HCO ID:


Activity as of:
10/10/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
8/31/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
9/16/2017
9/15/2017
9/15/2017
 
8/11/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
9/16/2017
9/15/2017
9/15/2017
 
6/27/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
9/16/2017
9/15/2017
9/15/2017
 
12/23/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
9/16/2017
9/15/2017
9/15/2017
 
10/5/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
8/15/2015
9/15/2017
9/15/2017
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
8/15/2015
8/14/2015
8/14/2015
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
6/29/2017
5/27/2016
6/29/2017
 
Laboratory
Accredited
8/15/2015
8/14/2015
8/14/2015
 
10/23/2016
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accreditation with Follow-up Survey
8/31/2016
5/27/2016
8/30/2016
 
Laboratory Accreditation Program
Accredited
8/15/2015
8/14/2015
8/14/2015
 
8/16/2016
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Preliminary Denial of Accreditation
5/28/2016
5/27/2016
7/8/2016
 
Laboratory Accreditation Program
Accredited
8/15/2015
8/14/2015
8/14/2015
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • A time-out is performed before the procedure.
  • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
  • Medication orders are clear and accurate.
  • Staff participate in ongoing education and training.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital assesses and reassesses its patients.
  • The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • The hospital conducts fire drills.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information)
  • The hospital has policies and procedures that guide and support patient care, treatment, and services.
  • The hospital implements its infection prevention and control plan.
  • The hospital inspects, tests, and maintains medical equipment.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital manages safety and security risks.
  • The hospital plans the patient’s care.
  • The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital safely administers medications.
  • The hospital safely prepares medications.
  • The hospital safely stores medications.
  • The hospital traces all tissues bi-directionally.
  • The hospital uses standardized procedures for managing tissues.
  • The hospital verifies staff qualifications.
  • The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
7/3/2016
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Preliminary Denial of Accreditation
5/28/2016
5/27/2016
5/27/2016
 
Laboratory Accreditation Program
Accredited
8/15/2015
8/14/2015
8/14/2015
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • A time-out is performed before the procedure.
  • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
  • Medication orders are clear and accurate.
  • Staff participate in ongoing education and training.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital assesses and reassesses its patients.
  • The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • The hospital conducts fire drills.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information)
  • The hospital has policies and procedures that guide and support patient care, treatment, and services.
  • The hospital implements its infection prevention and control plan.
  • The hospital inspects, tests, and maintains medical equipment.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital manages safety and security risks.
  • The hospital plans the patient’s care.
  • The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital safely administers medications.
  • The hospital safely prepares medications.
  • The hospital safely stores medications.
  • The hospital traces all tissues bi-directionally.
  • The hospital uses standardized procedures for managing tissues.
  • The hospital verifies staff qualifications.
  • The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
6/26/2016
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Preliminary Denial of Accreditation
5/28/2016
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/15/2015
8/14/2015
8/14/2015
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • A time-out is performed before the procedure.
  • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
  • Medication orders are clear and accurate.
  • Staff participate in ongoing education and training.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital assesses and reassesses its patients.
  • The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • The hospital conducts fire drills.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information)
  • The hospital has policies and procedures that guide and support patient care, treatment, and services.
  • The hospital implements its infection prevention and control plan.
  • The hospital inspects, tests, and maintains medical equipment.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital manages safety and security risks.
  • The hospital plans the patient’s care.
  • The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital safely administers medications.
  • The hospital safely prepares medications.
  • The hospital safely stores medications.
  • The hospital traces all tissues bi-directionally.
  • The hospital uses standardized procedures for managing tissues.
  • The hospital verifies staff qualifications.
  • The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
9/24/2015
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/14/2015
8/14/2015
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
6/15/2015
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
3/31/2015
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
1/15/2015
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
6/12/2014
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
11/14/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/24/2013
8/23/2013
8/23/2013
 
11/12/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
10/29/2013
 
Laboratory Accreditation Program
Accredited
8/27/2011
8/23/2013
8/23/2013
 
9/30/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
5/25/2013
5/24/2013
5/24/2013
 
Laboratory Accreditation Program
Accredited
8/27/2011
8/23/2013
8/23/2013
 
8/27/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
10/30/2010
5/24/2013
5/24/2013
 
Laboratory Accreditation Program
Accredited
8/27/2011
8/23/2013
8/23/2013
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Accredited
8/27/2011
8/26/2011
8/26/2011
 
Hospital
Accredited
10/30/2010
5/24/2013
5/24/2013
 
6/13/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Accredited
8/27/2011
8/26/2011
8/26/2011
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
3/27/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Accredited
8/27/2011
8/26/2011
8/26/2011
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
3/21/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
8/27/2011
8/26/2011
8/26/2011
 
3/20/2012
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
8/27/2011
8/26/2011
8/26/2011
 
10/31/2011
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
9/17/2009
8/26/2011
8/26/2011
 
8/30/2011
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
9/17/2009
8/26/2011
8/26/2011
 
6/14/2011
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
10/30/2010
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
9/17/2009
9/16/2009
3/23/2010
 
2/17/2011
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
11/21/2008
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
9/17/2009
9/16/2009
3/23/2010
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
11/21/2008
10/29/2010
10/29/2010
 
Pathology and Clinical Laboratory
Accredited
9/17/2009
9/16/2009
3/23/2010