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Based on record review and interview the Governing Body failed to insure the medical staff followed the Medical Staff bylaws, Rules and Regulations. There was no definition of the process for peer review letters of reference required during the credentialing period and the medical staff failed to complete medical records within the defined time limits and to suspend, in accordance with their Rules and Regulations, those physician's who would not comply for 9 months November 2018 through July 2019.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


During the survey of the facility that began 7/22/2019 and was completed on 7/25/2019, thirty-eight (38) medical records (MR) were reviewed.

Based on observation, interview, and record review the facility failed to include all departments and outpatient services in the Quality program. Outpatient services, Dialysis and Physical Therapy, Environmental services, Laundry/Linen, and plant operations were not reflected in the quality program.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.
1. On 7/25/2019 in the morning an interview with the Quality Director, staff #4, confirmed all departments and services areas were not reflected in the Quality program.

On 7/24/2019 accompanied by the Quality Director, staff #4, the facility's RHC (rural Health Clinic) was toured. The Quality Director and Director of Outpatient Services, staff #43, and Laboratory Director were present to observe and confirmed excessive infection control risks in the laboratory.

The RHC 's did not participate in the Quality program.

2. On 7/24/2019 in the morning a tour of the Physical Therapy Department revealed a clean and orderly program, however, an interview with the Director of the program confirmed the department followed no Quality specific guideline and had no process improvement other than tracking cancellations and scheduling.

Physical Therapy did not participate in the Quality program.


3. On 7/22/2019 during a tour and observation of the Dialysis program and the services it provided, Immediate Jeopardy was found. The facility staff failed to check the ****, every 4 hours as required for safety of the patient use solution.

After interview and attempts to review the documentation collected for the quality program it was determined the Dialysis services were not participating in the Quality program and had no process improvement or data collection that was submitted for quality review.

4. Environmental services tracked no data that was submitted to the Quality program and had no definitive process improvement.

5. Linen and Laundry tracked no specific data. This services was a contracted service. There was no data reflecting a process improvement.

Observation of the room (closet) dedicated to the collection of soiled linen prior to pick up was in need on deep cleaning, and repair.

6. Plant operations collected sufficient data, but did not turn the data into the Quality program for review. There was no data that reflected a process improvement.