Ascension St Vincent Evansville

“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: 50584 Based on document review and interview, the facility failed to measure, analyze, and track quality indicators for facility services including Discharge Planning, Laundry, Security, Nursing Professionals, Pest Control and Housekeeping in the facility’s Quality Assessment and Performance Improvement (QAPI) program. The cumulative effects of this systemic problem resulted in the facility’s inability to ensure that it had an effective Quality Assurance program.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to ensure all services, including those furnished by a contractor, were evaluated and reviewed through the Quality Assessment and Performance Improvement (QAPI) program for fiscal year 2024 and 2025 for 3 contracted services. (Pest Control, Nurse Professionals, Environmental Services. Findings Include: 1. Facility document titled Quality Strategic Plan 2024, indicated facility leaders with authority and oversight by the Quality and Patient Safety Committee of the Board of Directors, establish the Quality and Safety standards, programs and monitoring process; Safety contract reviews will contain, at minimum, one performance indicator. 2. Review of Governing Board Meeting minutes from 12/2023 through 10/2024 lacked evidence of quality data collected for contracted services including Pest Control, Nurse Professionals, and Environmental Services. 3. In interview on 2/14/25 at approximately 1100 hours with A5 (Executive Assistant/Board Secretary), he/she confirmed preparing a Governing Board Meeting packet, but it does not include Quality data/tracking. A4 (Director of Pharmacy) also confirmed contracted services are not discussed at Quality Committee Meeting or Governing Board Meetings. Quality Committee Chair Physician picks one hot topic for quality to discuss such as Sepsis at a Governing Board Meeting, and that is all that is discussed or reviewed. A4 confirmed the Governing Board is not reviewing Quality data from every service the facility offers. 4. In interview on 2/14/25 at approximately 1315 hours with A1 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings: Pest Control, Nurse Professionals, and Environmental Services.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to measure, analyze, and track quality indicators for facility services including Discharge Planning, Laundry, Security, Nursing Professionals, Pest Control and Housekeeping in the facility’s Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1. Facility document titled Quality/Patient Safety Committee Charter indicated under I. Purpose and Responsibilities, Hospital Quality/patient Safety Committee supports the Hospital Board of Directors in its commitment to assure that individuals receiving services from Hospital are provided safe, effective, and quality services. III. Authority and Responsibilities, A. The Committee will monitor the Hospital’s quality improvement and performance improvement program, metrics and goals to determine congruence with the mission, vision and values of the Hospital. 2. Review of Quality and Patient Safety Committee meeting minutes from 1/2024 through 11/2024 lacked evidence of quality data collected for contracted services including Pest Control, Nurse Professionals and Environmental Services; lacked evidence of quality data collected for facility services including Laundry, Security and Discharge Planning. 3. In interview on 2/14/25 at approximately 1315 hours with A1 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings. Services included Pest Control, Nurse Professionals, and Environmental Services. A1 also confirmed the facility is not evaluating the following facility services in the Quality and Safety Meetings including but not limited to Laundry, Security and Discharge Planning.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... 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) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 50584 Based on document review and interview the Governing Board failed to assure all services, including those furnished by a contractor were included in the Quality Assessment and Performance Improvement (QAPI) program. Findings Include: 1. Facility document titled Quality/Patient Safety Committee Charter indicated under I. Purpose and Responsibilities, Hospital Quality/patient Safety Committee supports the Hospital Board of Directors in its commitment to assure that individuals receiving services from Hospital are provided safe, effective, and quality services. III. Authority and Responsibilities, A. The Committee will monitor the Hospital’s quality improvement and performance improvement program, metrics and goals to determine congruence with the mission, vision and values of the Hospital. 