HospitalInspections.org

29708

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure provisions for emergency power as required.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. Refer to the applicable findings identified on the attached Life Safety from Fire SOD.

29708

Based on observations, interviews, and review of documents and records it was determined that the CAH failed to ensure compliance with applicable Life Safety from Fire Codes.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. Refer to the applicable findings identified on the attached Life Safety from Fire SOD.

29708

Based on observation and interview, it was determined that the CAH failed to ensure compliance with requirements for installation of alcohol based hand sanitizers.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. Refer to the applicable findings identified on the attached Life Safety from Fire SOD.

29708

Based on observation, interview, review of policies and procedures and review of documents and records it was determined that the CAH failed to ensure appropriate handling and control of drugs:
* High alert drugs were not managed and labeled consistently;
* Narcotic and emergency drugs were not managed and controlled to prevent theft, misuse, and tampering; and
* Outdates on drug labels were altered and unclear.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. High alert drugs were not managed and labeled consistently. Examples include:

* Two RSI kits were observed in the ED triage room on 10/27/2016 at 1330 with the CNO. Each kit contained a single-dose vial of Etomidate Injection 20mg/10ml, a hypnotic agent used to provide anesthesia, and a MDV of Neostigmine Methlysulfate Injection 5mg/10ml (0.5 mg/ml), a drug used to reverse the effects of neuromuscular agents. There was no information on the vials indicating that the medications were high alert drugs.

* A box containing MDVs of Rocuronium Bromide Injection 50mg/5ml, a neuromuscular blocking agent/paralytic, was observed in the pharmacy with the CNO on 10/27/2016 at 1445. The outside of the box had a handwritten note in red marker on it that read "High Alert Med." There was no information reflecting who or when the handwritten note was made. The CNO stated that Etomidate, Neostigmine Methlysulfate and Rocuronium Bromidewere were considered high alert drugs. However, he/she stated the CAH had not developed a list of high alert drugs and had not developed a policy and procedure for how high alert drugs would be identified and managed.

2. Narcotic and emergency drugs were not managed and controlled to prevent theft, misuse, and tampering. Examples include:

The ED was toured with the CNO on 10/27/2016 beginning at 1320. The following observations were made:

* Observations of the two RSI kits observed in finding 1 above reflected one had breakaway lock #002403 on it, and the other had breakaway lock #002483 on it.

The "RSI Lock Record" log for the RSI kits for 10/14/2016 through 10/25/2016 was reviewed with the CNO. The CNO stated the log was used to track the numbered breakaway locks on the RSI kits. Review of the log reflected it had unclear and had inconsistent information recorded on it. Examples include:
* The entry on the log for 10/14/2016 at 1100 for RSI "[kit] #1" reflected the "Lock # and Action" was "#573." It was unclear if lock #573 was removed or applied to the kit. There was no other information reflecting what that entry meant.
* The entry for 10/15/2016 at 0300 on the log for "RSI [kit] #1" reflected the "Lock # and Action" was "#559." It was unclear if lock #559 was removed or applied to the kit. There was no other information reflecting what that entry meant.
* The 10/14/2016 entry on the log for "RSI [kit] #2" had no time recorded and reflected the "Lock # and Action" was "#559." It was unclear if lock #559 was removed or applied to the kit. There was no information reflecting why the lock number was the same lock number recorded for RSI kit #1 on 10/15/2016 at 0300 above. There was no other information reflecting what that entry meant.
* The 10/15/2016 entry on the log for "RSI [kit] #2" had no time recorded and reflected the "Lock # and Action" was "#573." It was unclear if lock #573 was removed or applied to the kit. There was no information reflecting why the lock number was the same lock number recorded for RSI kit #1 on 10/14/2016 at 1100 above. There was no other information reflecting what that entry meant.
Similar inconsistent and unclear information was recorded on the log for RSI kit #s 1 and 2 on 10/16/2016, 10/18/2016, 10/19/2016, 10/21/2016, 10/22/2016, 10/23/2016, 10/24/2016 and 10/25/2016. There was no evidence reflecting actions taken to address the inconsistent and unclear entries. The CNO acknowledged the entries on the log were unclear and inconsistent.

