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Based on record review and interview, the provider failed to ensure the licensed certified social worker, speech therapist, and four of seven medical providers (A, B, C, and D) had submitted copies of their current licenses. Findings include:

1. Review of credential files revealed the following three providers' licenses had expired and no current license in file:
* Provider A's license expired 6/15/15.
* Provider B's license expired 6/15/15.
* Provider C's license expired 5/01/16.
* Provider D had no credential file to confirm if a current copy of her license was present.

2. Review of the licensed certified social worker and speech therapists contracts revealed their licenses were not current.

Interview on 7/13/16 at 1:40 p.m. with the human resources manager revealed she had just taken over the credentialing responsibility. She had made a list of what was needed and thought all the licenses were current.

Interview on 7/13/16 at 1:55 p.m. with the chief executive officer revealed she:
*Confirmed the findings of the above interview.
*Was not aware the human resources manager had not completed the list of credentialing requirements that she had provided to her.
*Agreed the providers had been providing medical care without a current license.
*Was not aware the provider did not have current copies of the speech therapist and licensed certified social worker's licenses.

A. Based on observation, testing, and interview, the provider failed to maintain the following areas in a cleanable, usable, and/or durable condition:
*The wall by the two compartment sink in the soiled linen room of laundry had gouges and scrapes.
*The south end of the table used for folding clean linen in the laundry was missing the gasket and had chipped wood.
*The fan in the clean side of laundry by the folding table was dirty.
*The walls and fan grille in the bathroom of the south lobby was dirty.
*The north wall in patient room 115 was gouged and had holes.
*The wall around the air conditioner in patient room 107 had chipped paint.
*The wall on the west side of the hopper in the small emergency room (ER) supply closet was gouged and had holes.
*The handle was missing on the bi-fold door of the supply closet by the handwashing sink of the single ER.
*The black fan in the single ER was dirty.
*Two of two wheelchairs stored in the hall outside of x-ray had missing parts and/or were dirty.
Findings include:

1. Observation and testing on 7/13/16 from 9:00 a.m. to 11:45 a.m. revealed:
a. The wall by the two compartment sink in the soiled linen room of laundry had gouges and scrapes and had flaking paint making it uncleanable.
b. The south end of the table used for folding clean linen in laundry was missing the rubber gasket around the edge and was chipped down to raw wood.
c. The fan in laundry had layers of dust and was set up to blow directly onto the clean linen.

Interview at the time of the observation with the housekeeping manager confirmed the above a, b, and c conditions. He stated it was hard to get maintenance to repair items in the building. He had a cleaning schedule for the fan, but it must have been missed this week.

d. The walls in the bathroom of the south lobby had holes where old handwashing equipment had been removed.
e. The grille on the exhaust fan in the bathroom was layered with dust. The dust enveloped the patterns on the grille and made it appear to be a smooth surface.
f. The north wall of patient room 115 had severe damage. It was gouged, had holes, scrapes, and dents in the gypsum board. The damaged surface covered an approximate three foot by one foot area. An unidentified patient for overnight observation occupied that room, and the head of the bed was by the damaged wall.
g. The wall around the air conditioner in patient room 107 was stripped of paint and had scratches and scrapes. Duct tape had been put in place to seal the area around the air conditioner.
h. The wall on the west side of the hopper in the small ER supply area had eroded and would flake chalk and plaster when touched. The damage was approximately a three by three foot area.
i. The bi-fold door by the scrub sink for the single ER had no handle. To open the door you had to pull on the top that was layered with dust to get to additional ER supplies.
j. The black fan in the single ER had layers of dust and was directed to blow air on the patients in that ER.
k. The two wheelchairs stored in the hall outside of x-ray were filthy. One of the two wheelchairs had no arm rest. The other arm rest was cracked open and revealed the cotton batting beneath the vinyl.

Interview on that same day at 11:55 a.m. with the maintenance person confirmed the above findings of d through k. He stated he tried to keep up in "this old building." He stated there was no set guideline on how he received work orders. Some were verbal and some were on a sticky note. He did not have a scheduled maintenance that he performed. Nor did he have a scheduled walk-through that he did to ensure the facility was maintained.

B. Based on observation, document review, and interview, the provider failed to establish and maintain a preventive maintenance program for the facility. Findings include:

1. Random observation of the facility from 7/12/16 through 7/14/16 revealed:
*Floors, walls, ceilings, shower rooms, sinks, and patient use equipment were not maintained or kept in a durable, cleanable, usable condition.
*Refer to C222 A, C278, and C279.

