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Based on personnel file review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a new employee with a potential dependent adult abuse hit, received a Iowa Department of Human Services clearance to work, according to State law, for 1 of 5 personnel files reviewed, (Staff P, Housekeeping).

Iowa Administrative Code 481 - 51.41(2)d. If a department of human services child or dependent adult abuse record check shows that a person being considered for employment in a hospital has a record of founded child or dependent adult abuse, the department of human services shall notify the hospital that upon the request of the hospital the department of human services will perform an evaluation to determine whether the founded child or dependent adult abuse warrants prohibition of employment in the hospital.

Iowa Administrative Code 481 - 51.41(3) A person who has committed a crime or has a record of founded child or dependent adult abuse shall not be employed in a hospital unless an evaluation has been performed by the department of human services.

Failure to ensure new employees with a potential child and/or dependent adult abuse history are cleared to work through the appropriate agency may result in placing patients at risk for potential abuse.

Findings include:

1. Review of a CAH policy titled "Background Investigations for Employment Purposes", approved 6/2016, revealed in part ". . . applicants may not begin employment until a criminal history check and dependent adult and child abuse record check have been satisfactorily completed . . ."

2. Review of the personnel file for Staff P, Housekeeping, revealed a hire date of 1/26/16. A document titled "Single Contact License and Background Check" (SING), dated 1/14/16, revealed a possible dependent adult abuse hit with the instructions to initiate a request for dependent adult abuse registry information through DHS.

3. During an interview on 3/1/17 at 1:15 PM, Staff D, Human Resources, acknowledged Staff P's SING check revealed a possible dependent adult abuse hit and paperwork should have been submitted to the Department of Human Services for clearance to work at the CAH, prior to commencing employment. Staff D reported she contacted their network hospital, who conducted the pre-employment background checks, and confirmed the DHS clearance should have been obtained and they lacked documented evidence it was done.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Medical Staff approved the Blood Bank Agreement dated July 2013. The CAH laboratory staff identified 59 units of blood were used during the year 2016.

Failure of the Blood Bank Agreement approved by the Medical Staff could potentially result in a lack of provider input for changes in the agreement.

Findings include:

1. Review of the document titled "Blood Product Supply and Services Agreement" signed 7/8/2013 by Administrative Staff I revealed a lack of approval by the CAH Medical Staff.

2. During an interview on 2/28/2017 at 1:30 PM, Staff A, Chief Executive Officer (CEO), acknowledged the Blood Bank Agreement, dated July 2013, lacked approval by the Medical Staff.

Based on observation, document and credential file review, and staff interview the Critical Access Hospital (CAH) Governing Body failed to ensure the credentialing process by the medical staff occurred for 1 of 2 non-employee surgical assistants (Staff J). Non-employee Staff J, Registered Nurse (RN), assisted with 52 surgical procedures from January 2016 to March 1, 2017 completed by Physician K.

Failure to privilege all non-employee assistants that accompany providers could result in patients receiving surgical intervention from unqualified professionals.

Findings include:

Observation on 3/1/17, at 9:15 AM, revealed Staff J, RN, present in the surgical suite and provided assistance to Staff K, Otolaryngologist.

During an interview on 3/2/17, at 9:30 AM, Staff A Chief Executive Officer, confirmed she was aware Staff J assisted Staff K in surgery but did not have a credential file. Staff A reported as a non-employee registered nurse (RN), the CAH did not require the credentialing process or granting of specific privileges by the medical staff and governing body. Staff A reported the CAH did not have a policy to address the requirements for this type of non-employee but the CAH required verification of the information similar to an employed RN.

During an interview on 3/6/17, at 2:20 PM, Staff A, Chief Executive Officer, confirmed Staff J, had not gone through the credentialing process to grant privileges to assist Staff K in surgery. Staff A reported as a registered nurse (RN), the process for a non-employee would included the same requirements as an employed RN, including license verification, health status, etc, but did not include the request for privileges or approval from the medical staff and governing body. Staff A acknowledged she did not know the medical staff by-laws required such persons be credentialed.

Review of the CAH's Medical Staff By-laws, approved by the governing body on 1/23/13, revealed in part, "... The surgeon shall utilize such assistants at surgery as he or she deems appropriate and such assistants may include any practitioner, Allied Health Professional, nurse, aide or technician who is properly trained, qualified, and credentialed consistent with the Medical Staff Bylaws ... "

Review of the CAH's Medical Staff Credentials Policy, revised 3/17/2010, revealed in part "... Medical Staff appointment or reappointment at Hospital shall not confer any clinical privileges or right to practice at any Alegent Health Hospital ... Each individual who has been appointment to the Medical Staff at Hospital is entitled to exercise only those clinical privileges specifically granted by the Board ..."

Review of the CAH's governing body bylaws, approved 5/26/16, revealed in part "... the Community Board shall have the following general powers and duties: ... Reviewing credentialing recommendations for medical and clinical professional at the hospital ..."