* An unlabeled drawer with breakaway lock #002434 on it was observed in the ED triage room with the CNO. The CNO stated the drawer was called the "ED narcotic drawer" and contained narcotic drugs.

An emergency crash cart with breakaway lock #002402 on the outside of it was observed with the CNO. The CNO stated that emergency drugs were kept inside the cart.

A "Breakaway Locks For Crash Carts and ED Narcotic Drawer" log for 10/12/2016 through 10/25/2016 was reviewed with the CNO. The CNO stated that a supply of breakaway locks were kept in a cupboard in the ED and were checked out by staff prior to being used in the ED. The CNO stated the log was for tracking those locks. Review of the log reflected it had unclear and inconsistent information recorded on it. Examples include:
* On 10/19/2016 the log reflected the "Lock # Being Checked Out" was "2477." The "Where is Lock Being Replaced" space on the checklist reflected "New Lock" and that entry was lined through. There was no information reflecting where the lock was placed or any other information reflecting what that entry meant. There was no evidence reflecting actions taken to address the unclear and lined through entries.
* On 10/24/2016 the log reflected the "Lock # Being Checked Out" was "2483, 2403." The "Where is Lock Being Replaced" space reflected "RSI kits-old" and the "Initials" space reflected "2420, 559." It was unclear what those entries meant. There was no evidence reflecting actions taken to address the unclear entries. At the time of the review, the CNO acknowledged the entries recorded on the log were unclear.

An undated policy titled "Crash Carts - Checks and Locks" was reviewed and reflected the following: "...A new tab-lock will be applied to the medications drawers anytime they have been opened. The tab-locks are located...in the ED Triage Room and will be signed out on the Breakaway Lock log..."

* A "Narcotic Count Verification Sign-Off" form used to count and verify narcotic drugs in the "LTC" medication cart for October 2016 was reviewed with the CNO on 10/27/2016 at 1440. The top of the form reflected it was for October 2016 and included the following instructions: "Narcotic count to be completed at least once every 24 hours by two members of the nursing staff verified by signing their names in the space provided." The form had a row for each day of the month. Each row had four signature spaces, an "IN" and "OUT" signature space for each of two shifts. Entries on the form were altered and unclear. Examples include:
* On 10/14/2016 the second shift "OUT" space had a signature that was lined through. There was no information reflecting who altered the entry, or why it had been altered.
* On 10/20/2016 the first shift "OUT" space had a signature that was lined through. There was no information reflecting who altered the entry, or why it had been altered. There was no evidence reflecting actions taken to address the altered entries. At the time of the review, the CNO stated that each shift two nursing staff should verify the narcotic count and sign the form in the signature space provided on the form. This was inconsistent with the instructions on the top of the form which reflected the narcotic count was "to be completed at least once every 24 hours." The CNO acknowledged the entries on the form had been altered and were unclear.

3. Outdates on drug labels were altered and unclear. Examples include:

During tour of the "LTC" unit on 10/27/2016 at 1440 the medication cart was observed with the CNO and CMA. The cart contained more than twenty cards of "bubble-packed" drugs. Each card contained approximately 15 to 30 capsules or tablets and had a printed pharmacy label on it. The expiration dates on the cards were unclear and inconsistent on many of the cards. Examples include:
* A bubble-pack drug card with a pharmacy label on it for furosemide 40mg tablets was observed. The label had a printed expiration date of "3/18/2017" that was lined through in handwriting with ball point pen. Below the lined through entry, "10-3-17" and an individual's initials were handwritten in ball point pen.
* A bubble-pack drug card with a pharmacy label on it for Nexium 40mg capsules was observed. The label had a printed expiration date of "3/21/2017" that was lined through in handwriting with ball point pen. Below the lined through entry "10-3-17" and an individual's initials were handwritten in ball point pen.
* A bubble-pack drug card with a pharmacy label on it for Metroprolol Tartrate 25mg tablets was observed. The label had a printed expiration date of "12/30/2018" that was lined through in handwriting with ball point pen. Below the lined through entry "9-9-17" and an individual's initials were hand written in ball point pen.
* A bubble-pack drug card with a pharmacy label on it for Cyclobenzaprine HCL 10 mg tablets was observed. The label had a printed expiration date of "1/30/2019" that was lined through in handwriting with ball point pen. Below the lined through entry "9-12-17" and an individual's initials were hand written in ball point pen.
* A bubble-pack drug card with a pharmacy label on it for Gabapentin 300 mg capsules was observed. The label had a printed expiration date of "12/16/2016" that was lined through in handwriting with ball point pen. Below the lined through entry "10-24/17" and an individual's initials was hand written in ball point pen.
Similar findings were identified on bubble pack drug cards containing Citalopram 10mg tablets and Oxycontin 20mg tablets. There was no information on any of the drug cards to describe when or why the expiration dates had been altered.

