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Based on personnel record review, policy review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure the established system to identify and prevent transmission of infections and communicable diseases to patients included required health examinations and tuberculosis (TB) screening for all employees and volunteers. Problems were identified for 7 of 18 sampled employees (Staff A, B, C, D, E, F, and I) and 2 of 2 volunteers (Volunteer G and H) selected for review. The CAH staff reported there were currently 123 employees and 9 volunteers at the time of the survey.

Failure to identify infections and communicable diseases could potentially result in causing harm to patients and staff through transmission of communicable diseases.

The Iowa Administrative Code for the Department of Inspections and Appeals, Chapter 51 titled "Hospitals", last updated 12/10/14, revealed in part ". 51.24(3) Health examinations for all personnel shall be required at the commencement of employment and thereafter at least every four years. The examination shall include, at a minimum, the health status of the employee . . . Screening and testing for tuberculosis shall be conducted pursuant to 481-Chapter 59.

Findings include:

1. Review of a CAH policy titled "Tuberculosis Control Plan", revised in 12/14, revealed in part ". . . The tuberculin skin test should be used as a diagnostic aid to detect tuberculosis infection.. . ." The policy identified initial screening is completed for all employees and volunteers working with patients.

Review of a CAH policy titled "Employee Health - Employment Physical", reviewed in 11/11, revealed in part ". . . Every four years . . . employees are required to have a physical . . . "

2. Review of the employee health information for Staff A, Food Service Manager, revealed a document titled "Employee Physical" dated 10/12/10.

Review of the employee health information for Staff B, Physical Therapist, revealed a document titled "Employee Physical" dated 6/30/10.

Review of the employee health information for Staff C, Registered Nurse (RN), revealed a document titled "Employee Physical" dated 7/14/09.

Review of the employee health information for Staff D, Pharmacist, revealed a document titled "Employee Physical" dated 6/28/10.

Review of the employee health information for Staff E, Certified Nurse Aid (CNA), revealed a document titled "Employee Physical" dated 1/28/08.

Review of the employee health information for Staff F, Respiratory Therapist, revealed a document titled "Employee Physical" dated 12/2/10.

Review of the employee health information for Staff I, Pharmacy Technician, with a hire date of 11/2/14, lacked documentation of TB testing.

Review of the employee health information for Volunteer G, revealed a document titled "Post Offer Health Assessment", dated 11/25/13. The document included health information identified by the volunteer but lacked documentation of TB testing and a health examination by a practitioner.

3. During an interview on 1/21/15 at 1:00 PM, Staff J, Employee Health Nurse, reported she lacked documentation of a health assessment and TB testing for Volunteer H, and lacked documentation of TB testing for Volunteer G. She reported the facility does not perform TB testing for volunteers and acknowledged she did not know it was required. Staff J acknowledged all of the identified volunteers had patient contact, and met the requirement for the need of TB testing, as set forth in the Iowa Administrative Code 481-Chapter 59.

During a follow-up interview, on 1/21/15 at 2:00 PM, Staff J confirmed the "Post Offer Health Assessment" completed by Volunteer G lacked documentation of a health examination by a practitioner. Staff J acknowledged the 6 identified employee physicals exceeded 4 years and reported the facility stopped requiring them about 1 1/2 years ago, shortly after she took over employee health. She reported she contacted other CAH's and was told they no longer required physicals, so stopped requiring them for their employees.

During an interview on 1/21/15 at 3:15 PM, Staff C, RN/Infection Control, reported she was aware the employee physical requirement had apparently been discontinued because hers had been due in 2013. She provided a copy of the CAH's current "Employee Health - Employment Physical" policy and acknowledged it identifies employee physicals are done every 4 years. Staff K reported she wrote the CAH's current TB control plan, which identifies the need for TB testing with volunteers and employees upon hire.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Network Hospital staff reviewed the CAH's quality assurance plan and its implementation on an annual basis, in accordance with the Network Agreement for Quality Assurance.

Failure to ensure the Network Hospital staff reviewed the CAH's quality assurance plan and its implementation annually, in accordance with the Network Agreement for Quality Assurance, could potentially result in the CAH's quality staff failing to identify and act on patient care related issues promptly and potentially cause adverse patient outcomes.

Findings include:

1. Review of the Network Agreement, dated December 1, 2000, revealed the following in part, ". . . [Network Hospital] will review Hospital's quality assurance plan and its implementation of such plan on an annual basis and make appropriate recommendations for modification, if any. . . ."

