Initial Comments:
This report is the result of a full Medicare recertification survey conducted onsite on April 4, 2023 to April 7, 2023 and completed offsite on April 10, 2023, at KidsPeace Orchard Hills Campus. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
It was also determined the facility was in compliance with 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals at 482.42(g)(1)-(3)(i)-(x) COVID-19 Vaccination of Facility Staff.
Plan of Correction:
482.12(e)(1) STANDARD
CONTRACTED SERVICES
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The governing body must ensure that the services performed under a contract are provided in a safe and effective manner.
Observations:
Based on review of policy and procedures, facility documents, and staff interview (EMP), it was determined that the governing body failed to ensure the contracted services for clinical laboratory testing services, patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services were provided in an effective manner.
On April 5, 2023, at approximately 11:15 AM a request was made to EMP1 for the facility's policy regarding evaluation of contacted services. None was provided.
On April 5, 2023, at approximately 11:30 AM a request was made to EMP1 for documentation of governing body's review and evaluations of the contracted services: clinical laboratory testing services, patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services. None was provided.
On April 5, 2023, at approximately 11:35 AM a request was made to EMP1 for documentation of the quality assessment and performance improvement (QAPI) committee's review and evaluation of the following contracts: clinical laboratory testing services, patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services. None was provided.
Interview with EMP1 on April 5, 2023, at approximately 2:30 PM confirmed the governing body or QAPI committee does not review and evaluate the contracted services of patient transportation services, biohazardous waste disposal, translation services, and mobile x-ray services.
Plan of Correction:All contracted services employed by KidsPeace Children's Hospital will be assessed annually by the hospital Risk Management Department and the KidsPeace Board of Directors.
An assessment form and policy outlining the review procedure will be developed by the Hospital Risk Management department.
The review procedure will be as follows:
An assessment will be documented for each vendor by the Risk Management Department annually. These assessments will be reviewed by the hospital Quality, Safety and Compliance (QSC) committee in monthly meetings. The results of the assessments and QSC review will be added to the KidsPeace Board of Directors Meeting for final approval.
Target date for completion of policy and implementation of new process: July 1st,2023
Responsible Party:
Hospital Director of Risk Management
482.13(c)(2) STANDARD
PATIENT RIGHTS: CARE IN SAFE SETTING
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The patient has the right to receive care in a safe setting.
Observations:
Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to maintain a safe environment for patients by failing to conduct an annual comprehensive environmental risk assessment.
Findings include:
Review on April 6, 2023 of facility policy "Building Safety Tour", approved January 7, 2020 revealed "I. Policy Statement: Building Safety Tours shall be conducted in KidsPeace buildings and all necessary corrective actions shall be promptly performed..."
Review on April 6, 2023 of facility documents revealed there was no documented evidence a environmental risk assessment was conducted for the year 2022.
Interview conducted on April 5, 2023, with EMP2 at 10:45 AM confirmed an enviironmental risk assessment for 2022 was not conducted.
Plan of Correction:A comprehensive risk assessment will be scheduled for completion by July 1st, 2023. The risk assessment will be conducted annually thereafter. The assessment will be jointly conducted by the Director of PA Operations and the Risk Management Department of KidsPeace Children's Hospital. Results of the assessment will be communicated to the Environment of Care (EOC) Committee and reported to Hospital leadership through the Quality, Safety and Compliance (QSC) committee. The annual report will be added as a Board of Directors agenda item to be reviewed by the board.
Policy Number: CH.4211 Ligature Risk at the Hospital will be reviewed and updated to include specific responsible parties and deadlines for completion.
Policy Number: ORG.1407
Building Safety Tour will be reviewed with members of the Risk Management department in individual supervision.
Target date for completion: July 1st,2023
Responsible Parties:
Director of PA Operations
Hospital Director of Risk Management
482.28(b)(3) STANDARD
THERAPEUTIC DIET MANUAL
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A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel.
Observations:
Based on review of facility documents, facility policy and staff interviews (EMP), it was determined the facility failed to create and maintain a therapeutic diet manual approved by the dietitian and medical staff and make it readily available to all medical, nursing, and food service personnel.
Review of facility policy on April 4, 2023 "Menu Planning, approved August 4, 2004 revealed "I. It is the policy of KidsPeace that all clients shall be provided with meals that are nutritionally adequate, properly prepared, and served in pleasant surrounds...C. Special Diets 1. Therapeutic diets shall never be offered as a reward or punishment, but shall be provided to clients only under the following conditions: a) When prescribed by appropriate medical or dental staff; b) As directed or approved by a registered dietitian; and c) As a complete meal service and not as a supplement to or choice between dietary meals and regular meals..."
Request was made to EMP7 for the facility's Therapeutic Diet Manual on April 4, 2023. None was provided.
Interview with EMP7 on April 4, 2023, at 1:45 PM confirmed "We do not have a therapeutic diet manual"
Plan of Correction:KidsPeace Children's Hospital will obtain a subscription to the "Pediatric Nutrition Care Manual" provided by the Academy of Nutrition and Dietetics.
The "Pediatric Nutrition Care Manual" will be reviewed by the KidsPeace Children's Hospital licensed dietician and the Vice President of Medical Affairs. The approved manual will be uploaded to the KidsPeace Sharepoint intranet site, KidsWeb making it readily accessible to all medical, nursing and food services personnel.
A Standard Operating Protocol will be developed to ensure the Pediatric Nutrition Care Manual is reviewed annually and any updates are incorporated.
Target date for completion June 1st, 2023.
Responsible Parties:
Licensed Dietician
Vice President of Medical Affairs
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