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Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure policies and procedures were developed and implemented related to the provision of a signed acknowledgment by the patient stating that he/she understands that a doctor of medicine or doctor of osteopathy (MD / DO) was not present at the hospital 24 hours a day, seven days a week, at the beginning of all inpatient admissions. All patients admitted after March 2016 had not signed a written acknowledgment form stating they understood that a MD/DO may not be present at all times services were furnished to the patient, this included 2 patients (P1, & P2) closed records that were reviewed. In addition the emergency room failed to have the appropriate signage posted with the appropriate disclosure information. This affects all patients admitted to the CAH and all patients who received emergency room services.
Findings Include:

P1's admitted 8/15/16 discharged same day with diagnosis of breast cancer with metastatic cancer to lungs and liver according to admission history and physical. P1 had not signed and acknowledgment of no 24-hour MD/DO services.

P2 admitted 6/8/16 discharged 6/11/16 with diagnosis of Pneumonia according to the admission history and physical. Again no signed and acknowledgment of no 24-hour MD/DO services.

During an interview on 1/11/17 at 9:00 a.m. patient care director (PCD) stated there was a notice to patients provided that informed the patient there was not a MD/DO on site at the hospital twenty-four hours a day, seven days a week. The PCD verified patients did not sign a written acknowledgment form stating they understood that a MD/DO may not be present at all times services were furnished to the patient. The PCD stated when they switched to electronic medical record systems, the signed acknowledgment form was overlooked in the transition and stated all patients admitted to the CAH since March of 2016 had not signed an acknowledgement form. In addition, the PCD stated there used to be a sign posted in the emergency room alerting all patients there was not a MD/DO on site at the hospital twenty-four hours a day, seven days a week. The PCD stated the they have no idea what happened to the sign and no idea how long the sign had not been posted. A policy and procedure was requested and not provided.


34083

During the tour of the emergency department on 1/9/17, at 2:00 p.m., there was not a notice concerning not having a medical doctor on duty 24/7 conspicuously located so it would be seen by all individuals entering the dedicated emergency department. The posted notice must state that the Critical Access Hospital (CAH)) does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition at a time when there is no doctor of medicine or doctor of osteopathy present in the CAH. During interview with registered nurse (RN)-A at the time of the tour it was confirmed there was not a notice posted in a conspicuous area of the emergency department.

The patient care director (PCD) was interviewed on 1/10/17, at 12:05 p.m. and confirmed there was not a notice posted in the emergency department area informing persons entering the area that a doctor of medicine or osteopathy was not present in the CAH 24 hours/day and 7 days/week. The PCD indicated she was not aware of the notice not being posted and that it should have been.

Based on the Life Safety Code (LSC) survey. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiencies cited at: K0321, K0346, K0354, and K0712.

Based on observation, staff interview, and record review, the Critical Access Hospital (CAH) failed to maintain the confidentiality of record information and provide safeguards against loss, destruction, or unauthorized use in 2 of 2 medical record storage areas used for CAH medical records storage.

Findings include:

On 1/10/17 at 10:18 a.m. the medical record storage on the main floor of the CAH was toured. Multiple shelves containing CAH medical records were observed in the room directly behind the clinic nurses station. There was no door from the clinic nurses' station to the room the CAH's medical records were stored, which allowed the clinic staff members that worked in this area unauthorized access to the CAH medical records. In addition, the room where the medical records were stored had an office for human resources and the human resources staff member had unauthorized access to all of the CAH medical records. The health information representative (HIMR)-A verified the CAH medical records were not fully secured from unauthorized access.

The CAH's medical records were also found to be unsecured in the basement storage area, as the door to the basement was found to be opened upon tour. The maintenance director (MD)-A stated the medical records stored in this area used to be stored in a room that was locked that only the maintenance and medical record staff had access to and stated the records were moved to this basement location in July 2016. The CAH medical records were stored in an open room on 9 shelves. The MD-A stated this basement storage area could be accessed by hospice staff, activity staff, maintenance staff and office support staff. MD-A verified the CAH medical records were not secured from unauthorized use and unauthorized personnel would have access to the CAH records kept in this location. Both the MD-A and HIMR-A stated the door to the basement area was often kept unlocked and open.

