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Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 17 of 17 patient care services provided (Emergency Room, Surgery, Pharmacy, Infection Prevention, Medical/Surgical, Respiratory Therapy, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Laboratory, Radiology, Urgent Care, Health Information Management, Nutritional Services, Environmental Services, Cardiac Rehabilitation, and Infusion). The CAH administrative staff identified a current census of 13 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 at the CAH.

Findings include:

1. Review of CAH policy "Periodic Evaluation of the Critical Access Hospital and the Rural Health Clinic Programs," dated revised 09/22/2020, revealed in part, "...A periodic evaluation of the total CAH program is completed on an annual basis...which includes...A representative sample of both active and closed clinical records...."

2. Review of the annual program evaluation, presented December 2019, lacked documentation the CAH staff reviewed a sample of both active and closed clinical records for Emergency Room, Surgery, Pharmacy, Infection Prevention, Medical/Surgical, Respiratory Therapy, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Laboratory, Radiology, Urgent Care, Health Information Management, Nutritional Services, Environmental Services, Cardiac Rehabilitation, and Infusion.

3. During an interview on 11/18/2020 at 1:30 PM, the Chief Executive Officer verified the annual program evaluation lacked documentation the CAH staff performed a review of a sample of both active and closed records for Emergency Room, Surgery, Pharmacy, Infection Prevention, Medical/Surgical, Respiratory Therapy, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Laboratory, Radiology, Urgent Care, Health Information Management, Nutritional Services, Environmental Services, Cardiac Rehabilitation, and Infusion.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total CAH program included a review of patient health care policies. The CAH administrative staff identified a current census of 13 patients at the beginning of the survey. Failure to include a review of patient care policies as part of the CAH's total program evaluation could potentially result in the failure of staff to evaluate and update policies as needed to improve patient care and meet the needs of the patient and the community.

Findings include:

1. Review of the CAH policy "Periodic Evaluation of the Critical Access Hospital and the Rural Health Clinic Programs," revised 09/22/2020, revealed in part, "... A periodic evaluation of the total CAH program is completed on an annual basis ... which includes ... A representative sample of both active and closed clinical records ...."

2. Review of the annual program evaluation, presented December 2019, lacked documentation the CAH staff included the review of the policies as part of the Annual Critical Access Hospital report.

3. During an interview on 11/18/2020 at 1:30 PM, the Chief Executive Officer acknowledged the CAH staff failed to include a review of policies as part of the Annual Critical Access Hospital report.

Based on review of the Quality Plan, Quality activities, Board of Trustees Bylaws and Meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the governing body evaluated the quality of 17 of 17 patient care services (Emergency Room, Surgery, Pharmacy, Infection Prevention, Medical/Surgical, Respiratory Therapy, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Laboratory, Radiology, Urgent Care, Health Information Management, Nutritional Services, Environmental Services, Cardiac Rehabilitation, and Infusion) and 7 of 7 contracted patient care services (Sleep Study, TeleHealth, Nuclear Medicine, Stereotactic Breast Biopsy, Anesthesia including pain clinic, Healogics, and Speech Therapy) to include information provided to the Governing Body. Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

The CAH administrative staff identified the CAH staff provided care to patients for 12 months for Fiscal Year 2019 as follows:
- Emergency Room - 4,873 patient visits
- Surgery - 1,545 procedures
- Medical/Surgical - average of 2 patients per day
- Respiratory Therapy - 3,032 patients
- Wound - 654 patients
- Physical Therapy - 9,910 patient visits
- Occupational Therapy - 5,222 patient modalities
- Specialty Clinic - 1,032 patient visits
- Laboratory - 13,018 patient visits
- Radiology - 11,618 patient visits
- Urgent Care - 3,565 patient visits
- Nutritional Services - average of 16 meals served per day
- Cardiac Rehabilitation - 158 patients
- Infusion - 2,287 procedures
- Sleep Study - 185 patients
- TeleHealth - 41 visits
- Nuclear Medicine - 218 patients
- Stereotactic Breast Biopsy -
- Anesthesia - 1,169 procedures/consults
- Healogics - 146 patient treatments
- Speech Therapy - 412 patient modalities

Findings include:

1. Review of the "Quality Improvement and Patient Safety Program," dated Fiscal Year 2021, revealed in part, "The [Board of Trustees] has ultimate accountability for the quality program and is responsible for making sure the correct oversight is in place, that quality and safety data are systematically reviewed, and that safety receives the appropriate attention as a standing agenda item ... The board oversees all dimensions of quality, reviews data to assess progress over time."