At the time of the observation the CMA stated he/she didn't know why the expiration dates had been altered.

29708

Based on observations, interview, review of policies and procedures, and other documents, it was determined the CAH failed to develop and/or implement policies and procedures for infection prevention in the following areas:
* Separation of clean and dirty areas and supplies;
* Sterilization processes;
* Humidity and temperature monitoring; and
* Infection control monitoring.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. Clean and contaminated areas and supplies were not consistently managed and maintained separately to prevent cross contamination.
Examples include:

* Observations of the "Sterilization" room were made with the SP Tech on 10/27/2016 at 1110. The room had one door that entered the room from the corridor on the basement level of the CAH. The room had a narrow path down the center of it. Upon room entry on the right side, floor to ceiling cupboards with shelves inside them were observed. Sterile packs were observed on two shelves inside one of the cupboards. In the same cupboard on two other shelves, numerous patient care supplies and items were observed cluttered and disorganized. Those items included two metal emesis basins, two round metal pans, numerous unwrapped surgical instruments, a speculum in a sterile pack dated "11-12-14," an open unlabeled zip lock bag and several other unlabeled plastic bags with instruments and other small metal parts in them. There was no information on the cupboards or any of the shelves indicating whether those areas were "clean" or "dirty." There was no clear separation between the sterile supplies and the other patient items in the cupboard. There was no assurance that clean/sterile patient care items and dirty/contaminated items would be maintained separately .

Just past the cupboards, a sink with a work counter on both sides of it was observed. Directly above the sink, a sign was posted on the wall that read "Dirty Area." Above the work counter on the left side of the sink, a sign was posted on the wall that read "Dirty." There was no information at or near the work counter on the right side of the sink indicating whether it was "clean" or "dirty." There were no other sinks in the room.

At the end of the room, just past the work counter that was labeled "Dirty," an autoclave was observed on the same work counter with a sign posted on it that read "Clean!!"

At the end of the room on the left side, directly across the narrow path from the autoclave, a multi-shelf metal unit was observed. A rectangle shaped metal container with a red biohazard label on it was observed on a towel on one of the shelves. The container had a lid on it that read "Dirty instruments." Surgical masks, gowns, disposable drapes and other supplies were observed on the same shelving unit. There was no information on or near the shelving unit reflecting whether that area was a "clean" or "dirty" area. There was no assurance that contaminated and clean items would be maintained separately.

Just past the multi-shelf metal unit, on the left side of the room, a work counter was observed directly across the narrow path from the sink. It had a sign posted on the wall above it that read "Clean Area."

Near the room entry on the left side, a multi-shelf wire rack was observed directly across the narrow path from the floor to ceiling cupboards identified above. Whereas some areas and items in the room were labeled as "clean" or "dirty," there was no information at or near the rack reflecting whether it was a "clean" or "dirty" area.

At the time of the observations, the SP Tech stated the sink was used for hand washing and also used for cleaning contaminated instruments. The SP Tech stated that after cleaning the instruments he/she placed them on the work counter on the right side of the sink to dry. The SP Tech stated the metal container that was observed on the multi-shelf metal unit was used to transport contaminated instruments to the sterilization room. The SP Tech stated that the multi-shelf wire rack was used to store sterile packs after they were removed from the autoclave.

Dirty, contaminated, sterile and clean patient care supplies were commingled in the room. In addition, the process for identifying "clean" and "dirty" areas throughout the room was inconsistent and did not ensure the integrity of those supplies.

