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Based on record review and interview, the facility failed to monitor and evaluate emergency services policies conducted by the medical staff on an ongoing basis. This has the potential to affect all emergency department patients. Findings include:

During a review of the facility policy and procedures, the last documented policy reviews were completed in 2012 after the last recertification survey.

On 10/5/16 at 11:00 a.m., a request was made for the facility to submit a copy of the review checklist for each department of the facility to include the emergency department. No information was submitted to reflect that a current review had been completed for the emergency department policy and procedures.

During an interview on 10/3/16 at 2:00 p.m., staff member B stated revision of the policies and procedures were in process but were never completed. She stated the facility had experienced a high turnover rate with the CEO position and the policy reviews kept getting pushed back. Concerns were discussed regarding the governing board and medical staff involvement in making sure the facility policy and procedures were reviewed annually. She stated she was not sure why this was not addressed. She stated the issue was documented and brought to the administration's attention during the annual review on October 26, 2015.

During an interview on 10/3/16 at 3:00 p.m., staff member A did not offer an explanation for the lack of annual reviews. He said that the staff would need to submit any information related to policy and procedure annual reviews that would reflect the review process from department head review to the CEO for approval to the governing body for approval. No other information was submitted prior to the exit to show this process of reviews and signed approvals by the medical director, CEO and the governing body had taken place.

During an interview on 10/6/16 at 1:30 p.m., staff member D stated she attended the committee meetings and the facility had no formal schedule of review for their policies and procedures. She stated reviews of policy and procedures occurs when it is a point of concern for that particular policy and procedure. She stated there is no documentation to reflect that the medical director reviewed the clinical policies and procedures.

Review of the governing body board of trustees meeting minutes from 9/25/15 through 8/18/16 did not reflect policy and procedure review for each department in the meeting minutes.

Review of the CAH and RHC annual review report reflected a concern to become current with all department policy and procedure reviews. The annual review reflected, "the policies and procedures would be reviewed and signed off by the new CEO when he is in place and then taken to the board for final approval. New CEO is anticipated to be in place by December 2015."

A review of the facility policy titled policy and procedure review reflected each department manager would be responsible for drafting policies and procedures for their departments. Once the draft policy had been developed by the department manager, and was deemed to be appropriate, the final policy would be approved by the CEO. All clinical policies must be approved by the medical director. The department manager is required to complete the facility form titled policy and procedure review form. The completed form is to be reviewed at the annual CAH and RHC reviews.

Based on record review and interview, the facility failed to conduct an annual disaster drill to ensure staff received necessary training in handling emergencies. Findings include:

During an interview on 10/5/16 at 4:30 p.m., staff member E stated she was informed on this date she would be in charge of conducting and evaluating the facility disaster plan. Staff member E stated she believed the facility had not had a drill or plan for 2 years since the risk manager resigned.

Staff member E stated the facility had recently experienced three actual events that qualify as disaster drill experiences. Staff member E stated the facility experienced a mass casualty incident on 6/21/16, a water outage on 7/28/16 and a power outage on 10/5/16.

On 10/6/16 staff member E submitted documentation for the above listed incidents. The documentation included an analysis, recommendations and staff assignments. Each analysis was dated 10/5/16.

No other documentation was submitted to reflect annual disaster drills and their evaluation were conducted on an annual basis.

Based on record review and interview, the facility failed to ensure the governing body was monitoring policies governing the facility's total operation. This has the potential to affect all patients receiving care and services in the facility. Findings include:

On 10/3/16 at 3:35 p.m. a request for documentation of the following items was submitted: names of facility health care advisory group, the annual facility policy and procedure review by the advisory group and documentation of the policy and procedure approvals for all departments and services by the CEO and the governing body.

Review of the facility's department policies and procedures manuals reflected the last reviews occurred in 2012 for most departments in the facility. Some departments had a 2016 review date for all of their policies. All departments lacked a final approval signature from the CEO, medical director for clinical policies, and the governing body.

During an interview on 10/3/16 at 3:40 p.m., staff member B stated the facility had not continued with the policy review committee since December of 2012.