2. Review of the "Bylaws of the Board of Trustees," dated October 23, 2018, revealed in part, "... Powers & Duties ... Require and approve a quality assurance plan providing for specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital and related programs of patient care. The Board shall receive and review a report of quality assurance activities on a regular basis."

3. Review of Quality Meeting Minutes dated 11/25/2019 and 2/26/2020 revealed the lack of department quality reports for Emergency Room, Surgery, Pharmacy, Infection Prevention, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Radiology, Cardiac Rehabilitation, and Infusion.

4. Review of Board of Trustees Meeting minutes dated November 26, 2019 through October 27, 2020 revealed the governing body received a quality dashboard which included only broad indicators and not department specific reports.

5. During an interview on 11/18/2020 at 10:30 AM, the Patient Safety Officer confirmed the Board of Trustees only received a quality dashboard monthly which included only broad indicators and not department specific reports.

During an interview on 11/18/2020 at 4:30 PM, the Chief Executive Officer acknowledged the Board of Trustees did not receive quality reports from the identified departments.

Based on document review, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 2 family medicine physicians received outside entity peer review and 4 of 4 radiologists selected for review, received outside entity peer review by the appropriate entity, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to the CAH patients (Family Medicine Physician E, Radiologist F, Radiologist G, Radiologist H, and Radiologist I).

The CAH administrative staff identified Family Medicine Physician E provided care to patients from as follow:

From 1/1/2020 to 11/17/20 - 431 urgent care and medical/surgical patients
From 7/1/2018 to 8/31/19 - 164 emergency room patients
From 8/1/18 to 11/17/20 - 229 procedures

The CAH administrative staff identified the radiologists provided services to patients from 11/1/18 to 11/1/2020 as follows:

Radiologist F provided care to 472 patients.
Radiologist G provided care to 1011 patients.
Radiologist H provided care to 483 patients.
Radiologist I provided care to 460 patients.

Findings include:

1. Review of the CAH's network agreement, dated 5/31/16, revealed in part " ... Hospital has or will enter into an Affiliation Agreement with [Network Hospital] through which [Network Hospital] will provide quality assurance services, among other services, to Hospital ..."

2. Review of the CAH's network affiliation agreement, dated 5/31/16, revealed in part "... Hospital and [Network Hospital] are entering into this agreement to further improve the quality and coordination of care in the region and to improve patient access to care ..." Exhibit A of the agreement titled "Services Provided Under Affiliation Agreement", revealed the Network Hospital would provided quality assurance and performance improvement support on a purchased cost basis.

3. Review of a CAH agreement titled "Radiology Information Services Agreement", dated 9/2/05, revealed in part "... This Radiology Information Services Agreement ("Agreement") is between [Radiology Entity A] ... and [CAH] ..." and identified the scope of radiology services.

4. Review of a CAH policy "Peer Review," revised 4/28/20, revealed in part "... It is the policy of [CAH] to conduct and facilitate the Peer Review process to promote quality assurance and improvement related to medical care provided. The Medical Staff is responsible for the quality of care at [CAH] according to the established standards for evaluation of practitioner competency and conduct, consistent with recognized national standards and clinical guidelines. Each provider who provides billable services at [CAH] will have at least one external peer review performed per credentialing cycle on a randomly selected chart ...".

5. Review of external peer review for the selected physicians revealed the medical staff approved Family Practice Physician E for reappointment to the Medical Staff on 8/19/19. The Board of Trustees approved Family Practice Physician E for reappointment to the Medical Staff on 8/27/19. Family Practice Physician E's file lacked the results of any external peer review conducted by the Network Hospital, prior to Family Practice Physician E's reappointment to the Medical Staff.

6. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist F for reappointment to the Medical Staff on 4/23/20. The Board of Trustees approved Radiologist F for reappointment to the Medical Staff on 4/28/19. Radiologist F's file lacked the results of any external peer review conducted by the Network Hospital, prior to Radiologist F's reappointment to the Medical Staff.

7. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist G for reappointment to the Medical Staff on 2/17/19. The Board of Trustees approved Radiologist G for reappointment to the Medical Staff on 2/25/19. Radiologist G's file lacked the results of any external peer review conducted by the Network Hospital, prior to Radiologist G's reappointment to the Medical Staff.

8. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist H for reappointment to the Medical Staff on 12/16/19. The Board of Trustees approved Radiologist H for reappointment to the Medical Staff on 12/17/19. Radiologist H's file lacked the results of any external peer review conducted by the Network Hospital, prior to Radiologist H's reappointment to the Medical Staff.

9. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist I for reappointment to the Medical Staff on 10/21/19. The Board of Trustees approved Radiologist I for reappointment to the Medical Staff on 10/22/19. Radiologist I's file lacked the results of any external peer review conducted by the Network Hospital, prior to Radiologist I's reappointment to the Medical Staff.

10. During an interview on 11/18/20, at 2:00 PM, the Patient Safety Officer reported external peer review is conducted by their network hospital on all members of the medical staff providing services to CAH patients and the results become part of the appointment/reappointment packet. She reported she sent one Family Medicine Physician E's patient medical records to the network hospital for peer review, prior to his reappointment, but confirmed it did not get returned previous to his reappointment. The Patient Safety Officer reported she does not send any patient medical records to their network hospital for external peer review but she receives peer review from Radiology Entity A.

11. During an interview on 11/18/20, at 2:45 PM, the CEO reported he did not know if the individual(s) with [Radiology Entity A], who conduct the radiologists peer review, are medical staff members of their network hospital, but would find out.

12. During an interview on 11/18/20, at 4:30 PM, the CEO confirmed [Radiology Entity A] is not part of the network hospitals system.

13. During an interview on 11/19/20, at 10:30 AM, the Patient Safety Officer confirmed she did not receive any external peer review from their network hospital. for Family Medicine Physician E or Radiologists F, G, H and I, prior to their reappointment to medical staff.

I. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 3 of 3 patient exam rooms and 1 of 1 patient bathroom in the Wound Clinic and Urgent Care Clinic shared space, and in Specialty Clinic Pod A Urology Clinic, 2 of 2 patient exam rooms and Pod B, Gastrointestinal (GI) Clinic, 2 of 4 unoccupied patient exam rooms. Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in significant skin burns. The CAH staff identified the clinics saw an average yearly number of patients as follows:

Urgent Care Clinic: 3105 patients of all ages (infant through geriatric)
Wound Care Clinic: 197 adult patients
Urology Clinic: 1040 patients of all ages
Gastrointestinal Clinic: 432 adult patients

Findings include:

1. Observations, on 11/17/2020 from 1:15 PM to 2:50 PM, during tour of the Wound Care and Urgent Care Clinic space, the Executive Director of Ambulatory Services, Wound Clinic Manager, and Urgent Care Lead revealed steam rising from the running water and the following water temperatures:

At approximately 1:30 PM:
Exam Room 1: 140.7 degrees Fahrenheit
Patient Bathroom: 137.7 degrees Fahrenheit

At approximately 2:50 PM
Exam Room 2: 140.7 degrees Fahrenheit
Exam Room 3: 139.5 degrees Fahrenheit


During an interview on 11/17/2020, at the time of the observation, the Wound Clinic Director, verified that she saw steam rising from the running water in patient exam room 1 and the elevated water temperature of 140.7 degrees F.

Observation, on 11/17/2020 at 1:52 PM, Maintenance Staff A checked the water temperature of Patient Exam room 1 with facility thermometer, confirmed the water temp was elevated, and reported a result of 143 degrees Fahrenheit.

During a an interview, on 11/17/2020 at the end of the tour, Executive Director of Ambulatory Services verified the elevated water temperatures in patient exam room 1, exam room 2, exam room 3, and the patient bathroom.