2. Review of documentation revealed the lack of documented evidence of the Network Hospital annually reviewed the CAH's quality assurance plan and its implementation of the plan per the Network Agreement.

3. During an interview on 1/26/14 at 2:20 PM, Staff L, Director of Pharmacy/Administrator of Clinical Services, acknowledged the lack of documented evidence showing the Network Hospital annually reviewed the CAH's quality assurance plan and its implementation of the plan per the Network Agreement.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner, for 2 of 3 sampled mid-level practitioners reviewed (Practitioners HH and II). The hospital had 7 mid-level practitioners on staff at the time of the survey.

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in failure to evaluate the quality of the midlevel practitioners' patient care and determine areas for improvement in patient care.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed the lack of a policy to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed no documentation of Physician review of the mid-level practitioners' patient medical records in conjunction with the mid-level practitioners (Practitioners HH and II)

3. During an interview on 1/26/15 at 1:20 PM, Staff K, Health Information Manager/Credentialing Coordinator, acknowledged Mid-level Practitioners HH and II provided care to patients at the CAH and acknowledged there was no documentation to show the physician reviewed the mid-level practitioners' medical records of patients, in conjunction with the mid-level practitioners. Staff K also acknowledged the lack of a policy to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) failed to ensure 2 of 3 sampled mid-level practitioners participated with a physician in the periodic review of the mid-level practitioner's patient medical records (Practitioners HH and II). The CAH staff reported there were 7 mid-level providers on staff at the time of the survey.

Failure of the mid-level practitioner to participate with a physician in the periodic review of the mid-level practitioner's patient records could potentially result in mid-level practitioners missing opportunities for learning and implementing improvements in the quality of their patient care at the CAH.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed the lack of a policy to ensure the mid-level practitioners participated with a physician in the periodic review of the patients' medical records with the mid-level practitioners.

2. Review of documentation revealed no documentation of mid-level practitioner participation with a Physician in the review of patient medical records with the mid-level Practitioners HH and II.

3. During an interview on 1/26/15 at 1:20 PM, Staff K, Health Information Manager/Credentialing Coordinator, acknowledged Mid-level Practitioners HH and II provided care to patients at the CAH and acknowledged there was no documentation to show the mid-level practitioner participated with a physician in the review of the mid-level practitioner's patient medical records. Staff K also acknowledged the lack of a policy to ensure the mid-level practitioners participated with a physician in the periodic review of the mid-level practitioners' patient care as documented in the medical records of patients that received care from the mid-level providers.

Based on review of policies/procedures, meeting minutes and staff interview, the Critical Access Hospital (CAH) failed to ensure the professional group of healthcare staff, including a physician and a mid-level provider, reviewed the patient care policies for 12 of 22 patient care departments (Respiratory Therapy, Pulmonary Rehabilitation, Sleep Study, Environmental Services, Infection Prevention, Nursing, Surgery, Anesthesia, Emergency Room, Clinics, Health Information Management, and Plant Operations).

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies and the opportunity to update the policies as needed.

Findings include:

1. Review of CAH policy titled "Critical Access Hospital Advisory Committee", dated 1/15, revealed in part, ". . . Patient care policies are reviewed annually by the Critical Access Hospital Advisory Committee. . . Committee composition: Physician, Mid-level Provider. . . ."

2. Review of Critical Access Hospital Advisory Committee Meeting Minutes for October 16, 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Respiratory Therapy, Pulmonary Rehabilitation, Sleep Study, Environmental Services, and Infection Prevention.

Review of Critical Access Hospital Advisory Committee Meeting Minutes revealed there were no minutes for the January 2014 meeting and the policies for Nursing, Surgery, Anesthesia, Emergency Room, Clinics, Health Information Management, and Plant Operations lacked evidence of annual review.

3. During an interview on 1/26/14 at 3:40 PM, Staff L, Director of Pharmacy/Administrator of Clinical Services, acknowledged a physician and a mid-level provider were not present at the Critical Access Hospital Advisory Committee meeting on October 16, 2014 for annual review of the above stated policies/procedures and lacked documentation showing a physician and a mid-level reviewed those policies. Staff L also acknowledged the lack of meeting minutes for January 2014 and the policies for Nursing, Surgery, Anesthesia, Emergency Room, Clinics, Health Information Management, and Plant Operations lacked evidence of annual review.