Interview on 7/14/16 at 2:00 p.m. with the chief executive officer (CEO)/administrator revealed she was aware the maintenance and preventive maintenance in the building had not been satisfactory for some time. She stated she had a plan in place to improve the maintenance program. She stated there was a housekeeping and cleaning schedule, but she had not ever seen a preventive maintenance schedule in the four years she had been the CEO/administrator.

C. Based on observation and interview, the provider failed to ensure:
*Chemicals and cleaners were stored separately from patients' toiletries.
*All cleaners and chemicals were labeled and identified to avoid misuse.
Findings include:

1. Observation on 7/13/16 from 9:30 a.m. to 10:00 a.m. revealed:
*The housekeeping office storage room had paper towels and toilet paper directly next to cleaners and chemicals.
*The housekeeping closet next to the stairwell had two spray bottles of what appeared to be window cleaner. One bottle had the wrong label, and the other had no label.

Interview with housekeeper V at the time of the above observations confirmed those findings. She stated she was not aware paper goods and chemicals/cleaners could not be stored together. She also stated she was aware the spray bottles should have been labeled to identify the product and its purpose.

D. No policies were provided regarding the cleanability and integrity of the floors, walls, and ceilings throughout the facility.

An undated Hazardous and Toxic Substances policy revealed "all hazardous/toxic substances used in our facility will be identified and labeled prior to being used."

An undated Storage Areas policy revealed "storage areas must be maintained in a clean and safe manner."

An undated Supplies and Equipment policy revealed "care should be exercised in the handling and in the use of our equipment to prevent damage or breakage."

Based on credential record review, record review, interview, and governing body by-laws review, the provider's governing body failed to ensure seven of seven medical providers had gone through an initial credentialing and privileging process for two of two new providers (C and E) and for five of five established providers (A, B, D, T, and U). Findings include:

1. Review of the credentialing and privileging files for the medical providers revealed:
*Certified nurse practitioner (CNP) A's hired date was 9/19/09.
*CNP B's hired date was 10/17/05.
*There was no record of CNP D's hire date.
*Physicians Assistant/Certified (PA/C) T's hire date was 11/28/11.
*PA/C E's hire date was 2/22/16.
*PA/C C's hire date was 3/1/16.
*Medical doctor U's hire date was 1/1/13.
*CNPs A, B, and D had not completed the provider's Application for Medical Facilities Privileges for their initial appointment or for a re-appointment.
*PA/C T had not completed the provider's Application for Medical Facilities Privileges for her initial appointment or for a re-appointment.
*PA/Cs C and E who had been recently hired had not completed the provider's Application for Medical Facilities Privileges for their initial appointments.
*Medical doctor U had not completed the provider's Application for Medical Facilities Privileges for his initial appointment.

Review of the governing board and medical staff meeting minutes for 2015 and 2016 revealed no documentation of credentialing for any medical providers.

Interview on 7/13/16 at 1:40 p.m. with the human resources (HR) manager revealed she:
*Had recently been assigned the credentialing task.
*Had a checklist of what was to have been completed for the credentialing.
*Stated she did not understand that an application had to have been completed and forwarded to the medical committee and governing board for approval.
*Agreed none of the above provider's credentialing files were complete.
*Agreed PA/C C's Appointment Signature Form had been signed by the governing board president on 1/28/16 and by the medical director on 2/9/16. PA/C C's hired date was 3/1/16.
*Agreed PA/C E's Appointment Signature Form had been signed by the governing board president on 1/28/16 and by the medical director on 2/9/16. PA/C C's hired date was 2/22/16.

Interview on 7/13/16 at 1:55 p.m. with the chief executive officer revealed she:*Had recently gone over the checklist and credentialing process with the HR manager.
*Was not aware the credential files were not complete.

Interview on 7/14/16 at 8:55 a.m. with the governing board secretary revealed he:
*Was not aware of the credentialing process.
*Did not remember discussions regarding appointments of medical staff.

Review of the provider's Board of Directors By-Laws signed on 1/17/05 revealed:*All applications for appointment to the medical and dental staff would be in writing and addressed to the administrator of the facility.
*The application would contain full information concerning the acknowledgement, agreement, qualifications, request, references, licensure, professional sanctions, professional liability, experience, notification of release and immunity provisions, staff references, and administrative remedies.
*All appointments to the medical staff shall be for one year only, renewable by the board of directors upon the recommendation of the medical staff without reapplication.

