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Based upon review of the contracted services, the Quality Assurance/Performance Improvement (QA/PI) Plan, and administrative staff interviews, the hospital failed to evaluate all contracted services as evidenced by failing to evaluate Radiology Services provided by contractor #2. Findings:

Review of the QA/PI Program revealed there failed to be documented evidence the contracted services for Radiology was evaluated through the QA/PI Program. Interview with the Quality Assessment Coordinator S4 on 07/13/10, 3:00 PM, confirmed Radiological Services were not evaluated through the QA/PI Program.

Based upon review of the list of contracted services, Hospital Policies and Procedures, and administrative staff interviews, the hospital failed to ensure the list of contracted services was maintained and included the contractors who were responsible for furnishing Laboratory Services and Radiology Services. Findings:

Interview with the Medical Director S2 on 07/12/10, 1:30 PM, revealed during the day contractor #1 provided Laboratory Services. After hours and on weekends, the Medical Director stated that a local acute care hospital (Contractor #2) provided Radiological Services and if after hour Laboratory Services were needed, the patient would be transferred to Contractor #2's emergency department and the physician there would made the determination what laboratory tests would be required.

During an interview with S1, the Interim Hospital Administrator, the list of contracted services was requested. Review of the list revealed contractor #1 and contractor #2 was not identified.

Based upon review of Quality Assurance/Performance Improvement (QA/PI) Program Data and staff interview, the hospital failed to monitor the effective of all services provided to the patients as evidenced by failing to monitor Respiratory Services and the contracted Radiology Services through the QA/PI Program. Findings:

Review of the QA/PI Program Data for the past six months revealed there failed to be documented evidence Contractor #2, responsible for providing Radiological Services, and Respiratory Services failed to be identified. It was confirmed through interview with QA Coordinator S4 Radiology and Respiratory Services failed to be monitored through the QA Program.

Based upon reviews of hospital policies and procedures, contract agreement for laboratory services and Administrative interviews the hospital failed to ensure emergency laboratory services were available to each patient, should they require these services, 24 hours a day, 7 days a week. Findings:

Review of the hospital's Laboratory policies and procedures revealed the following: "NURSING POLICY NO. 1519 SUBJECT: LAB PROCEDURES ....STAT LAB SERVICES Stat lab services are available through (hospital's) lab provider during regular lab hours. Notify lab personnel once a stat lab order is noted 6:00 a.m. - 2:00 p.m. Monday - Friday. NO STAT PICK UP AFTER 2:00 PM..."

Review of the Laboratory policies and procedures revealed the hospital failed to have the provision of emergency laboratory services after 2:00 PM, Monday-Friday and no laboratory services on weekends.

Interview, 07/13/2010, with Quality Assurance Registered Nurse (RN) S4 revealed the hospital has an active contract for laboratory services furnished by Contractor #1. Review of the contract agreement revealed: "Contract Line Description Referral lab testing services as requested by (hospital) beginning 08/14/2009 thru 08/13/2010 Supplies required...Courier pickup of lab specimens will be provided by vendor two times daily Monday thru Friday...Reports of lab results will be telecommunicated to agency by printer. Equipment and forms for the telecommunication lab results is to be furnished by the vendor. Vendor will provide consultation for medical staff if needed. Certification of Licensing required and should be included with Bid. All reference and contract lab services meet the applicable Federal Regulations for Clinical Laboratories and maintain evidence of the same. Contract must meet all standards requirement of JCAHO"

Review of the contract agreement with Contractor #1 revealed there failed to be a provision of emergency laboratory services after regular hours (6:00AM-2:00PM) and weekends.

Interview, 07/13/2010, with Medical Director S2 revealed when questioned about emergency laboratory services after hours, he replied "we send the patient to the hospital" if they need lab studies after hours. It was noted Medical Director S2 was referring to a local acute care hospital in the above sentence.

The hospital failed to ensure emergency laboratory services were available, should a patient require this service, 24 hours a day, 7 days a week.

Based upon review of dietary policies and procedures, dietary observations on 07/12/10, and staff interview, the dietary staff failed to follow dietary policies and procedures and properly measure food temperatures as evidenced by inserting the thermometer through the Styrofoam containers to measure the food temperatures. Findings:

Observation of the noon meal on 07/12/10, 12:26 PM, revealed meals arrived to the unit in ice chests. The meals were in Styrofoam containers and consisted of Salisbury steak, mashed potatoes and gravy and field peas. Dietary staff removed two of the Styrofoam containers, one of which was wrapped in saran wrap. The Dietary staff were observed to measure the meal temperature by inserting the thermometer through the saran wrap and Styrofoam container. The thermometer was then pulled out and inserted into the other Styrofoam container. After the dietary staff measured the two meals, the QA Coordinator, S4, told the staff that was not the correct procedure to follow for measuring food temperatures and instructed the dietary staff to re-order these two patient meals.

Review of dietary policy and procedure #IV-10, Subject: Food Temperatures, Procedure #5. To check temperatures: a. Wash, rinse, sanitize, and air drive thermometer before use. b. Insert the thermometer stem directly into the thickest part of the food or the center of a pan of food. c. The thermometer must be in the food at least 2 inches or up to the sensing mark on the stem. d. Hold the thermometer in the food for a minimum of 15 seconds. e. Check and record the temperature of the food. f. Sanitize the thermometer stem before checking another food item.

Review of the in-service training conducted 06/28/10 revealed Registered Dieticians S3 and S15 conducted in-service training to the dietary staff on obtaining food temperatures along with hands-on return demonstration. Interview with Registered Dietician S3 on 07/12/10, 2:30 PM, revealed after the in-service training on 06/28/10, return demonstrations were conducted with the dietary staff and she was not aware the staff on unit 7 were measuring patient meals by inserting the thermometer through the Styrofoam containers.

