract this service had an annual cost of $420. The contract elaborated upon what was involved in the monitoring including “Alarm signal initiated by a fire alarm control panel. Central Station will endeavor to notify the fire department and Customer when an alarm or trouble signal is received. This service includes 1-800 toll-free signal transmission, 24-hour auto dialer test, and notification of Customer-provided Emergency Call List.” The contract noted a “Payment term” which indicated the fee was to be paid annually and in advance. The contract also contained a “Default” clause indicating “An event of default shall include . . . failure of the customer to pay any amount within ten (ten) days after the amount is due and payable. . . Upon the occurrence of an Event of Default, Company may pursue one or more of the following remedies, 1) discontinue furnishing services, 2) by written notice to Customer declare the balance of unpaid amounts due and to become due under the agreement to be immediately due and payable . . . “ Upon request on 05/23/2024, the facility produced documentation of their last testing of the fire alarm system with verification of contractor notification on 04/29/2024. This was the last date for which the facility had any evidence that the system was in operation, even with the expired contract. During an interview of the Chief of Quality on 05/23/2024 at approximately 2:00 PM, she confirmed that after the contract had expired, there was no renewed contract for monitoring and no payments had been sent to the contractor. The document “Annual Review of Contract Clinical Services” of 12/05/2022 for the contractor Johnson Controls Inc. read: “Scope of service provided: Fire Alarm Test and Inspection, Sprinkler testing.” A different document was used in 2023. Review of the document “Contracted Services Quality Indicator” for annual reviewing of contracts, dated 12/21/2023, revealed “Contracted Service: Johnson Controls (Fire Testing and Inspections) . . . At this time, the vendor is not able to provide the regulatory testing that is outlined in the contract due to financial constraints. Normal test and inspection services have been delinquent due to a credit hold status.” The form did not reflect any contract expiration information, and per interview with the Chief Quality Officer and review of facility documentation, 12/21/2023, was the first mention of financial concerns with the monitoring system. The Chief Quality Officer also produced a document which she stated was a review of contracts performed by the Regional Facilities Director on 01/18/2023 and included Johnson Controls, which had purchased Tyco SimplexGrinnell at some point after the creation of the contract in February of 2018. This document noted that the services provided under this contract were performed on time 100% of time and noted a Medical Executive Committee Annual Approval Date of 01/18/2023,a Board of Directors Annual Approval Date of 01/24/2023, with notation to continue with Contracted Service. Confirmation of this decision was found in Governing Body (Board of Directors) meeting minutes of 01/24/2023 under “Annual Contracted Services Review”. However, this document did not have any information regarding the contract’s upcoming expiration date of 01/31/2023 and an interview with Chief Quality Officer confirmed the Governing Body (Board of Directors) were unaware. During an interview of the Chief of Quality on 05/23/2024 at approximately 2:00 PM, she stated that after the contract had expired, there was no renewed contract for monitoring and no payments had been sent to the contractor. The surveyor reviewed a series of emails beginning on 01/02/2024 with the subject heading of “Monitoring Renewal Multiple Sites Direct Billing.” An email, from the facility’s Financial Analyst to an individual at Johnson Controls on 01/11/2024 discussed the expired contract, acknowledging their awareness of the Hospital’s expired contract and being made aware by the contractor that with the nonpayment for services rendered (even during the expiration of contract) “will most likely have to terminate the current monitoring”, making facility aware of contractor’s plan to terminate their services for current monitoring. Therefore, the facility was aware of the likelihood for services to be terminated soon. This correspondence took place prior to 01/23/24, the date of the Government Body (Board of Directors) meeting where contracts were discussed. Facility policy Approval and Monitoring of Contracted Services / External Services indicated that “Contracted/externally provided service quality monitoring data will be presented to the Quality and Safety Committee and other related committees annually or at the specified intervals identified in Attachment A.” A review of Attachment A, Contracted / Externally Provided Services Quality Indicator revealed it to have an area where pertinent information could be entered related to contracted services. However, there was no information entered related to the Fire Monitoring and Detection contract’s expiration dates. During an interview of the Chief of Quality on 05/23/2024 at approximately 3:05 PM, she stated that in 2023, in lieu of using that corporate Attachment A form in 2022, they used one adapted to their facility, titled Annual Review of Contract Clinical Services and that form provided no area to enter any type of pertinent information related to the contracted services being reviewed. Review of the Quality Assurance Committee minutes of 01/08/2024, provided by the Chief of Quality on 5/23/2024, noted the committee had performed their annual review of contracted services. However, there was no mention of any expired contracts. The minutes for the Quality Assurance Committee dated 01/09/2023 read “The annual contracted services metrics grid was reviewed and approved.” Again, there was no mention of any upcoming expired contracts During an interview of the Chief of Quality on 05/23/2024 at 4:10 PM, she stated that the administration became aware of a problem in the Fire monitoring system a weekend (05/18/2024) after the last drill of 04/29/2024. She stated that phones had gone out during a storm. When they re-initialized the phone system, they noticed on 05/20/2024 that the fire alarm panel was still in test mode. At that point, the Regional Director of Facilities contacted Johnson Controls and learned that they were no longer monitoring the facility due to non-payment. She stated that until 05/22/2024, after the arrival of an AHCA Life Safety surveyor, they had not instituted a fire watch.”