* The policy and procedure titled "Reprocessing of surgical instruments" dated "Review/Revised: 09/16" reflected "Rinse instruments with clean cold water, place in enzymatic presoak and cleaner for 10 minutes...Lay clean towels on cabinet (R) of sink...Rinse each item thoroughly with cold tap water, lay on clean towels...Dry thoroughly with clean towels...If not sterilizing right away, cover items with dry clean towels label clean." The policy did not include information about the stated practice of using the same sink for cleaning contaminated instruments and for hand washing. There was no assurance that instruments would not be subject to splashing during hand washing at the sink, or that the sink would be available and suitable for hand washing. In addition, the policy contained no information reflecting the observed practice of labeling some areas as "clean" or "dirty" or any other information reflecting how clean and contaminated areas and supplies would be managed and maintained separately to prevent cross contamination.

* Observation of the inpatient unit on 10/27/2016 at 1400 with the CNO reflected the following: A metal container was observed on the work counter next to the hand washing sink near the drug prep area. The metal container had a lid on it with a label affixed to it that read "Dirty instruments." Two instruments were observed inside the container. A spray bottle of enzymatic solution was also on the counter next to the hand washing sink. Drug preparation, lab specimen collection and other patient care supplies were observed on the same counter. There was no information indicating where the container of contaminated instruments should be kept in relation to the hand washing sink, patient care supplies, and drug preparation area in order to ensure they were maintained separately and to prevent cross contamination. At the time of the observation, the CNO acknowledged that drugs were prepared for patients on the work counter near the metal container, and there was no clear separation between the areas.

* The policy and procedure titled "Care and handling of soiled instruments in the ED and Hospital," dated "Review/Revised: 10/2016" was reviewed. The Purpose reflected "To ready used soiled surgical instruments properly before returning to Central Supply Processing." The Procedure reflected "...Instruments should be sprayed with prepzyme forever wet completely with hinges open as soon as possible and put in stainless steel containers supplied for dirty instruments in the emergency department and nurse's station...Central supply personal [sic] will check containers daily when working, all other days when containers are full nursing staff needs to take full containers to central processing place in dirty sink and replace with a clean container that is kept on the gray metal shelves..." The policy contained no information reflecting where in the respective departments contaminated instruments should be sprayed with enzymatic and kept in relation to clean patient care supplies, in order to prevent cross contamination.

2. Sterilization monitoring processes were not appropriately managed. Examples include:

* On 10/27/2016 at 1130 the SP Tech stated the CAH had one autoclave used for sterilizing instruments. The SP Tech stated that a BI was to be put in the autoclave with the first load every day the autoclave was used in order to monitor the sterilization process.

* Review of the autoclave "Sterilization Log Sheet" for October 2016 reflected the autoclave was used to sterilize instruments on 10/06/2016, 10/10/2016, 10/12/2016, 10/23/2016 and 10/24/2016. Review of autoclave and BI records reflected no documentation that a BI was used for the autoclave on 10/12/2016. This was confirmed with the SP Tech on 10/27/2016 at 1200.

* The undated policy and procedure titled "Duo-Record, 3M Thermalog Integrator and Duo-Spores #14" was reviewed. The Purpose section of the policy reflected "To make sure steamed autoclaved instruments have met all safety regulations." The Procedure section reflected "Duo-Spores Biological Indicator...are to be done once a day when running the autoclave, make a test pack or pouch to run with the first load of the day...Put the indicator strips in the test pack...be sure you put the test on the Dou-Record (sic)...After autoclaving is complete take test pack to the Lab for processing they will send back a report, this is put in the Autoclave QA book."

3. Temperature and humidity were not managed and addressed appropriately. Examples include:

* The temperature and humidity log for the ED for October 2016 was reviewed. The top of the log indicated the temperature was to be 68-75 degrees and the humidity was to be 35-60 percent. The bottom of the log reflected "If the temperature and/or humidity fall out of range, maintenance notify Maintenance." It was unclear what that entry meant. Log entries for temperature and humidity were only recorded 19 out of 25 days between 10/03/2016 and 10/27/2016, and for 13 of the days recorded, the humidity was outside the required range. Examples included but were not limited to the following:
On "10-3" at "9:25AM" the humidity was recorded 28 percent;
On "10-5" at "8:45AM" the humidity was recorded 30 percent;
On "10-12" at "8:30" the humidity was recorded 26 percent;
On "10-19" at "8:25" the humidity was recorded 30 percent; and
On "10-20" the humidity was recorded 32 percent.
Although the log had a space each day that read: "Out of Range Action," there was no documentation that maintenance was notified or other actions were taken to correct the humidity readings that were outside the required range.