Based on observation and interview, the provider failed to ensure medications were secured and not accessible to unauthorized individuals in one of one labor room. Findings include:

1. Observation on 7/12/16 at 11:00 a.m. in the labor room revealed a red plastic, tool box type, container. There was an un-numbered plastic lock that secured the lid to the base. A list was on the outside and indicated it contained medications for use during labor and delivery. That list did not contain the expiration dates.

Interview on 7/13/16 at 9:55 a.m. with the registered pharmacist revealed she:
*Was responsible for ensuring the medications in the labor room were not expired.
*Agreed there was no monitoring of the medications in the labor room.
*Agreed the medications could have easily been taken from the box and the room.

Interview on 7/13/16 at 3:00 p.m. with the director of nursing confirmed the labor medication box was not monitored. She stated other medication storage areas were either locked with limited access or checked on a daily basis to ensure security of medications.

The administrator was asked for a policy for the storage of medications, but one was not provided.

A. Based on observation, testing, interview, policy review, and record review, the provider failed to ensure:
*All paper towel dispenser levers were cleaned and disinfected.
*One of one sink in patient room 112 was in working condition.
*One of one metal bassinet had no areas of chipped paint.
*One of one sink faucet in the labor room was cleanable.
*One of one wooden wound cart in the single emergency room (ER) was cleanable.
*Four of four doors on the supply cabinet in the double ER did not have splintered wood or tape residue.
*The SonicPlus cart in the therapy gym was free of dust and residue.
*One of one patient shower was clean, cleanable, and durable.
Findings include:

1. Observation and testing on 7/13/16 from 9:00 a.m. to 11:45 a.m. revealed:
*All paper towel dispenser levers had a layer of grime under the lever. It appeared the leftover residue from wet hands would run down the lever to the bottom. The wet residue had built up under the lever and made the gray lever appear brown.
Interview with housekeeper V at the time of the observation confirmed that finding. She stated she cleaned the dispensers but did not clean the entire lever.
*Testing of the sink in patient room 112 revealed neither the hot or cold faucet could be turned on.
*The metal bassinet in the labor room had several areas of chipped paint the size of dimes and quarters.
*The sink faucet in the labor room was pitted and eroded making the surface uncleanable.
*The wooden wound cart in the single ER had bulged wood and and chipped paint on the top. The plastic corners of the cart were broken.
*The four doors on the supply cabinet in the double ER were splintered and had tape residue on them.
*The SonicPlus cart in the therapy gym had layers of dust on the shelves and around the equipment.
*The patient shower had the following:
-The metal corner brackets had lost their finish and were no longer cleanable. They had been painted in the past, but the paint had chipped and peeled off the metal.
-The metal pipe installed as a grab bar had been painted in the past. The paint had started to chip over the entire surface of the bar.
-The soap dish had been painted. But the paint had chipped and pitted allowing the white paint to appear rusted.
-The fan did not work and was covered with lint.
-Two holes had been drilled in the old shower wall and had not been adequately sealed and fixed leaving open areas.
-Hair was found under the shower mat.
-The outside of the shower had large bolts that had chipped paint.
-The outside wall of the shower had been taped in place with black electrical tape.

Interview on that same day at 11:55 a.m. with the maintenance person revealed he was not aware of all of the above findings. He stated he tried to keep up in "this old building." He stated there was no set guideline on how he received work orders. Some were verbal and some were on a sticky note. He did not have a scheduled maintenance that he performed. Nor did he have a scheduled walk-through that he did to ensure the facility was maintained.

Interview on 7/14/16 at 2:00 p.m. with the chief executive officer (CEO)/administrator revealed she was aware the maintenance and preventive maintenance in the building had not been satisfactory for some time. She stated she had a plan in place to improve the maintenance program. She stated there was a housekeeping and cleaning schedule but she had not ever seen a preventive maintenance schedule in the four years she had been the CEO/administrator.



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B. Based on interview, the provider failed to ensure the appointed infection control (IC) professional had been qualified through on-going education, training, and experience to oversee the IC program. Findings include:

1. Interview on 7/13/16 at 3:15 p.m. with the director of nursing (DON) revealed she:
*Had been appointed as the IC professional for the hospital.
*Had been the DON since 2/1/15.
*Had not completed any IC education to ensure the IC program covered all areas.
*Did not do the IC in-service or orientation education.
*Agreed the hospital did have patients with urinary catheters and central line ports. She did not track any infections related to those.

