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UT HEALTH EAST TEXAS QUITMAN HOSPITAL
No Description Available
Tag No.: C0275
Based upon record review and interview, the facility failed to have policies and procedures for the annual evaluation of all services provided by the Critical Access Hospital (CAH).
Refer to Tag C-0331
PERIODIC EVALUATION
Tag No.: C0331
Based upon record review and interview, the facility failed to have policies and procedures for the annual evaluation of all services provided by the Critical Access Hospital (CAH).
Review of administrative policy and procedure manual revealed no policies related to conducting an annual evaluation of the services provided. There were no policies noted to be specific to the Critical Access Hospital.
An interview was conducted with the Administrator on 9/22/10 at 11:00 am. The Administrator reported the facility had not done anything official related to the CAH due to not having that designation granted yet. He reported that corporate officials instructed him to continue to run the facility as an acute care facility until after the initial survey and approval as a CAH. The Administrator confirmed there was no policy or procedure in place related to conducting an annual evaluation of services.
PERIODIC EVALUATION
Tag No.: C0332
Based upon record review and interview, the facility failed to have policies and procedures for the annual evaluation of all services provided by the Critical Access Hospital (CAH), including patients served and the volume of services.
Refer to Tag C-331
PERIODIC EVALUATION
Tag No.: C0333
Based upon record review and interview, the facility failed to have policies and procedures for the annual evaluation of all services provided by the Critical Access Hospital (CAH), including a review of active and closed medical records.
Refer to TAG C-331
PERIODIC EVALUATION
Tag No.: C0334
Based upon record review and interview, the facility failed to have policies and procedures for the annual evaluation of all services provided by the Critical Access Hospital (CAH), including review and revision of health care policies.
Refer to TAG C-331
PERIODIC EVALUATION
Tag No.: C0335
Based upon record review and interview, the facility failed to have policies and procedures for the annual evaluation of all services provided by the Critical Access Hospital (CAH) to determine the appropriateness of the services provided.
Refer to TAG C-331