During an interview on 1/10/17 at 4:11 p.m. patient care director (PCD) stated she had concerns about the security of the medical records kept in the basement area, as they used to be stored in a locked room where only the medical records staff members had access.
During an interview on 1/11/17 at 9:00 a.m. PCD stated every department in the clinic, hospital, nursing home, homecare/hospice had access to basement location where medical records are stored. The PCD stated this was approximately 130 employees. The PCD stated they were aware this was an issue and stated they were going to take ownership of it and fix it. The PCD stated staff did not rely on medical records staff members to pull records. The PCD stated nurses and physicians have all pulled patient medical records when needed.
During an interview on 1/11/17 at 12:54 p.m. health information representative (HIM)-B stated from 7:30 a.m. to 4:00 p.m. medical records staff should be the only staff members that have access to the hospital patient records. HIM-B stated after medical record office hours, staff have a key and could access the medical records in an emergency. HIM-B stated when the previous administrator was here the plan was to move the medical records out of the medical record storage area upstairs and to relocate all of the medical records to the current basement location. HIM-B verified the CAH was not following the policy and procedure for safeguarding protected health information from those with unauthorized access.
During an interview on 1/12/17 at 11:39 a.m. the administrator stated it was an oversight of the hospital to not secure the medical records in the storage areas. The administrator stated walls could be built to enclose the human resource office that was located in the medical record storage area on the main floor of the hospital. The administrator stated facility staff had talked about putting a gate with a lock to secure the medical records in the basement location.
Review of the Medical Record Retention and Storage policy revised 1/9/17, included, "Medical records are stored within the hospital are kept in secure areas at all times."
Review of Safeguarding Protected Health Information policy dated 12/2016 included, "Thinned Records, Inactive medical Records: 1. Thinned and inactive medical records will be filed in a systematic manner in a location that ensures the privacy and security of the information. The Health Information Manger or designee shall monitor storage and security of such medical records, when records are left unattended, records will be in a locked room, file cabinet or drawer. 2. The administrator will identify and document those staff members with keys to stored medical records. The minimum number of staff necessary to assure that records are secure yet accessible shall have keys allowing access to stored medical records. Staff members with keys shall assure that the keys are not accessible to unauthorized individuals. 3. Medical records must be signed out if removed from their designated storage area. Only authorized persons shall be allowed to sign out such records. "

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure policies and procedures were developed and implemented related to the provision of a signed acknowledgment by the patient stating that he/she understands that a doctor of medicine or doctor of osteopathy (MD / DO) was not present at the hospital 24 hours a day, seven days a week, at the beginning of all inpatient admissions. All patients admitted after March 2016 had not signed a written acknowledgment form stating they understood that a MD/DO may not be present at all times services were furnished to the patient, this included 2 patients (P1, & P2) closed records that were reviewed. In addition the emergency room failed to have the appropriate signage posted with the appropriate disclosure information. This affects all patients admitted to the CAH and all patients who received emergency room services.
Findings Include:

P1's admitted 8/15/16 discharged same day with diagnosis of breast cancer with metastatic cancer to lungs and liver according to admission history and physical. P1 had not signed and acknowledgment of no 24-hour MD/DO services.

P2 admitted 6/8/16 discharged 6/11/16 with diagnosis of Pneumonia according to the admission history and physical. Again no signed and acknowledgment of no 24-hour MD/DO services.

During an interview on 1/11/17 at 9:00 a.m. patient care director (PCD) stated there was a notice to patients provided that informed the patient there was not a MD/DO on site at the hospital twenty-four hours a day, seven days a week. The PCD verified patients did not sign a written acknowledgment form stating they understood that a MD/DO may not be present at all times services were furnished to the patient. The PCD stated when they switched to electronic medical record systems, the signed acknowledgment form was overlooked in the transition and stated all patients admitted to the CAH since March of 2016 had not signed an acknowledgement form. In addition, the PCD stated there used to be a sign posted in the emergency room alerting all patients there was not a MD/DO on site at the hospital twenty-four hours a day, seven days a week. The PCD stated the they have no idea what happened to the sign and no idea how long the sign had not been posted. A policy and procedure was requested and not provided.