A. Based on observation, testing, and interview, the provider failed to maintain the cleanliness, cleanability, and/or integrity of the following items or areas in the kitchen:
*One of one dirty tray line area by the dishwasher was filthy.
*One of one floor behind the chemical cart and under the dishwasher was dirty.
*The walk-in cooler door drug on the metal threshold and was hard to open.
*Ceiling by the north and south exhaust hood, walk-in cooler, and in the walk-in freezer were broke open.
*The wall by the walk-in cooler was pitted, scrapped and gouged.
*The floor in the walk-in freezer was heaved and broke open.
*The drain line of the vegetable preparation sink was leaking.
*Six of six fluorescent light bulbs were not shielded or shatterproof. One of one light fixtures was hanging loose from the fixture in the store room.
Findings include:

1. Observation and interview on 7/13/16 from 1:30 p.m. to 2:30 p.m. in the kitchen with the dietary manager (DM) revealed:
*The dirty tray line caulking, wall, and floor beneath the tray line and dishwasher needed to be thoroughly cleaned.
-The caulking was mildewed and had receded from the wall. The wall was splattered with old dried food debris that could be flaked off with a fingernail.
-The floor under the tray line and dishwasher appeared to be slimy and had old food debris.
*The floor behind the chemical cart was littered with old spray bottles, rags, and empty boxes.
*The walk-in cooler door was very hard to open. Testing of the door revealed both arms and a foot wedged against the step were needed to open the door. That door drug on the threshold and appeared to be crooked on the hinges.
*The ceilings, walls, and floors in the following areas were in need of complete repair:
-The ceiling by the north and south exhaust hood system had layers and layers of texturing tape that had not held and the ceiling had cracked open again. The layers of tape and texture left loose fragments on the ceiling.
-The ceiling by the walk-in cooler had an approximate four foot long by one inch wide crack that someone had tried to partially cover with a painted board.
-The ceiling in the walk-in freezer had separated at the metal seam and hung open in the middle of the freezer. The open ceiling had created condensation to drip on the freezer floor. That frozen condensation had caused the floor to bulge and crack open at the seam.
*The drain line of the vegetable preparation sink had a leak and was dripping on the floor.
*Six fluorescent bulbs in the kitchen and store room were not shielded or shatterproof. One of the light fixture covers in the store room was hanging from the fixture.
*The DM stated it was hard to get minor things done by the maintenance department. And when maintenance repaired something it was always a quick fix and never done right. The roof over the kitchen area needed repairs. Whenever it rained it would leak in the kitchen in several places and they would put buckets under the leaks.

Interview on 7/14/16 at 2:00 p.m. with the administrator revealed she was aware the maintenance and preventive maintenance in the building had not been satisfactory for some time. She stated she had a plan in place to improve the maintenance program.

No policy could be provided from the DM on the above identified concerns.



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B. Based on record review, interview, and policy review, the provider failed to ensure a nutritional screening process was in place to determine a patient's nutritional risk at the time of admission for five of six swing bed patients (2, 3, 4, 5, and 6) and eight of ten acute care patients (15, 16, 18, 19, 21, 22, 23, and 24). Findings include:

1. Review of the medical records of patient's 2, 3, 4, 5, 6, 18, 19, 21, 22, 23, and 24 revealed:
*The initial nutritional assessment had been completed by a licensed nurse.
*The nutritional assessment included information regarding a patients: dentures, weight loss or gain, digestive problems, type of diet ordered by the physician, time of their last meal, and any skin integrity concerns.
*There was an area to indicate if dietary had been notified. If yes had been marked it stated "Checking YES will reflex mail to dietary."
*The nutritional assessments for patient's 2, 5, 6, 23, and 24 had indicated dietary had been notified.
*The nutritional assessments for patient's 3, 4, 16, 18, 19, 21, and 22 did not indicate dietary had been notified.
*The nutritional assessment for patient 15 had not been fully completed.

2. Review of patient 2's medical record revealed a 1/25/16 at 7:34 p.m. certified nurse practitioner (CNP) progress note. The noted stated "Nursing reports a 13# weight gain over the last 2 weeks." The plan included "Daily weight to monitor weight gain. Suspect it may be prednisone related, since pt is on med for pulmonary fibrosis." She was discharged on 1/29/16 with no further mention of her weight gain. No registered dietician/licensed nutritionist (RD/LN) assessment had been completed. No daily weights were recorded in her medical record.

