More Information on UMC Joint Commission Inspection

When UMC failed their Joint Commission inspection earlier this year, very few details were released to the public.  However, we have found a database that lists out the violations at any hospital in the United states. says the following:  “The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.”

You can read their entire report here.  We’ve included the highlights below:

  • About the equipment used for sterilization:  In an interview on the afternoon of 7/15/15 at 12:30 p.m. in the hospital meeting room, the Biomedical Manager and the Facilities Management Director confirmed that the facility had not been following the manufacturers’ instructions for equipment preventative maintenance or a facility-approved alternate equipment maintenance program on the equipment used to sterilize surgical instruments. In addition, the hospital, through a “computer glitch,” lost documents necessary to demonstrate preventative maintenance performed on this equipment in 2014. (emphasis added)
  • Infection Control:  “Based on a review of documentation and interview, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.”
  • Infection Control Officer Responsibilities: “The facility was not performing biological indicator testing according to manufacturer’s instructions, facility policy and current standards of practice.”

Based on this, the Medical Executive Committee at UMC is right to be concerned about the spread of infectious diseases to patients.  If they are unable to prove that they were doing preventative maintenance in 2014 on the sterilization equipment, all we have is their word that they were doing it.  That means that the issues found by the Joint Commission could have been going on for months, if not years.

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