I. Based on observation, policy review, and staff interviews, the Critical Access Hospital (CAH) dietary staff failed to follow sanitary practices and ensure completion of proper hand hygiene. The administrative staff reported a census of 8 patients and the Supervisor of Food and Nutrition Services (FNS) reported the dietary staff provided approximately 15 patient meals daily .

Failure to use sanitary practices for hand hygiene could potentially result in the contamination of the patients' food and cause food borne illness.

Findings include:

Kitchen observations on 2/27/17, from 11:30 AM to 12:30 PM, revealed a small sink on the soiled dish-machine table which held a couple soiled glasses and dishes. During the observation period, Staff Q, Dietary Aide emptied liquid from some soiled glasses in the sink. Continued observation during this time period revealed Staff Q and Staff R, Cook, used the sink to wash their hands on 2 occasions and then handled clean dishes and participated in food preparation activities.

During an interview on 3/7/17, at 8:45 AM, Staff B, Supervisor of FNS reported the purpose of the small sink in the dish machine was for hand washing and acknowledged dietary staff did not need to empty glasses or place soiled dishes in it.

Review of a CAH policy titled "Hand Hygiene", approved 12/2016, revealed in part "... all food handlers will use sinks designated for hand washing ... do not use food preparation sinks, service sinks, or curbed cleaning areas used for disposal of wastewater ..."

The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires a handwashing sink to be used only for handwashing and no other purpose.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) failed to ensure the designated diet manual, used as the basis for diet orders and therapeutic diet planning, was approved by the medical staff. The Food and Nutrition Services (FNS) department failed to have standardized recipes with nutritional analysis and /or menu analysis to ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for patient care. The CAH administrative staff identified a census of 8 patients. The Supervisor of FNS reported the department provided approximately 15 patient meals per day.

Failure to ensure the CAH has a system to ensure medical staff approval of the diet manual and nutrition analysis to aid in menu planning could potentially result in therapeutic diets served to patients which do not meet the patients nutritional needs and/or national standards for the therapeutic diets ordered by practitioners.

Findings include:

Observation during the initial kitchen environment tour on 2/27/17, beginning at 11:30 AM, revealed a diet manual titled "Simplified Diet Manual 12th edition", available in the kitchen and accessible to FNS staff.

Observation of the recipe books for cafeteria menu items on 2/27/17, at 3:00 PM, and the patient menu items on 3/6/17, at 3:40 PM, revealed the recipes failed to include nutritional analysis.

During an interview on 2/27/17, at 12:30 PM, Staff B, Supervisor of FNS, reported she purchased the "Simplified Diet Manual 12th edition, to replace the previous 11th edition. Staff B acknowledged she did not know the required process for the diet manual but thought she needed to replace the old ones because she thought it was the designated diet manual for the CAH. Staff B reported the CAH also had the The Academy of Nutrition and Dietetics Nutrition Care Manual available on the intranet, which would be accessible to all the employees. Staff B acknowledged she did not know if either diet manual had been approved by the medical staff and did not know it needed approval.

During an interview on 2/28/17, at 9:00 AM, Staff B reported an old policy designated the Simplified Diet Manual 11th edition as the CAH diet manual but lacked documentation to support it had been approved by the medical staff. Staff B reported the current menus have been in place since she started approximately 3 years ago. Staff B reported the department has recipes for some patient menu items but acknowledged the department did not have nutritional analysis on the recipes or the menus.

During an interview on 2/28/17, at 11:10 AM, Staff C, Administrative Assistant, confirmed a policy had been approved in October 2016, which identified the The Academy of Nutrition and Dietetics Nutrition Care Manual and Pediatric Care Manual but acknowledged she did not have any documentation to show approval of the manual itself.

During an interview on 3/6/17, at 3:40 PM, Staff B reported the FNS department has some recipes for the patient menu items but acknowledged the department did not have recipes for all patient menu items.

Review of a CAH policy titled "Review and Approval of Nutrition Care Manual", approved 10/2016, revealed in part "... The Academy of Nutrition and Dietetics Nutrition Care Manual and Pediatric Care Manual are the standard guides for nutrition care ... They are approved every five years by the Director of Clinical Nutrition (or authorized clinical dietitian) and the Chief Medical Officer per hospital policy ... The Director of Clinical Nutrition keeps a copy of the signed approval form ..."

Review of a CAH policy titled "Nutritional Adequacy of Menus/Menu Approval", approved 10/2016, revealed in part "... meal selections are bundled to assure patients select a nutritional balanced diet; nonselective rotations meet nutritional guidelines as outlined in the Academy of Nutrition and Dietetics Nutrition Care Manual ... Modified diet menus offer foods consistent with requirements as outline in the Academy of Nutrition and Dietetics Nutrition Care Manual ... Computer-generated nutrient analysis of menus is available ..."

