Many healthcare organizations contract specialized healthcare services to provide essential treatments that cannot be supported by in-house resources. These services can vary such as radiology studies, rehabilitation services, dialysis services, nutrition services and the like. Unfortunately, organizations sometimes forget that even though these services are provided by outside entities, they are still responsible for ensuring that services are provided safely and in alignment with regulatory requirements. Our teams have observed instances where organizations have failed to implement processes to monitor performance for safety concerns. Our teams have found expired supplies, missing entries for testing logs and quarterly reports, and unsafe infection control practices.
§482.12(e)(1) from the CMS State Operations Manual states that, “The governing body must ensure that the services performed under a contract are provided in a safe and effective manner”. This requires the organization to establish and implement processes to ensure quality and patient safety which can include quality monitoring data and rounding. Organizations must ensure that they are implementing the same measures used on their own services for those contracted services. Recently our team surveyed an organization with contracted dialysis services. Review of their processes found multiple expired reagents/testing strips, incomplete water testing and cleaning logs, and missing quality reporting to the organization. Discussion with the organization found that they had not been rounding on the contracted service spaces or reviewing documentation. The combination of findings could place the organization into a significant patient safety finding during a real regulatory survey. This could include a significant leadership finding for lack of adequate oversight.
Organizations must ensure they are rounding on their contracted services to ensure alignment with regulatory requirements. Ensure that service contracts address the need for meeting regulatory standards and that the organization has the right to review, observe and round for compliance.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