2. Facility document titled Quality Strategic Plan 2024, indicated facility leaders with authority and oversight by the Quality and Patient Safety Committee of the Board of Directors, establish the Quality and Safety standards, programs and monitoring process; Safety contract reviews will contain, at minimum, one performance indicator. 3. Review of Governing Board Meeting minutes from 12/2023 through 10/2024 lacked evidence of quality data collected for contracted services including Pest Control, Nurse Professionals and Environmental Services; lacked evidence of quality data collected for facility services including Laundry, Security and Discharge Planning. 4. Review of Council on Clinical Exellence Meeting minutes from 11/2023 through 11/2024 lacked data collected for contracted services including Pest Control, Nurse Professionals and Environmental Services; lacked evidence of quality data collected for facility services including Laundry, Security and Discharge Planning. 5. In interview on 2/14/25 at approximately 1100 hours with A5 (Executive Assistant/Board Secretary), he/she confirmed preparing a Governing Board Meeting packet but it does not include Quality data/tracking. Packet includes but not limited to Quality and Operations meeting minutes, consent items, resolutions, last meeting minutes, then packet is downloaded into a portal for the governing Board to review. A4 (Director of Pharmacy) also confirmed contracted services are not discussed at Quality Committee Meeting or Governing Board Meetings. Quality Committee Chair Physician picks one hot topic for quality to discuss such as Sepsis at a Governing Board Meeting, and that is all that is discussed or reviewed. 6. In interview on 2/14/25 at approximately 1315 hours with A1 (Director of Quality), he/she confirmed the facility is not evaluating the following contracted services in the Quality and Safety Meetings. Services included Pest Control, Nurse Professionals, and Environmental Services; confirmed facility is not evaluating the following hospital services in the Quality and Safety Meetings including Laundry, Security and Discharge Planning.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to notify patient representative of patient health decline, and failed to involve patient representative in patient treatment, services, and decisions for 1 of 10 patient medical records reviewed. (P2) Findings include: 1. Facility policy titled Patient Rights and Responsibilities, PolicyStat ID 10309215, last revised 5/23/2022, indicated on Page 2, under Patients Rights and Responsibilities, Participation in Care, You have the right to have your family and surrogate decision makers involved in your care, treatments, services, and decisions. 2. Review of P2 MR indicated: a. Facility lacked documentation of notifying FM1 (P2’s Family Member) of P2’s decline in condition on 3/30/24, and involve FM1 in treatment, services, and decisions when patient decline occurred. 3. In interview on 9/30/24 at approximately 1010 hours with A3 (Patient Safety Leader) and A4 (Accreditation), they confirmed FM1 was not notified of P2’s decline in condition and treatment being administered to P2. FM1 phoned facility after two attempts to contact P2 the morning of 3/30/24 and was notified at that time of patient’s decline and procedure. A4 confirmed there was a lapse in communication by the facility.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to complete documentation of consent for treatment per facility policy for 3 of 10 MRs reviewed. ( P8, P9, P10) Findings include: 1. Facility policy titled Consent to Medical Care for Adult Patients, PolicyStat ID: 10458941, last revised 2/22/22, Page 1, under policy statement, ERD #27. Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all. Page 2, under Informed Consent Form: Form used by hospital or practice to document the patient has agreed to the medical intervention. This policy will use the general term “Informed Consent Form” with the understanding that each hospital or practive may refer to their Informed Consent Form by a specific name or that there may be specific forms for specific procedures. 2. Review of P8 MR indicated: a. Patient admitted to facility on 8/19/24 with diagnosis of Pneumothorax. b. Lack of documentation of signed Consent and Conditions of Admission form per facility policy. 3. Review of P9 MR indicated: a. Patient admitted to facility on 9/15/24 with diagnosis of Respiratory Failure. b. Lack of documentation of signed Consent and Conditions of Admission form per facility policy 4. Review of P10 MR indicated: a. Patient admitted to facility on 9/13/24 with diagnosis of Small Bowel Obstruction. b. Lack of documentation of signed Consent and Conditions of Admission form per facility policy. 5. In interview on 9/30/24 at approximately 1000 hours with A3 (Patient Safety Leader), he/she confirmed P8, P9 and P10 MR lacked documentation of a signed Consent and Conditions of Admission form per facility policy.”