During an interview on 11/17/2020 at 3:30 PM, Maintenance Staff A reported hospital water temperatures in patient care areas are randomly checked throughout the hospital. Patient Exam Room 1 (room # 1421) was last checked on 9/1/2020, and had a temperature of 119 degrees Fahrenheit. Maintenance Staff A verbalized the hospital does not have a policy on monitoring hot water temperatures in patient care areas.



2. Observations, on 11/18/2020 at approximately 2:00 PM, during a tour of the Specialty Clinics, revealed in Pod A, 2 of 2 patient exam rooms and in Pod B, 2 of 4 unoccupied patient exam rooms with the following water temperatures:

Pod A
Exam Room 1: 131 Degrees Fahrenheit
Exam Room 2: 131 Degrees Fahrenheit

Pod B
Exam Room 3: 127.8 Degrees Fahrenheit
Exam Room 4 124.7 Degrees Fahrenheit

During an interview on 11/18/2020, at the time of the observation, Urgent Care Clinic Lead verified the elevated water temperatures.

During an interview on 11/18/2020, at approximately 2:30 PM, Maintenance Staff L verified the elevated water temperatures in the specialty clinic and reported he obtained a water temperature reading of 137 degrees Fahrenheit with use of a facility thermometer.

During an interview on 11/19/2020, at 8:45 AM, Chief Nursing Officer (CNO) verified the elevated water temperatures found in the Wound Care/Urgent Care Clinic and Specialty Clinic areas. The CNO provided documentation from the maintenance department that the water temperature in the Specialty Clinic area was last checked on 10/14/2020 in Pod B, exam room 2, and had a temperature of 115.2 degrees Fahrenheit.




II. Based on observation, document review and staff interviews the Critical Access Hospital's (CAH) Staff failed to follow the manufacturer's instructions for the ACCU-CHEK Inform II Blood Glucose Monitoring System when it failed to label a newly opened Control Solution bottles with the opened date on the label. Failure to follow the ACCU-CHEK INFORM II Blood Glucose Monitoring System manufacturer's instructions for use may result in inaccurate blood glucose readings which may lead to inappropriate care. The CAH reported the Emergency Department (ED) performed approximately 15 blood glucose checks per month.

Findings include:

1. Observation on 11/16/2020 at 10:00 AM, during a tour of the Emergency Department, revealed an ACCU-CHEK Inform II Blood Glucose Monitoring System in its case with two opened bottles of ACCU-CHEK Inform II control solution bottles, Control Level 1 and Control Level 2. The bottles were not labeled with the date that the bottles were opened.

2. Review of the ACCU-CHEK Inform II Control manufacturer's information, dated 2014 revealed in part, "Note: Write the date the bottle was opened on the bottle label ... control solution is stable for 3 months from that date" "Sources of error: ... Were the ... control solutions expired?"

Review of the policy "Blood Glucose Monitoring", last reviewed 11/24/2020, revealed the policy lacked direction to label the ACCU-CHEK Inform II Control Solution bottles when opened and to discard the control solution 3 months from that date.

3. During an interview on 11/16/2020, while on tour of the Emergency Department, the Emergency Department Manager verified the ACCU-CHEK Inform II Blood Glucose Control bottles had not been labeled when opened.

Based on review of policies/procedures, meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider reviewed all patient care policies biennially for 17 of 17 patient care departments (Emergency Room, Surgery, Pharmacy, Infection Prevention, Medical/Surgical, Respiratory Therapy, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Laboratory, Radiology, Urgent Care, Health Information Management, Nutritional Services, Environmental Services, Cardiac Rehabilitation, and Infusion). The CAH administrative staff identified a census of 13 patients at the beginning of the survey. 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/procedures.

Findings include:

1. Review of CAH policy "Policy Development and Management," dated revised 04/28/2020, revealed in part, "...Policy Approval Process...Owner presents policy to the policy email ... to be logged for approval at the appropriate committees (Medical Staff, which includes at least one [Nurse Practitioner] or [Physician's Assistant], and Board of Trustees)...."