* The temperature and humidity log for Central Supply for October 2016 was reviewed. The top of the log indicated the temperature was to be 68-75 degrees and the humidity was to be 35-60 percent. Entries for temperature and humidity were only recorded 19 out of 25 days between 10/03/2016 and 10/27/2016, and for approximately 15 of the days recorded, the temperature and/or humidity was outside the required range. Examples included but were not limited to the following:
On "10-3" at 9:00AM" the the humidity was recorded 25 percent. The log reflected "IC was notified." However, there was no documentation of any other actions taken.
On "10-5" at "8:30AM" the temperature was recorded 76 degrees and humidity was recorded 26 percent. There was no documentation reflecting actions taken to correct the temperature and humidity that were outside the required range.
On "10-14" at "8:50" the temperature was recorded 76 degrees and humidity was recorded 31 degrees. There was no documentation reflecting actions taken to correct the temperature and humidity.
On "10-20" at "8:30" the temperature was recorded 76 degrees and humidity was recorded 26 percent. There was no documentation reflecting actions taken to correct the temperature and humidity.

Similar findings were identified during review of the October 2016 temperature and humidity logs for the Procedure Room and Sterile Processing.

* The policy and procedure titled "Temperature and Humidity in Select Rooms" dated last approved "September 2016" reflected the "Applicable Areas" were the Procedure Room, Emergency Department, Sterile Processing Room, and Central Supply Room. The procedure section reflected the following: "The temperature, humidity and airflow...shall be maintained with acceptable standards in order to inhibit bacterial growth and prevent infection, as well as promote patient comfort and safety...Relative humidity shall be maintained at 35 to 60 percent...Temperature of the operating rooms shall be maintained at 68 to 75 degrees...The information will be recorded on the respective log sheets in Emergency Department, Procedure Room, Decontamination Room and Central Supply located in Maintenance Log Book and reported monthly to the Infection Control/ Prevention Committee. If the temperature and/or humidity fall out of range, Maintenance will be notified. Maintenance will recheck the room in 2 hours. If temperature and humidity remain out of range, Maintenance will notify Infection Control and sterile packages will be inspected for sterility. Any instruments/supplies that are compromised will be removed immediately and discarded or preprocessed (sic) per manufacturer's instructions."

4. The policy and procedure titled "Surveillance Monitors" dated last approved "N/A" reflected the following: "In order to detect nosocomial infection...to promote and ensure appropriate prevention and treatment of infections, the ICO...will conduct ongoing surveillance..." The policy reflected that "Inflection (sic) Control Monitors" included "...Invasive procedures: This will include...endoscopes..." However, on 10/27/2016 at 1715 the Infection Prevention Officer stated the hospital no longer performed endoscopy services and therefore the policy did not reflect accurate and appropriate surveillance and monitoring for infections.

29708

Based on interview, review of policies and procedures and other documentation, it was determined that the CAH failed to evaluate the provision of services rendered under contract, arrangement or agreement to ensure the services were furnished in a manner that enabled the CAH to comply with all applicable conditions of participation and standards for those services.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. A list of contracted services was provided by the CEO. The list contained approximately 100 contracts, arrangements and agreements with various agencies, organizations, and companies. The list reflected that each of the contracted services was "Reviewed" on "9/25/16." There was no documentation or other information reflecting what the review entailed, including that the contracted services were evaluated to ensure they were furnished in a manner that enabled the CAH to comply with all applicable conditions of participation and standards for those services.

