HospitalInspections.org

Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel biennially review the CAH's health care policies for 2 of 2 years (May 2020-April 2022) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH's ability to ensure treatment of CAH patients followed current policies, regulations, and standards of practice.

Findings include:

Review of the policy "Policy Review" occurred on 05/04/22. This policy, effective 04/01/17, stated,
". . . Policy: Departments will be on a schedule and divided up between April and October each year for all policies to be reviewed by the following:
Department Manager
CEO [Chief Executive Officer]
Medical Staff
Mid-Level
Outside Professional
A policy review form will be signed confirming review."

Review of the CAH's policies occurred on all days of the survey. A physician and physician's assistant had reviewed the laboratory's policies in January and April of 2022. All other CAH policies lacked evidence of biennial review from May 2020-April 2022 by a physician and physician assistant/nurse practitioner/clinical nurse specialist (the required members of a group of professional personnel).

Upon request on 05/02/22, the CAH failed to provide evidence a physician and a physician assistant/nurse practitioner/clinical nurse specialist biennially reviewed the CAH's policies from May 2020-April 2022.

During interview on 05/02/22 at 4:10 p.m., an administrative staff member (#1) confirmed the CAH failed to document evidence a physician and a physician assistant/nurse practitioner/clinical nurse specialist biennially reviewed the CAH's policies in the past two years.

Based on document review, policy review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 1 of 1 year reviewed (April 2021-March 2022). Failure to evaluate services furnished by contractors limited the CAH's ability to ensure the contractors provided quality services for the CAH and its patients.

Findings include:

Review of the CAH's list of services occurred on May 2-4, 2022. The undated list showed fifteen contracted services available at the CAH.

Review of the policy "Quality Improvement Program" occurred on 05/04/22. This policy, effective 07/01/20, stated,
"I. Overview (C-0336)
The purpose of the Quality Improvement Program of the Hazen Memorial Hospital Association d/b/a [doing business as] Sakakawea Medical Center is to continuously improve the quality of patient care services. . . .
VI. Contracted Services (C-0336, C-0337)
Contracts for patient care services will be reviewed on an annual basis . . ."

Reviewed on May 2-3, 2022, the medical staff and QAPI (Quality Assessment and Performance Improvement) meeting minutes from May 2021-March 2022 failed to include evidence CAH staff had evaluated contracted services.

Upon request on 05/04/22, the CAH failed to provide evidence staff had evaluated contracted services in the past year to ensure the contractors provided quality services for the CAH and its patients.

During interview on 05/04/22 at 9:20 a.m., an administrative staff member (#1) confirmed the CAH had failed to document the evaluation of contracted services in the past year.