2. Review of Medical Staff Meeting minutes for October 15, 2018 through September 16, 2020 lacked approval for all policies for Emergency Room, Surgery, Pharmacy, Infection Prevention, Medical/Surgical, Respiratory Therapy, Wound, Therapy - Physical Therapy and Occupational Therapy, Specialty Clinic, Laboratory, Radiology, Urgent Care, Health Information Management, Nutritional Services, Environmental Services, Cardiac Rehabilitation, and Infusion.

3. During an interview on 11/18/2020 at 1:00 PM, the Executive Assistant acknowledged the policy review process included the department reviewed the policies and then the policy was sent to the Medical Staff where a physician and mid-level provider approve the list of revised policies. The Executive Assistant acknowledged the Medical Staff Meeting Minutes lacked evidence they approved the policies.

Based on observation, document review and staff interviews, Critical Access Hospital (CAH) administration failed to ensure 2 of 2 reviewed laboratory staff members (Medical LabTechnologist C and Medical Lab Technologist D), had color vision proficiency prior to interpreting the results of fecal occult blood (blood in stool) tests for all laboratory, nursing and medical staff who read the results of the test. Failure to test all laboratory for color blindness before performing this test may result in staff misreading the results of the fecal occult blood test which could potentially adversely affect the diagnosis and treatment plan for patients. The CAH performed 65 fecal occult blood tests from January 2020 to November 2020.

Findings include:

1. Observation on 11/16/2020 at 1:00 PM, during a tour of the Laboratory revealed the laboratory staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

2. Observation on 11/16/2020 at 10:00 AM, during a tour of the Emergency Department (ED), revealed staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood but the lab staff was responsible to read the results.

3. During interviews on 11/17/2020 at 4:10 PM, the Laboratory Manager and Medical Lab Technologist B reported the staff are not color blind tested upon hire. The staff would need to identify a positive Hemoccult test and to interpret the test would require the ability to identify the color blue.

4. Review of manufacturer's recommendations from March 2015, for Beckman Coulter Hemoccult slides, revealed in part: "Because the test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness)."

5. Review of personnel files revealed the following:

a. Medical Lab Technologist C started working at the CAH on 07/21/2014. Medical Lab Technologist A's personnel file lacked documentation the CAH staff tested Medical Lab Technologist A for blue color vision proficiency upon hire or at any time after hire.

b. Medical Lab Technologist d started working at the CAH on 07/21/2014. Medical LabTechnologist B's personnel file lacked documentation the CAH staff tested Medical Lab Technologist B for blue color vision proficiency upon hire or at any time after hire.

6. During an interview on 11/18/2020 at 9:05 AM, the Infection Preventionist/Employee Health Coordinator confirmed the CAH staff did not perform testing for color blindness on any of the CAH employees, including the Medical Lab Technologists.

7. During an interview on 11/18/2020 at 12:00 PM, the CNO reported the CAH employs 10 Medical Lab Technologists that could be required to read and interpret the results of fecal occult blood tests.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Respiratory Therapy staff kept patient medical information secure from unauthorized access in 1 of 1 Respiratory Therapy Department FAX Machines. Failure to keep patient medical information confidential could potentially result in unauthorized access of a patients personal/medical information and potentially result in unauthorized release of personal information. The CAH staff identified the FAX machine received approximately 3600 EKG over read reports in the past year.

Findings include:

Review of the policy, "Protection of Information Guidelines" effective 01/22/2019, revealed in part, "Scope: BCHC system wide ... all information ... e.g. fax machines ... must be protected from unauthorized access ...[or] disclosure" "... individual should have access only to ... information which is necessary to perform [their jobs]" "[Medical Records should be kept in a] ... Secure area ... not accessible to unauthorized persons ..."

Review of policy, "Access By Workforce," last reviewed 07/26/2016, revealed in part, " purpose...to outline...protected health information (PHI) by...workforce...Access...to...view data, records information...PHI..individually identifiable information about a patient...Role of Department Manager...implement...physical and administrative safeguards... [to] limit access...PHI"

Observation on 11/19/2020 at 09:15 AM, during a tour of the respiratory therapy department, revealed 1 of 1 FAX machines located in an unlocked area of the respiratory therapist office/supply space, potentially allowing unauthorized personnel access to confidential patient information.