During an interview on 10/5/16 at 1:45 p.m., staff member F stated the facility had not had a consistent DON since 2012. Staff member F stated she reviews patient complaints, emergency room charts, meets with providers one time per month for issues and training opportunities. Staff member F stated she reviews patient cases every second Tuesday of the month. She stated physician orders are reviewed monthly and pharmacy conducts a drug regimen review, lab reviews and gradual dose reduction that are in progress. Staff member F submitted the medical staff meeting minutes for the last year. No documentation reflected a formal review of facility policies and procedures.

During an interview on 10/6/16 at 1:30 p.m., staff member D stated she attended the committee meetings and the facility had no formal schedule of review for the facility's policies and procedures. She stated reviews of policy and procedure occur when it is a point of concern for that particular policy and procedure. She stated there is no documentation to reflect that the medical director reviewed the clinical policies and procedures.

Review of the governing body board of trustees meeting minutes from 9/25/15 through 8/18/16 did not reflect policy and procedure review for each department in the meeting minutes.

Review of the governing board policies and procedures reflected a final approval date of 3/1/13. No other documentation was submitted to reflect policy review after 3/1/13.

A review of the facility policy titled policy and procedure review reflected each department manager would be responsible for drafting policies and procedures for their departments. Once the draft policy had been developed by the department manager, and was deemed to be appropriate, the final policy would be approved by the CEO. All clinical policies must be approved by the medical director. The department manager is required to complete the facility form titled policy and procedure review form. The completed form is to be reviewed at the annual CAH and RHC reviews.

Based on record review and interview, the facility failed to ensure the medical director reviewed the facility's clinical policies and procedures. This has the potential to affect all patients receiving care and services in the facility. Findings include:

During an interview on 10/5/16 at 1:45 p.m., staff member F stated she reviews patient complaints, emergency room charts, meets with providers one time per month for issues and training opportunities. Staff member F submitted the medical staff meeting minutes for the last year. No documentation contained in the medical staff minutes submitted reflected a formal review of facility policies and procedures.

During an interview on 10/6/16 at 1:30 p.m., staff member D stated she attended the committee meetings and the facility had no formal schedule of review for the facility's policies and procedures. She stated reviews of policy and procedure occur when it is a point of concern for that particular policy and procedure. She stated there is no documentation to reflect that the medical director reviewed the clinical policies and procedures.

Review of the governing body board of trustees meeting minutes from 9/25/15 through 8/18/16 did not reflect policy and procedure review for each department in the meeting minutes.

A review of the facility policy titled Policy and Procedure Review reflected each department manager would be responsible for drafting policies and procedures for their departments. Once the draft policy had been developed by the department manager, and was deemed to be appropriate the final policy, would be approved by the CEO. All clinical policies must be approved by the medical director. The department manager is required to complete the facility form titled policy and procedure review form. The completed form is to be reviewed at the annual CAH and RHC reviews.

Based on record review and interview, the facility failed to show documentation that patient health records were sent to the receiving facility the patient was transferred to for 1 (#1) out of 22 sampled patients. This has the potential to affect all patients requiring transfer to another facility and/or that are referred for services to another provider. Findings include:

Review of the medical record for patient #1 reflected a transfer to another facility from the emergency room. Review of the transfer authorization reflected the patient condition and reason for transfer with all necessary signatures. The box titled copies of medical records sent was blank.

During an interview on 10/6/16 at 2:00 p.m., a request was submitted for documentation to reflect that the receiving hospital had received copies of the patient's medical record. Staff member C stated there was no documentation to show the patient's medical record was sent to the receiving hospital.

Based on record review and interview, the facility failed to ensure patient care policies and agreements were reviewed, revised if appropriate, and approved by the medical professional director, the CEO and the governing body for all CAH policies and procedures since 2012 (C272); failed to review and revise policies and procedures for infection control, and ensure the facility maintained an infection control committee (C278); and failed to ensure nursing care plans were developed for inpatients (C298).

