| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670029 | (X3) Date Survey Completed 03/15/2011 |
| Name of Provider or Supplier First Surgical Hospital | Street Address, City, State 4801 Bissonnet Blvd, Bellaire, TX | |
| 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 observation, interview, and record review the Hospital failed to ensure seven out-patient emergency departments were monitored by the performance improvement program. (Bellaire Emergency Center, Memorial Heights Emergency Center, St. Michaels Emergency Room Sugar Land, St. Michaels Emergency Room Westheimer, St. Michaels Emergency Room Woodlands, Preferred Emergency Room, and River Oaks Emergency Center. Findings include: Interview 3/9/11 at 11:15 a.m. with the Chief Executive Officer (CEO) revealed the hospital has seven out-patient emergency rooms that are provider based. The CEO stated the hospital has established contracts / leases with each emergency room and the emergency rooms are operated by a contract management agreement with contract Medical Directors at each location. Interview 3/14/11 at 11 a.m. with the Medical Director of Emergency Room Services (ID# 53) revealed he does not supervise the seven out-patient emergency room locations but does attend Medical Executive Committee meetings to provide over-sight regarding emergency services. Record review the hospitals "Performance Improvement Plan" dated 4/2009 stated "Policy: the scope of the Performance Improvement Plan encompasses all services provided at First Street Hospital. The hospital-wide program will monitor the performance of Medical Staff and hospital departments compliance with regulatory and accreditation requirements." Record review of Governing Board / Quality Assurance meetings dated 9/22/10, 12/8/10, 2/23/11 revealed the hospital was tracking transfers to a higher level of care, patients that left against medical advise, and the total volume of emergency room patients. The hospital documented that all transfers to a higher level of care were appropriate. Interview 3/14/11 at 10:40 a.m. with the Director of Quality Assurance revealed the hospital does not have a specific policy establishing quality indicators for the emergency departments. Problems identified: Four out-patient emergency room indigent patients were inappropriately transferred to other hospitals (Patient ID#'s 10, 15, 35, 41) Performance Improvement Reviews completed by the contract management company revealed the transfers to a higher level of care was appropriate for each patient ***Refer to CMS tag A0043 Governing Body Two Contract Emergency room Medical Directors mis-represented the out-patient emergency center / hospital as a "Free Standing Emergency Center" to other hospitals (Physician ID#'s 58 and 62) ***Refer to CMS tag A0043 Governing Body One Emergency room Contract Medical Director was not forthright with another hospital when asked if he had a "Transfer agreement with any hospitals." (Physician ID# 58) ***Refer to CMS tag A0043 Governing Body One of seven out-patient emergency room laboratories failed to meet Federal Laboratory requirements (no CLIA certificate: Clinical Laboratory Improvement Amendments at the Bellaire Emergency Center) ***Refer to CMS tag 576 Laboratory Services The Governing Body failed to obtain a laboratory contract between Bellaire Emergency Center and hospital ID# 90. ***Refer to CMS tag A0043 Governing Body Infection control activities at 3 out-patient emergency rooms were not integrated with the hospital. Three locations were using autoclaves without implementing quality controls. (St Michael's Sugar Land, Westheimer, and the Woodlands) ***Refer to CMS tag 747 Infection Control |