Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 010001 (X3) Date Survey Completed 08/24/2017
Name of Provider or Supplier Southeast Health Medical Center Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0263 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:
Based on review of the facility policy, medical records, Occurrence Report summary, Risk Management Worksheets, Minutes Houston County Health Care Authority Quality Committee, Facility's Corrective Action Plan and interviews with facility staff, it was determined the facility failed to ensure: 1. Patient occurrences were reported, investigated, analyzed and preventative measures were implemented to prevent further occurrences. 2. The sentinel event involving Patient Identifier (PI) # 1, a patient who successfully committed suicide while a patient in the Behavioral Medicine Unit (BMU) was reviewed in monthly quality meetings of the governing body. 3. Governing Body Quality Committee meetings were conducted for the months of July 2017 and as of the date of this survey (8/24/17) August 2017. This affected 2 of 3 medical records (PI # 1, PI # 2) and 3 of 6 patients with adverse occurrences (PI # 4, PI # 6 and PI # 7). This also has the potential to negatively affect all patients admitted to this facility. Findings include: Refer to A286 and 309 for findings.