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Based on interview and document review, the critical access hospital (CAH) failed to ensure the governing body received reports evaluating provisions of care for services provided by arrangement or agreement including: echo cardiogram.

Findings include:

On 7/22/14, at 9:30 a.m. the Radiology Supervisor was interviewed and stated that she was not involved in the quality assurance process for the contracted service of echo cardiogram. The Radiology Supervisor confirmed the facility did not have any current quality assurance or process improvement plans developed for the echo cardiogram contracted service.
Review of the contract CARDIOLOGY OUTREACH SERVICES AGREEMENT dated 1/1/13, under step 5 "Facility Responsibilities in Regard to Technical Services." section e. described the following: "Facility shall be responsible for conducting quality assurance activities related to the Technical Services as necessary."
On 7/22/14, at 10:45 a.m. the chief nursing officer CNO acknowledged echo cardiogram services did not have a current quality improvement project which was integrated into the CAH's quality improvement program.



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Based on interview and document review the critical access hospital (CAH) failed to ensure quality assurance/performance improvement projects were developed and integrated into the critical access hospital's (CAH) quality improvement program for the following services: dietary and health information systems (clinical records department). This had the potential to affect all current and future patients of the CAH.

Findings Include:

DIETARY
The dietary manager was interviewed on 7/22/14, at 10:30 a.m. during which she stated the registered dietician (RD) had developed a dietary quality assurance plan, however, did not share the QA plan and the dietary supervisor could not articulate what the plan included and how the plan was going to be implemented.

Review of the "Dietary Quality Assurance 2014" revealed the dietary department had identified 2 problems. The first problem was identified as "The hospital menu is not user-friendly for patients or staff. The second problem was identified as "Dinner trays were not consistently delivered to the patients rooms in a timely manner." The dietary QA plan had not identified how they were going to correct both of the issues and how the improvement would be measured.

The chief nursing officer was interviewed on 7/22/14, at 10:45 a.m. and confirmed the "Dietary Quality Assurance 2014" had not included methodology for how they were going to correct the identified problems and how the improvement would be measured.

Health Information Systems (clinical records department)

The chief nursing officer was interviewed on 7/21/14, at 3:00 p.m. and stated the clinical record department manager was not available for interview and confirmed the written quality assurance or process improvement plan was developed for the clinical records department.



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