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Based on review of policies/procedures, documentation, and staff interviews, the facility failed to ensure the physician periodically reviewed Critical Access Hospital (CAH) out patient clinic records, in conjunction with the mid-level practitioner, for 4 of 6 mid-level practitioners. (Practitioners A, B, C, D)

The Quality Services Director reported the volume of services by mid-level practitioners over the past 12 months as follows:
- Practitioner A - 1437 Clinic Out patients
- Practitioner B - 1223 Clinic Out patients
- Practitioner C - 1499 Clinic Out patients
- Practitioner D - 807 Clinic Out patients

Failure to ensure a physician periodically reviews, in conjunction with the mid-level practitioner, the care delivered by the mid-level practitioner affects the facility's ability to assure the mid-level practitioners are consistently providing quality care to its patients.

Findings include:

1. Review of CAH policy/procedure titled "Medical Staff/Mid-Level Practitioner Peer Review", dated August 2012, revealed, in part, ". . . Mid-level Practitioners: Doctors of Medicine or Osteopathy will periodically review and sign the record of patients cared for by midlevel practitioners. . . A periodical chart review is completed with physician and mid-level practitioner together to evaluate patient care and if all applicable policies are being followed. . . ."

Review of Medical Staff Rules and Regulations, dated December 18, 2012, revealed, in part, ". . . Responsibilities of Doctor of Medicine or Osteopathy and Mid-Level Providers. . . In conjunction with the mid-level provider(s), will review the CAH's patient records, provide medical orders, and provide medical care services to the patients of the CAH. . . The Mid-Level Provider (Physician Assistant/Advanced Nurse Practitioner) will: . . . Participate with a Doctor of Medicine or Osteopathy in a periodic review of the patient's health records. . . ."

2. The facility was unable to provide any documentation or evidence that showed physicians periodically reviewed outpatient clinic patient's medical records in conjunction with the outpatient clinic mid-level practitioners.

3. During an interview on 1/14/13 at 5:00 PM, Practitioner A stated she had provided outpatient services at the clinic for over one year and had not ever reviewed patient charts in conjunction with a physician.

During an interview on 1/15/13 at 7:55 AM, Practitioner B stated she had provided outpatient services at the clinic for over 8 years and had not ever reviewed patient charts together with a physician.

During an interview on 1/15/13 at 8:10 AM, the Clinic Supervisor acknowledged there is no formal process for physicians to review patient charts in conjunction with the mid-level practitioners.

During an interview on 1/16/13 at 8:55 AM, the Director of Quality Services stated the physicians sign the mid-level practitioner's clinic records after dictation is complete. However, there is no documentation to show the physician reviewed the patient records in conjunction with the mid-level practitioner.

During an interview on 1/16/13 at 10:25 AM, Practitioner C stated she had provided outpatient services at the clinic for 3 years. Practitioner C acknowledged there was no documentation of formal chart review together with a physician.

Based on review of policies/procedures, documentation, and staff interviews, the facility failed to ensure the mid-level practitioners participated with a physician in a periodic review of the Critical Access Hospital's (CAH) out patient clinic records, for 4 of 6 mid-level practitioners. (Practitioners A, B, C, D)

The Quality Services Director reported the volume of services by mid-level practitioners over the past 12 months as follows:
- Practitioner A - 1437 Clinic Out patients
- Practitioner B - 1223 Clinic Out patients
- Practitioner C - 1499 Clinic Out patients
- Practitioner D - 807 Clinic Out patients

Failure to ensure the mid-level practitioners participated with a physician in a periodic medical record review of the care delivered by the mid-level practitioner affects the facility's ability to assure the mid-level practitioners are consistently providing quality care to its patients.

Findings include:

1. Review of CAH policy/procedure titled "Medical Staff/Mid-Level Practitioner Peer Review", dated August 2012, revealed, in part, ". . . Mid-level Practitioners: Doctors of Medicine or Osteopathy will periodically review and sign the record of patients cared for by midlevel practitioners. . . A periodical chart review is completed with physician and mid-level practitioner together to evaluate patient care and if all applicable policies are being followed. . . ."