Based on observation, review of policy and procedures, and staff interview, the CAH (Critical Access Hospital) failed to secure patient medical records from unauthorized users in 1 of 2 offsite clinic areas (Panora). The Panora Clinic staff reported furnishing patient care services to approximately 75 patients a week.

Failure to secure patient's medical records could potentially result in access to patient information by unauthorized users.

Findings include:

Observation during tour of the Panora Clinic on 1/21/15 at 7:30 AM revealed approximately 2,000 patient medical records located on open shelves in the receptionist office. Staff could not secure the open shelving containing the medical records. The medical records contained patient information, (date of birth, social security number, diagnosis, tests, and treatments).

During an interview on 1/21/15 at 7:30 AM, Staff M (Receptionist), stated housekeeping staff clean the reception office during non-business hours while unsupervised. The housekeeping staff have a key to the office and access to information in the patients medical records.

Review of the CAH undated policy titled, Guthrie County Hospital Health Information Services, Record Security revealed the policy did not address securing medical records in the Panora Clinic.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 3 of 4 active physicians, 1 of 1 affiliate physicians, and 3 of 7 consulting physicians, selected for review, received outside entity peer review performed by the Network Hospital to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH in accordance with the CAH's agreement with the Network Hospital (Physicians A, B, C, D, E, F, and G). The CAH credentialed 4 active physicians, 2 associate physicians, and 55 consulting physicians.

Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure their physicians provided quality care to their patients and provide opportunities to increase the quality of patient care.

Findings include:

1. Review of CAH policy titled "Quality Assurance/Medical Records Review Plan", dated 11/11, revealed in part, ". . . Quality Assurance/Medical Records Review Committee: The Committee will provide a mechanism to monitor, assess and improve the quality and appropriateness of patient care, and the clinical performance and competency of all individuals with delineated clinical privileges including but not limited to: MD, DO. . . Network Hospital: Provide review staff for record review as recommended/requested on a periodic basis, as agreed upon, and submit a report of finding to the Committee. . . ."

Review of the Network Agreement, dated December 1, 2000, revealed the following in part, ". . . [Network Hospital] shall assist Hospital in reviewing the quality and appropriateness of the diagnoses and treatment furnished by Hospital's physicians and other practitioners on a quarterly basis for the purposes of assisting the Hospital in carrying out the requirements of its quality assurance plan. . . ."

2. Review of CAH documentation on 1/26/15 revealed the facility failed to ensure the CAH received a completed peer review by the Network Hospital specific for the services provided to patients at the CAH for Physicians A, C, F and G. Further review of documentation revealed the CAH did not obtain peer review by the Network Hospital for Physicians B, D, and E.

3. During an interview on 1/26/15 at 1:30 PM, Staff K, Health Information Manager/Credentialing Coordinator, stated the CAH staff only send inpatient medical records to the Network Hospital for outside entity peer review. Staff K acknowledged the CAH failed to obtain an outside entity peer review for patients cared for by Physicians A, B, C, D, and E. Staff K also stated the outside entity peer review received for Physicians F and G were not patients from the CAH.

Based on medical record review, policy review and staff interviews, the critical access hospital (CAH) staff failed to ensure patients were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, for 2 of 2 current swing bed patient records reviewed. (Patient #1 and #2) and 5 of 5 closed swing bed patients (Patient #3, 4, 5, 6 and 7). The CAH identified a current census of 2 swing bed patients at the time of survey.

Failure to inform patients of their visitation rights could potentially result in the staff failing to extend visitation rights to all swing bed patients and their visitors, including those visitors that might be the most supportive.

Findings include:

Review of the brochure titled, "Patient Rights and Responsibilities", undated provided to all patients upon admission to swing bed services did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of policy/procedure titled, "Patient Visitation", revised 12/2014, included the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of documentation for current Patients #1 and #2 and closed Patient #3, 4, 5, 6 and 7 medical records, revealed the patient's signed they received a copy of the Patient Rights and Responsibilities information without the updated verbiage for domestic partner.

During an interview on 1/21/15 at 8:40 AM, Staff N, Director of Nursing stated the new verbiage did not get added to the skilled patient rights provided to all skilled patients. The current patients and closed patient records showed the patients did not receive the correct patient rights with the new verbiage.