2. During an interview on 10/27/2016 at approximately 1800, the CEO stated that a "random sample" of patient care services provided under contract had been evaluated. The CEO provided a "Vendor/Contractor Evaluation Form" for 15 of the 100 contracted services on the list. All of the evaluation forms had a "Contract Period" of "2016/2017," were signed by the CEO and dated 10/10/2016. Evaluation forms were provided for the following contracted services:
* "Advantage Dental" emergency dental services;
* "American Red Cross" blood services;
* "Blue Mountain Diagnostic Imaging" radiology interpretation services;
* "Blue Mountain Pathology, Inc." pathology medical director services;
* "Interpath Labs" referral lab services;
* "Kadlec Regional Medical Center" biomed services;
* "MedCall Northwest" PICC insertion services;
* "Murray's Drugs" pharmacy services;
* "Rocky Mountain PT" physical and occupational therapy services;
* "Olympus" scope maintenance services;
* "Opal Butte Health Services, Inc." ED locum tenums agreement;
* "Providence Health" telestroke network agreement;
* "Red Hawk" IT Security assessments and testing services;
* "Scientific Instrument Repair" lab maintenance equipment services; and
* "Peter Willis" infusion services.
There was no information on the forms reflecting an evaluation to determine if the services were furnished in a manner that enabled the CAH to comply with all applicable conditions of participation and standards for those services.

3. The policy and procedure titled "Critical Access Hospital: Annual Review of Services" dated approved "10/20/16" reflected "Morrow County Health District is committed to complying with all aspects and requirements of the CAH program. Evaluation will formally be conducted on an annual basis to evaluate compliance, appropriate utilization and quality...Contracted services will be reviewed annually and reported in the CAH annual report..." The policy was not developed to include that contracted services would be evaluated to ensure they were furnished in a manner that enabled the CAH to comply with all applicable conditions of participation and standards for those services.

The policy and procedure titled "Critical Access Hospital: Annual Review of Contracted Services" dated "Revised: 11/16" reflected "Evaluation will be conducted on an annual basis to evaluate compliance, appropriate utilization and quality of the service...The evaluation will consist of...Selection of patient oriented contracts by the committee to review...Evaluation of services performed under the contract using the approved Vendor/Contractor Evaluation Form...Report findings of the committee via written report to the annual report of CAH services to be presented to the Board of Directors on an annual basis." The policy reflected that a "selection" of contracts would be evaluated and therefore it did not not provide an assurance that all patient care services provided under contract would be evaluated. In addition, the policy was not developed to include that contracted services would be evaluated to ensure they were furnished in a manner that enabled the CAH to comply with all applicable conditions of participation and standards for those services.

4. An email from the Administrator dated 12/07/2016 at 0930 reflected the CAH had no additional QA program policies, documents or other information reflecting evaluation of patient care services provided under contract.

Based on review of policies and procedures and other documentation it was determined that the CAH failed to develop and implement nursing services policies and procedures to ensure appropriate care and services for administration of moderate sedation.

This is a repeat deficiency that was previously cited on the provider's most recent recertification and relicensure survey completed 08/29/2016.

Findings include:

1. The policy and procedure titled "Moderate Sedation" dated as approved "N/A" reflected "Oversight and Responsibility...The privileged physicians of the Medical Staff in collaboration with the Director of Nursing Services will be responsible for the development of standards of practice for moderate sedation...The registered nurse shall have the primary responsibility of monitoring the patient's vital signs and level of consciousness and must remain with the patient until there is satisfactory recovery from the acute effects of the sedation agents...While the registered nurse is managing the care of the patient receiving moderate sedation, he/she shall have no other responsibility that would leave the patient unattended or compromise continuous monitoring. A backup registered nurse or paramedic will be in-house when moderate sedation is being administered." The policy and procedure provided no further information related to the responsibilities of the "backup" paramedic in the provision of moderate sedation services. Therefore, the policy did not provide an assurance that paramedics would not be administering moderate sedation, monitoring patients who were receiving moderate sedation, and that their scope of practice was limited to "pre-hospital" care.

2. OAR 847-035-0030, Emergency Medical Services Providers Scope of Practice, stipulates that a paramedic license authorizes the provision of "pre-hospital" care. That license is not transferable to the provision of nursing care and services in the hospital.

Based on interview, review of policies and procedures and other documentation, it was determined that the CAH failed to ensure its quality assurance program evaluated the quality and appropriateness of all patient care services furnished in the CAH. Patient care services provided under contract, arrangement or agreement were not evaluated.

Findings include:

Refer to Tag C292, CFR 485.635(c)(4) regarding services provided under arrangement or agreement. That deficiency reflects the CAH's failure to ensure that all patient care services provided under contract, arrangement or agreement were evaluated.