Based on record review and interview, the facility failed to conduct an annual review by the medical professional personnel of the facility's policies. This has the potential to affect all patients receiving care and services in the facility. Findings include:

During an interview on 10/5/16 at 1:45 p.m., staff member F stated the facility had not had a consistent DON since 2012. Staff member F stated she reviews patient complaints, emergency room charts, meets with providers one time per month for issues and training opportunities. Staff member F stated she reviews patient cases every second Tuesday of the month. She stated physician orders are reviewed monthly and pharmacy conducts a drug regimen review, lab reviews and gradual dose reductions that are in progress. Staff member F submitted the medical staff meeting minutes for the last year. No documentation reflected a formal review of facility policies and procedures.

During an interview on 10/6/16 at 1:30 p.m., staff member D stated she attended the committee meetings and the facility had no formal schedule of review for the facility's policies and procedures. She stated reviews of policy and procedure occur when it is a point of concern for that particular policy and procedure. She stated there is no documentation to reflect that the medical director reviewed the clinical policies and procedures.

During an interview on 10/3/16 at 2:00 p.m., staff member B stated they were in the process of reviewing the policies but the reviews were never completed. She stated the facility had experienced a high turnover rate with the CEO position and the policy reviews kept getting pushed back. Concerns were discussed regarding the governing board and medical staff involvement in making sure the facility policy and procedures were reviewed annually. She stated she was not sure why this was not addressed. She stated the issue was documented and brought to the administration's attention during the annual review on October 26, 2015.

A review of the facility policy titled Policy and Procedure Review reflected each department manager would be responsible for drafting policies and procedures for their departments. Once the draft policy had been developed by the department manager, and was deemed to be appropriate, the final policy would be approved by the CEO. All clinical policies must be approved by the medical director. The department manager is required to complete the facility form titled policy and procedure review form. The completed form is to be reviewed at the annual CAH and RHC reviews.

Based on record review and interview, the facility failed to ensure the infection control program policies and procedures had been reviewed and revised annually, and contained definitions for nosocomial infections and communicable disease. This has a potential to affect all the patients of the facility. Findings include:

A review of the infection control program showed the policies and procedures lacked definitions for nosocomial (now termed Healthcare-associated infection (HAI) by CDC) and communicable disease.

The program lacked having an infection control committee. The committee would have evaluated and revised the program and the programs policies and procedures.

During an interview on 10/5/16 at 8:00 a.m., staff member G stated she had just finished putting together an infection committee. She stated the committee had not met yet.

Based on record review and interview, the facility failed to develop a nursing care plan and discharge plan for each inpatient for 12 (#s 4, 6, 7, 8, 9, 10, 12, 13, 14, 16, 17, and 18) out of 22 sampled patients. This has the potential to affect all inpatients admitted to the facility. Findings include:

During the patient record review process a trend for no care plan development was reflected for the above sampled inpatient admissions. This in turn affected the initiation of discharge planning and a discharge care plan.

During an interview on 10/5/16 at 11:00 a.m., staff member C stated care plans were not being done consistently since it was discovered in August 2016. She stated the previous DON had discovered that staff had not been developing a care plan for inpatients in August, and took steps to remedy the concern. Staff member C stated the previous DON resigned her position prior to the issue being resolved.

Two patients were added to the survey process with admission dates after the discovery in August. Patient #11 and #12 were admitted as inpatients with admission dates in September 2016. Neither patient had a care plan or discharge plan developed.

Based on record review and interview, the facility failed to demonstrate health care policies were evaluated or reviewed as part of the QI annual program evaluation. This has the potential to affect all patients receiving care and services in the facility. Findings include:

Review of the facility report titled CAH and RHC annual review, dated 10/26/15, reflected in item #1 a concern for the review and revision of all CAH health care policies not being completed and/or addressed.

During an interview on 10/3/16 at 2:00 p.m., staff member B stated they were in the process of being reviewed but they were never completed. She stated the facility had experienced a high turnover rate with the CEO position and the policy reviews kept getting pushed back. Concerns were discussed regarding the governing board and medical staff involvement in making sure the facility policy and procedures were reviewed annually. She stated she was not sure why this was not addressed. She stated the issue was documented and brought to administration's attention during the annual review on October 26, 2015.

During an interview on 10/3/16 at 3:40 p.m., staff member B stated the facility had not continued with the policy review committee since December of 2012.