Review of Medical Staff Rules and Regulations, dated December 18, 2012, revealed, in part, ". . . Responsibilities of Doctor of Medicine or Osteopathy and Mid-Level Providers. . . In conjunction with the mid-level provider(s), will review the CAH's patient records, provide medical orders, and provide medical care services to the patients of the CAH. . . The Mid-Level Provider (Physician Assistant/Advanced Nurse Practitioner) will: . . . Participate with a Doctor of Medicine or Osteopathy in a periodic review of the patient's health records. . . ."

2. The facility was unable to provide any documentation or evidence that showed mid-level practitioners participated with a physician in a periodic review of CAH outpatient clinic records.

3. During an interview on 1/14/13 at 5:00 PM, Practitioner A stated she had provided out patient services at the clinic for over one year and had not ever, in conjunction with a physician, reviewed patient charts.

During an interview on 1/15/13 at 7:55 AM, Practitioner B stated she had provided out patient services at the clinic for over 8 years and had not ever reviewed patient charts together with a physician.

During an interview on 1/15/13 at 8:10 AM, the Clinic Supervisor acknowledged there is no formal process for physicians to review patient charts in conjunction with the mid-level practitioners.

During an interview on 1/16/13 at 8:55 AM, the Director of Quality Services stated the physicians sign the mid-level practitioner's clinic records after dictation is complete. However, there is no documentation to show the physician reviewed the patient records in conjunction with the mid-level practitioner.

During an interview on 1/16/13 at 10:25 AM, Practitioner C stated she had provided outpatient services at the clinic for 3 years. Practitioner C acknowledged there was no documentation of formal chart review together with a physician.

Based on medical record review and staff interview, the facility failed to ensure a physician ordered specialized rehabilitation (rehab) services for swing bed patients. Problem identified with 2 (of 2) active medical records (Patient #'s 1 and 2) and 4 (of 5) closed medical record (Patient #'s 3, 4, 5, and 6).

The Acute Care Nursing Director identified a daily average census of approximately 5 swing bed patients.

Failure to ensure a physician ordered specialized rehab services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition.

Findings include:

1. Review of Patient #1's medical record showed:

On 1/12/13 at 4:18 PM, Advanced Registered Nurse practitioner (ARNP) E, a mid-level provider wrote an order for physical therapy (PT) and occupational therapy (OT) (specialized rehabilitation services) to evaluate and treat Patient #1, who was admitted to the inpatient unit, on swing bed status 1/12/13 with a diagnosis of bilateral lower lobe pneumonia (an infection in both lungs).

PT power form notes dated 1/13/13 at 9:43 AM revealed, at the order of ARNP E; PT staff evaluated the Patient and formulated a treatment plan that included therapeutic activity, exercise, walking, and stair training. PA F approved the assessment and treatment plan and ordered continuation of PT services. At the time of survey, the Patient was still receiving PT services ordered by PA F, not a physician.

On 1/14/13 at 8:30 AM and 12:59 PM, the Patient received respiratory therapy (RT) services (a specialized rehabilitation service). The medical record lacked an order for RT services until 1/15/13 at 8:18 AM, when PA F, a mid-level provider, entered an order for RT evaluation and treatment. At the time of survey, the Patient continued receiving RT services approved by the mid-level provider, not a physician.

2. Review of Patient #2's medical record showed:

On 1/10/13 at 4:07 PM, PA F, wrote an ordered for PT and OT to evaluate and treat Patient #2, admitted to the inpatient unit, on swing bed status 1/10/13 with a diagnosis of a fall with weakness and symptomatic Congestive Heart Failure. (The inability of the heart to pump blood at an adequate rate, resulting in congestion in the lungs, shortness of breath, edema in the lower extremities)

On 1/10/13 at 6:01 PM, PA F ordered RT to evaluate and treat Patient #2.

RT power form notes dated 1/10/13 at 6:30 PM, revealed after evaluating the patient, RT staff formulated a respiratory treatment plan. At the time of survey, the patient was still receiving RT services ordered by a mid-level provider, not a physician.