Based on observation, policy review and staff interviews, the Critical Access Hospital failed to secure and protect patient information from unauthorized users in 1 of 1 Medical Records Department. The CAH administrative staff identified approximately 3,975 patient medical records are stored in the Medical Records Department.

Failure to secure the patient information could potentially cause a misuse of patient information and a loss of identity for the individual patients.

Findings include:

An observation in the medical records department on 3/1/17, at 8:30 AM, revealed patient medical records stored in multiple open shelving units throughout the area.

During an interview, at the time of the observation, Staff E and Staff F, Medical Record Techs, reported the area is locked when not staffed. Staff E and Staff F acknowledged the housekeeping staff had a key to gain access to the department but reported they usually cleaned while the area was staffed.

During an interview on 3/1/17, at 8:50 AM, Staff G, Environmental Services (EVS), reported EVS staff did have a master key that would allow access to the medical records department, but do not enter the area unless staff are present.

During an interview on 3/2/17, at 10:15 AM, Staff H, Maintenance and EVS Supervisor, confirmed the EVS 2nd shift staff are instructed to clean the Medical Records department during staffed hours but carried a key ring with a master key that would allow access to the medical records department and potentially allow unsupervised access to CAH patients personal and medical information. Staff H reported a total of 7 EVS employees but only the 3 scheduled for 2nd shift would access the key ring, and only 1 of them scheduled on any given day. Staff H confirmed when not in use, the key remained stored in a locked key box in the environmental services area, which all EVS staff could access but only the 2nd shift staff have a need to carry the key ring

Review of policy titled, "Workforce Limitations with Respect to Using, Requesting, or Disclosing Patient Information", revised 5/2011, revealed in part "... For each member of the workforce or class of persons in the workforce (e.g. job code), CHI Health will determine the category of PHI (Protected Health Information) to which access is authorized, consistent with their "job" responsibilities ... Will not receive routine and recurring access to any PHI, however, may occasionally be exposed to such information during the course of duties (Human Resources Level 5) ... "

Review of a document titled "Position Description: Housekeeper", reviewed February 2010, revealed PHI Level 5 designated for this position.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) failed to delineate privileges for 1 of 1 person who was not an employee of the CAH to assist with Surgical procedures. Non-employee Staff J, Registered Nurse (RN), assisted with 52 surgical procedures from January 2016 to March 1, 2017 completed by Physician K.

Failure to privilege all non-employee assistants that accompany providers could result in patients receiving surgical intervention from unqualified professionals.

Findings include:

1. Observation on 3/1/17 at 9:15 AM with Staff L, Operating Room (OR) Supervisor, revealed non-employee Staff J, RN, present in the surgical suite and provided assistance to Physician K during a surgical procedure.

2. Review of Medical Staff Bylaws, approved by Board of Directors 1/23/13, revealed in part, ". . . Assistants. The surgeon shall utilize such assistants at surgery as he or she deems appropriate and such assistants may include any practitioner, Allied Health Professional (AHP), nurse, aide, or technician who is properly trained, qualified, and credentialed consistent with the Medical Staff Bylaws. . .."

Review of the Operating Room Log revealed non-employee Staff J, RN, provided surgical assistance for Physician K during surgical interventions for patients. Non-employee Staff J assisted with 52 surgical procedures from January 2016 to March 1, 2017 completed by Physician K.

Review of the Practitioner surgical privileges available in the surgery area on 3/1/2017 lacked documentation of privileges for non-employee Staff J.

3. During an interview on 3/1/17 at 10:00 AM, Staff L, Operating Room (OR) Supervisor, verified that non-employee J lacked surgical privileges in the OR area to provide assistance during surgical procedures with Physician K. Staff L stated non-employee J scrubbed in and assisted Physician K during surgical procedures in the OR.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 9 of 12 patient care services provided. (Anesthesia, Respiratory Therapy, Sleep Study, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Dietary, and Radiology) The CAH staff identified a current census of 8 inpatients at the start of the survey.

Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided.

Findings include:

1. Review of CAH policy/procedure titled "Annual Critical Access Review Program", dated 10/15, revealed in part, ". . . The annual program evaluation will include at a minimum:. . .a random sample of both active and closed medical records will be reviewed for completeness and appropriateness of diagnosis and treatment. . . ."

2. Review of the "Annual Critical Access Hospital Program Evaluation" dated 9/22/16, lacked documentation of review of a sample of both active and closed clinical records for Anesthesia, Respiratory Therapy, Sleep Study, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Dietary, and Radiology.

3. During an interview on 3/2/17 at 9:15 AM, Staff A, Chief Executive Officer (CEO), verified the annual evaluation of the CAH Annual Program Evaluation lacked documentation of review of a sample of both active and closed clinical records for Anesthesia, Respiratory Therapy, Sleep Study, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Dietary, and Radiology.