During an interview on 11/19/2020 at approximately 0930 AM, at the time of the tour, the Respiratory Therapy Coordinator revealed the Fax machine is not secured and private patient information, predominately EKG over reads, are received after hours, print out, and remain on the Fax machines until respiratory therapy staff retrieves the information. The Respiratory Therapy Coordinator acknowledged that the private patient information on the FAX machine is available for unauthorized personnel access as patient care staff come into this area to obtain respiratory care supplies as needed, potentially on a daily basis. The Respiratory Therapy Coordinator acknowledged the private and confidential patient information is not secured as hospital policy requires.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 6 of 6 swing bed patients (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition. The CAH administrative staff identified an average of 4 swing bed patient admissions per month and a census of 1 swing bed patient on entrance.

Findings included:

1. Review of Patient #1's open medical record revealed the CAH staff admitted Patient #1 for swing bed level care on 11/11/2020. Advanced Registered Nurse Practitioner J (ARNP, a nurse with advanced training who may prescribe therapies) wrote an order on 11/11/2020 at 3:44 PM for the Physical Therapist to evaluate and treat Patient #1 and for the Occupational Therapist to evaluate and treat Patient #1.

2. Review of Patient #2's closed medical record revealed the CAH staff admitted Patient #2 for swing bed level care on 02/03/2020. The CAH staff discharged Patient #2 on 02/13/2020. ARNP J wrote an order on 02/03/2020 at 5:29 PM for the Physical Therapist to evaluate and treat Patient #2 and for the Occupational Therapist to evaluate and treat Patient #2.

3. Review of Patient #3's closed medical record revealed the CAH staff admitted Patient #3 for swing bed level care on 04/16/2020. The CAH staff discharged Patient #3 on 04/21/2020. ARNP J wrote an order on 04/14/2020 at 2:37 PM for the Physical Therapist to evaluate and treat Patient #3 and for the Occupational Therapist to evaluate and treat Patient #3.

4. Review of Patient #4's closed medical record revealed the CAH staff admitted Patient #4 for swing bed level care on 02/03/2020. The CAH staff discharged Patient #4 on 02/13/2020. ARNP K wrote an order on 08/28/2020 at 2:00 PM for the Physical Therapist to evaluate and treat Patient #4 and for the Occupational Therapist to evaluate and treat Patient #4.

5. Review of Patient #5's closed medical record revealed the CAH staff admitted Patient #5 for swing bed level care on 02/03/2020. The CAH staff discharged Patient #5 on 02/13/2020. ARNP J wrote an order on 09/16/2020 at 8:20 PM for the Physical Therapist to evaluate and treat Patient #5 and on 09/16/2020 at 4:32 PM for the Occupational Therapist to evaluate and treat Patient #5.

6. Review of Patient #6's closed medical record revealed the CAH staff admitted Patient #6 for swing bed level care on 02/03/2020. The CAH staff discharged Patient #6 on 02/13/2020. ARNP K wrote an order on 05/18/2020 at 5:27 PM for the Physical Therapist to evaluate and treat Patient #6 and for the Occupational Therapist to evaluate and treat Patient #6.

7. During an interview on 11/18/2020 at 8:15 AM, the Case Manager/Social Worker acknowledged that ARNP J and ARNP K wrote the therapy orders for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6 when the patients received swing bed services. The Case Manager/Social Worker acknowledged a physician did not write the therapy orders for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6.

8. During an interview on 11/18/2020 at 8:45 AM, the Med/Surg/Infusion Unit Manager confirmed the inability to provide information of physicians co-signing PT/OT orders for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6 by ARNP J and ARNP K.

9. During an interview on 11/18/2020 at 12:00 PM, the Chief Nursing Officer (CNO) was not aware of the requirement of physicians, both MD and DO, to co-sign physical therapy/occupational therapy (PT/OT) orders written for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6 by ARNP J and ARNP K. At the time of the interview, the CNO confirms the lack of a swing bed policy covering the requirement of physicians to co-sign PT/OT orders by mid-level providers.