During an interview on 1/15/13 at 8:00 AM, Register Nurse (RN) A, Acute Care Nursing Director confirmed Patient #1 and Patient #2's medical records lacked a physician's order for specialized rehab services and in fact ARNP E and PA F ordered the specialized rehab services for patient #1 and #2.

3. Review of Patient #3's medical record showed:

On 7/19/12 at 3:26 PM, PA F wrote an order for PT, OT, and speech therapy (ST) to evaluate and treat Patient #3, who was admitted to the inpatient unit, on swing bed status 7/19/12 with a diagnosis of urinary tract infection and aspiration pneumonia (pneumonia caused when a person inhales food into their lungs).

OT power form notes dated 7/20/12 at 10:41 AM, revealed after evaluating the patient, OT staff formulated an OT treatment plan. The patient continued receiving OT services, ordered by PA F, until 7/29/12.

PT power form notes dated 7/20/12 at 2:34 PM, revealed after evaluating the patient, PT staff formulated a PT treatment plan. The Patient continued receiving PT services, ordered by PA F, until 7/29/12.

ST power form notes dated 7/20/12 at 11:11 AM, revealed ST staff evaluated the Patient and documented the Patient appeared to safely chew and swallow regular texture foods and thin liquids at this time.

4. Review of Patient #4's medical record showed:

On 8/25/12 4:13 PM, ARNP E wrote an order for PT and OT staff to evaluate and treat Patient #4, who was admitted to the inpatient unit, on swing bed status 8/25/12 for rehabilitation after a total hip replacement.

PT power form notes dated 8/26/12 at 10:34 AM, revealed after evaluating the Patient; PT staff formulated a PT treatment plan. The Patient received PT services, ordered by PA F, until 9/4/12.

OT power form notes dated 8/27/12 at 9:00 AM, revealed after evaluating the Patient; OT staff formulated an OT treatment plan, ordered by PA F.

5. Review of Patient #5's medical record showed:

On 10/17/12 at 4:00 PM, PA F wrote an order for PT and OT staff to evaluate and treat Patient #5, who was admitted to the inpatient unit, on swing bed status 10/17/12 for rehabilitation after a fractured vertebrae.

OT power form notes dated 10/17/122 at 9:00 AM, revealed, after evaluating the Patient; OT staff formulated an OT treatment plan. The Patient continued receiving OT services ordered by PA F until discharge on 10/25/12.

PT power form notes dated 10/18/12 at 11:20 AM, revealed, after evaluating the Patient; PT staff formulated a PT treatment plan. The Patient continued receiving PT services ordered by PA F until discharge on 10/25/12.

6. Review of Patient #6's medical record showed:

On 11/23/12 at 12:57 PM, PA F wrote an order for PT and OT staff to evaluate and treat Patient #6, who was admitted to the inpatient unit, on swing bed status 11/23/12 after hip surgery.

PT power form notes dated 11/24/12 at 12:55 PM, revealed, after evaluating the Patient; PT staff formulated an PT treatment plan. The Patient continued receiving PT services ordered by PA F until discharge on 11/29/12.

OT power form notes dated 11/26/12 at 7:57 AM, revealed, after evaluating the Patient; OT staff formulated an OT treatment plan. The Patient continued receiving OT services ordered by PA F, until discharge on 11/29/12.

7. During an interview on 1/16/13 at 9:30 AM, RN B confirmed Patients 3, 4, 5, and 6's medical records lacked a physician order for specialized rehab services and, in fact, ARNP E and PA F ordered the specialized rehab services for these patients.

During an interview on 1/16/13 at 2:00 PM, the Chief Nursing Officer (CNO) reported they were not aware that a physician was required to order specialized rehab services so they had not developed a policy for this and, in fact, mid-level physicians ordered specialized rehab services for patients admitted to the hospital. The CNO acknowledged Patients 1, 2, 3, 4, 5, and 6 received specialized rehab services ordered by mid-level physicians E and F.