Review of the last policy review committee meeting minutes, dated 12/3/12, reflected a special meeting held for policy revision approval for three policies regarding low census staffing, paid time off accruals and exempt classification. No other documentation was provided to reflect the QI annual program evaluation included the concern for review and revision of all CAH health care policies and procedures being completed annually after 2012.

Based on record review and interview, the facility failed to evaluate utilization of services as part of the yearly annual program review. This has the potential to affect patient care and services provided in the facility. Findings include:

During an interview on 10/5/16 at 2:45 p.m., staff member C stated the facility just started their utilization review. Staff member C stated the facility has not completed a utilization review since 2012. She stated the facility just developed a draft policy for utilization review but it had not been approved. Staff member C submitted a copy of the draft policy, an email discussing agenda items and the proposed agenda schedule. She stated a utilization review meeting was scheduled for 10/12/16.

Review of the medical staff meeting minutes, dated 9/14/16, lists utilization review as a discussion topic. The minutes reflected what would be included in the utilization review and how often meetings would be held.

Review of the 2015 quality improvement annual report did not reflect utilization review was discussed or included in the facility wide review of care and services.

Based on record review and interview, the facility failed to have a system in place to ensure quality assurance improvement data was provided for the OPO program. This had the potential to affect all patients who may use the OPO services. Findings include:

A review of the OPO program showed the program lacked a QI activity. There was no documentation to show there was a QI project or whether the data had been shared with the medical staff or the governing board.

During an interview on 10/3/16 at 2:00 p.m., staff member B stated revisions of the policies and procedures were started but were never completed. She stated the facility had experienced a high turnover rate with the CEO position and the policy reviews kept getting pushed back. Concerns were discussed regarding the governing board and medical staff involvement in making sure the facility policy and procedures were reviewed annually. She stated she was not sure why this was not addressed. She stated the issue was documented and brought to the administration's attention during the annual review on October 26, 2015.

Based on record review and interview, the facility failed to show nosocomial infections were evaluated. This has a potential to affect all patients. Findings include:

A review of the infection control program showed there were no infection control committee minutes available to review the evaluation of the program and the nosocomial infections.

During an interview on 10/5/16 at 8:00 a.m., staff member G stated that she had a newly formed infection control committee and they have not met yet.

A review of the nursing quality improvement plan showed nursing would evaluate infection control data quarterly. There was no data documented to reflect that the nosocomial infection review was completed and evaluated.

A review of the medical staff meeting minutes dated February 10, 2015, August 25, 2015-December 8, 2015, and March 8, 2016- July 13,2016 showed the DON attended with no documentation to reflect that nosocomial infections were evaluated.

Based on interview and record review, the facility failed to show the agreement had been approved by the governing body, and the agreement reflected definitions for imminent death and timely notification as required. This has the potential to affect all patients requiring OPO services. Findings include:

A review of the facility's policies and procedures lacked definitions for "imminent death" and "timely notification."

-The definition of "imminent death" would have showed a balance between the needs of the OPO and the needs of the facilities care givers to continue treatment of a patient until brain death or the patient's family had made the decision to stop support measures. The definition would have also included the specific triggers for notifying the OPO about an imminent death.

-The definition of "timely notification" would have showed how soon the facility would have to contact the OPO by telephone after the patient has died, had been placed on a ventilator due to a severe brain injury, or had been declared brain dead.

The facility lacked documentation to show the governing body had approved the facility's organ procurement policies.

During an interview on 10/5/16 at 9:30 a.m., staff member C stated she knew when getting the requested policy and procedures for OPO, there were no definitions for "imminent death" and "timely notification." She was not sure if there was any documentation showing the governing body approved the agreement.

At the time of exit on 10/6/16 at 4:50 p.m., the facility had not produced documentation of the agreement being approved by the governing body.

Based on interview and record review, the facility failed to ensure as part of the OPO training of staff, that a quality improvement activity was included. This has the potential to affect all patients who need the OPO services. Findings include:

A review of the facilities OPO program showed the program lacked a QI activity improvement program.

During an interview on 10/5/16 at 9:30 a.m., staff member C stated there was no QI activity for the OPO program.