Based upon review of hospital policies and procedures, Governing Body/Medical Staff meeting minutes, and Administrative interviews the hospital failed to ensure the Governing Body and Medical Staff appointed and approved a physician to act as director of Respiratory Care Services as evidenced by a lack of a physician in this position. Findings:

Review of the hospital's Governing Body/Medical Staff meeting minutes (December 2009-June 2010) revealed there failed to be documented evidence a physician had been appointed as Director of Respiratory Services.

Interview, 07/13/2010 at 2:45 PM, with Medical Director S2 confirmed the Governing Body/Medical Staff had not appointed and approved a physician to serve as the Director of Respiratory Services.

There failed to be evidence the Governing Body/Medical Staff appointed and approved a physician to serve as Director of Respiratory Services.

Based upon observations, review of policies and procedures, 9 of 9 personnel files (#s S4, 5, 7, 8, 9, 10, 11, 13, 14), Governing Body/Medical Staff meeting minutes and Administrative and staff interviews, the hospital failed to ensure the Medical Staff determined the qualifications required for personnel who administered respiratory care services. Findings:

Observations made, 07/13/2010, 10:00AM, on patient #2's oxygen concentrator revealed the foam filters (located on either side of the machine) were covered in dust and debris. When Registered Nurse (RN) S9 was questioned in regard to how and/or who was responsible for ensuring the filters were routinely cleaned, she replied she did not know.

Interview, 07/13/2010, 3:00PM, with Director of Nursing (DON) S5 confirmed there were no written policies and procedures for respiratory services. When DON S5 was questioned as to how nurses were to change or clean the filters on the oxygen concentrator in use for patient #2, she replied, she would need to check. Follow up interview, 07/14/2010, 11:00AM, with DON S5 revealed when respiratory equipment was needed and obtained, the company representative, who was a Respiratory Therapist, trained the RN supervisor; who would then train the staff RNs.

DON S5 was questioned regarding the documentation of training and what type of training was received, she replied there was no record of the training. DON S5 was further questioned in regard to respiratory competencies of the nursing staff and what the hospital had in place to ensure training; DON S5 confirmed there were no policies and procedures, nor was there documented evidence of respiratory services competency evaluations.

Review of personnel files for S#s 4, 5, 7, 8, 9, 10, 11, 13 and 14 revealed there failed to be documented evidence the RNs (#s 4,5,7,8,9,10,11,13) and Licensed Practical Nurse, S14 had received training relative to the provision of respiratory care services.

Review of the Governing Body/Medical Staff meeting minutes, 12/2009 through 06/2010 revealed the Medical Staff failed to determine the qualifications of personnel who provided respiratory care services to patients.

Interview, 07/13/2010, with Medical Director S2 confirmed the Medical Staff had not determined the qualifications personnel were to have prior to the provision of respiratory care services.

Based upon observations, reviews of policies and procedures, Governing Body/Medical Staff meeting minutes, and Administrative interviews, the hospital failed to ensure the Governing Body/Medical Staff developed and implemented written procedures relative to respiratory services. Findings:

Observations made, 07/13/2010, 10:00AM, on patient #2's oxygen concentrator revealed the foam filters (located on either side of the machine) were covered in dust and debris. When Registered Nurse (RN) S9 was questioned in regard to how and who was responsible for ensuring the filters were routinely cleaned, she replied she did not know.

Interview, 07/13/2010, 3:00PM, with Director of Nursing (DON) S5 confirmed there were no written policies and procedures for respiratory services. When DON S5 was questioned as to how nurses were to change or clean the filters on the oxygen concentrator in use for patient #2, she replied, she would need to check. Follow up interview, 07/14/2010, 11:00AM, with DON S5 revealed when respiratory equipment was needed and obtained, the company representative, who was a Respiratory Therapist, trained the RN supervisor; who would then train the staff RNs.

DON S5 was questioned regarding the documentation of training and what type of training was received, she replied there was no record of the training. DON S5 was further questioned in regard to respiratory competencies of the nursing staff and what the hospital had in place to ensure training; DON S5 confirmed there were no policies and procedures, nor was there documented evidence of respiratory services competency evaluations.

Review of the hospital's policies and procedures revealed the hospital did not have written policies and procedures for the delivery of respiratory care services.

Review of the Governing Body/Medical Staff meeting minutes, dated 12/09 through 06/2010, revealed there failed to be documented evidence the Medical Staff had specified the type of respiratory care services the hospital provided.

Interview, 07/13/2010, 2:45 PM, with Medical Director S2 confirmed the Medical Staff had not formulated and implemented policies and procedures relative to respiratory services.

Based upon review of policies and procedures, Administrative and staff interviews, the hospital failed to ensure there were written policies and procedures that addressed: 1) each type of respiratory care services provided at the hospital; 2) the required qualifications and education of personnel providing the respiratory care; and 3) the personnel qualified to supervise the specific respiratory procedures. Findings:

The surveyors requested the Respiratory Care Services policies and procedures. Registered Nurse (RN) S4 stated the hospital did not have policies and procedures relative to Respiratory Care Services.

Interview, 07/13/2010, 3:30 PM, with Director of Nursing (DON) S5 confirmed the hospital did not have written policies and procedures for Respiratory Care Services that addressed: 1) the type of respiratory care services provided at the hospital; 2) the qualifications and education of personnel who provided the respiratory services; and 3) the personnel qualified to supervise the specific respiratory procedures.

Interview, 07/13/2010, with Medical Director S2 confirmed the hospital did not have written policies and procedures relative to Respiratory Care Services.