103.4 Functions
The governing body, with technical
assistance and advice from the
hospital staff, shall do the
following:
(1) Provide appropriate physical
resources and personnel required to
meet the needs of the patients and
participate in planning to meet the
health needs of the patients and
health needs of the community. A
quality control mechanism should be
established which includes as an
integral part thereof a risk
management component and an infection
control program.
|
Observations:
Based on review of the facility's 2026 Quality Improvement Plan, facility documents and staff interview (EMP), it was determined that the facility failed to ensure Quality Improvement (QI) activities were reported to the Governing Body; the facility failed to ensure the Quality Improvement (QI) Committee directed, monitored and reviewed all QI activities; the facility failed to ensure the QI Committee focused on all operational functions within the hospital for analysis and improvement opportunities and the facility failed to ensure each facility department followed the EMHS (Endless Mountain's Health Systems') process of identifying any problems or potential problems; make recommendations and follow up to the QI format.
Findings include:
Review on August 7, 2026, of the facility's "2026 Quality Improvement Plan, revealed "Executive Summary Endless Mountains Health Systems' Quality Plan utilizes a systematic approach to quality using valid methods for monitoring, analysis, evaluation, and improvement in operational processes and in the delivery of care and services provided. This plan supports the organizational mission to provide clinical excellence at a reasonable cost and to improve patient and operational outcomes ... Purpose The purpose of the Quality Plan supports the systematic organization-wide approach to design, measure, analyze and improve organizational performance ... This Plan intends to provide a framework of guiding principles for all participants in the provision of care. This structure will set the expectation and encourage all to participate proactively in the improvement and sustainability of all operational performance. The Quality Plan facilitates the identification of key functions of the organization; the assessment of the quality, safety and appropriateness of these functions; and the generation of measurable improvements ... Authority and Accountability The Governing Body It is the duty of the Board to assure the safe delivery of patient care within the guidelines established by the medical staff and hospital leadership while meeting all standards and regulations. The board may delegate responsibilities to other committees ... The Quality Improvement Committee This committee is a multidisciplinary group, which will meet bi-monthly, and more frequently as circumstances dictate. The QI Committee will be responsible for the directing, monitoring and reviewing of all QI activities at Endless Mountains Health Systems. The committee will report directly to the CEO who will present the QI activities to the governing body ... The QI Committee will focus on review of all operational functions within the hospital for analysis and improvement opportunities ... The Hospital Departmental QI ... The QI activities will be consistent with the EMHS QI process. Each department/service will conduct regular meetings to discuss the care rendered and to identify any problems or potential problems. The identification of problems, recommendations and follow up [sic] will conform to the QI format ..."
1. Review on August 7, 2026, of the facility's Medical Staff Committee / Performance meeting minutes held on January 28, 2025, February 20. 2025, March 17, 2025, April 23, 2025, June 19, 2025, August 29, 2025, September 18, 2025, November 17, 2025, and December 17, 2025, revealed no documentation Quality Improvement was discussed at these meetings. There were no meetings held in May and July 2025.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
Review on August 7, 2026, of the facility's Medical Staff Committee / Performance meetings held on January 22, 2026, February 19, 2026, March 17, 2026, April 20, 2026, May 18, 2026, and July 23, 2026, revealed no documentation Quality Improvement was discussed at these meetings.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
2. Review on August 7, 2026, of the facility's QI Committee Meeting Minutes held on June 17, 2025, October 8, 2025, and December 10, 2025, revealed no documentation the QI Committee directed, monitored and reviewed all QI activities.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
Review on August 7, 2026, of the facility's QI Committee Meeting Minutes held on February 11, 2026, April 8, 2026, and June 11, 2026, revealed no documentation the QI Committee directed, monitored and reviewed all QI activities.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
3. Review on August 7, 2026, of the facility's QI Committee Meeting Minutes held on June 17, 2025, October 8, 2025, and December 10, 2025, revealed no documentation the QI Committee focused on all operational functions within the hospital for analysis and improvement opportunities.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
Review on August 7, 2026, of the facility's QI Committee Meeting Minutes held on February 11, 2026, April 8, 2026, and June 11, 2026, revealed no documentation the QI Committee focused on all operational functions within the hospital for analysis and improvement opportunities.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
4. Review on August 7, 2026, of the facility's QI Committee Meeting Minutes held on June 17, 2025, October 8, 2025, and December 10, 2025, revealed no documentation each facility department followed the EMHS process of identifying problems or potential problems; making recommendations or follow up to the QI format.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
Review on August 7, 2026, of the facility's QI Committee Meeting Minutes held on June 17, 2025, October 8, 2025, and December 10, 2025, revealed no documentation each facility department followed the EMHS process of identifying problems or potential problems; making recommendations or follow up to the QI format.
Interview with EMP1 and EMP2 on August 7, 2026, confirmed the above findings.
| | Plan of Correction - To be completed: 09/18/2026
1) Endless Mountains Health Systems (EMHS) will provide updates on Quality Improvement (QI) activities to the Governing Board and Medical Staff at the October, January, April, and July meetings. The quarterly progress reports will be summarized and provided to the Governing Board and Medical Staff in advance and a review and discussion will be conducted by the QI Director. This will be documented in the Governing Board and Medical Staff minutes under the Quality Improvement section of the Governing Board and Medical Staff minutes. This will be monitored by the CEO for compliance. This process will be put in place on or before September 18, 2026. Any incidents of noncompliance will be addressed by the CEO.
2) The QI Committee meeting format will be revised to include formal progress reports from two to three departments at each meeting. The QI committee members, encompassing all departments of the facility, will discuss departmental improvement projects at each bi-monthly QI meeting and any performance issues that are brought up will be addressed by the Committee and the QI Director. The meeting minutes will reflect the activities of the Committee.
EMHS will continue to perform an annual evaluation of contracted services and review the results of such evaluation with the committee at least annually. The CEO and QI Director will monitor for compliance and address any occurrence of non-compliance. This change will be put in place on or before September 18, 2026.
3) The format of the bi-monthly meetings of the QI Committee will be changed to include departmental review of operational issues for consideration of improvement opportunities. All departments require representation on the QI Committee. This review will be documented in the minutes of the QI Committee. The CEO and QI Director will monitor for compliance and address any occurrence of non-compliance. This change will be put in place on or before September 18, 2026.
4) The department representatives on the QI Committee will review the QI Plan approved by the governing board and adhere to the requirement of department operational review and opportunities for QI projects. The QI Committee representatives will sign off on the review of the QI Plan. The CEO and QI Director will monitor for compliance and address any occurrence of non-compliance. This change will be put in place on or before September 18, 2026.
|
|