3. Review of patient 4's medical record revealed he had been admitted as an acute inpatient on 3/13/16. He was admitted to swing bed services on 3/16/16. He did not have another nutritional assessment completed for his swing bed stay.

4. Review of patient 6's medical record revealed he had been admitted as a swing bed patient on 5/16/16. His initial nutritional assessment indicated he was underweight, had gastric ulcers, was on a mechanical soft diet, and had skin integrity concerns. His weight on admission was ninety-eight pounds and ninety pounds when he was discharged on 6/2/16. He had diagnoses that included cachexia and malnutrition. No registered dietician/licensed nutritionist (RD/LN) assessment had been completed during his stay.

5. Review of patient 15's medical record revealed she had been admitted on 3/18/16 under observation. She was discharged on 3/20/16. The only part of her initial nutritional assessment that had been completed was dentures and weight.

6. Review of patient's 5, 23, and, 24's medical records revealed no documentation from the RD/LN. Those patients' records had indicated dietary had been notified.

7. Interview on 7/13/16 at 10:00 a.m. with the DM revealed:
*She received a print out of each patient's admission to the hospital.
*That print out contained the patient's diet order.
*She was to have received an email if an RD/LN nutritional assessment was to have been completed.
*She had never received any email that had requested the RD/LN be notified to complete an assessment.
*She did not visit with any of the swing bed patients about their likes and dislikes.
*She did not complete any dietary documentation.
*She did attend the care conferences for swing bed patients when they were held but did not contribute to any care plan writing.

Review of the provider's revised March 2015 Swing Bed Service Policies - Dietary Service policy revealed thedietary manager (DM) or staff would make weekly visits with the patients. This was to have ensured the proper diet had been received and discuss food preferences.

Review of the provider's revised March 2015 Admission to Swing Bed policy revealed the dietitian would write a summary within seven days after admission.

Based on document review, interview, and policy review, the provider failed to ensure:
*A department manager, the chief executive officer (CEO)/administrator, or the quality assurance performance improvement (QAPI) committee reviewed all contracted patient services of the hospital.
*An annual review was completed for the following contracted patient services:
-V-Rad twenty-four hour radiologist service.
-Registered dietitian/licensed nutritionist.
-Licensed social worker.
-Centurion Medical Products.
-Occupational therapist.
-Registered pharmacist.
-Speech therapist.
-Physical therapy.
-Medical waste.
-Bio-Med.
-Traveling staff including registered nurses, licensed practical nurses, and certified nurse assistants.
-Outside laboratory services with Avera Mitchell.
-Organ procurement program.
-Ophthalmologist and dental services.
Findings include:

1. Review of the QAPI reporting sheets for the last four meetings on 9/1/15, 12/22/15, 3/8/16, and 6/13/16 revealed no documentation or review of the contracted services.

Interview on 7/13/16 at 11:00 a.m. with the clinic's nurse manager revealed:
*She was the QAPI coordinator.
*The program did not review the contracted services for the hospital.
*They did not have reviews or reports from all department managers or administration in regards to their reviews or audits of contracted services or the unique services for the CAH.
*She was unaware all the contracted services must be reviewed that involved patient care or patient services.
*She was unaware the QA of the contracted services must include the effectiveness of the service and the quality of care.

Interview on 7/13/16 at 3:20 p.m. with the CEO/administrator revealed no one reviewed the contracted services when their contract was up for review. She was unaware all the contracted services must be reviewed annually or more often as needed. She was also unaware some of the contracted services had expired contracts or no contracts.

Review of the March 2015 QAPI policy revealed no plan to include an annual review of contracted services.

Based on record review, interview, and policy review, the provider failed to ensure care plans were in place for six of eight acute care patients (15, 16, 18, 19, 23, and 24). Findings include:

1. Review of patients 15, 16, 18, 19, 23, and 24's medical records revealed no care plans had been initiated or completed during their stays.

Interview on 7/14/16 at 2:00 p.m. with the medical records manager during the above patients' record review revealed she had been aware of missing care plans and incomplete charting. She had completed chart reviews up until one month ago. The information from those reviews had been given to the director of nursing and administrator. She was not aware of any actions that had been taken from her chart reviews.

Interview on 7/14/16 at 3:00 p.m. with the administrator revealed she was not aware all patients' care plans had not been completed.

Review of the provider's revised September 2004 Nursing Care Plans policy revealed:
*An individualized nursing care plan would be developed at the time of admission and kept current on each patient.
*The care plan was to have been reviewed daily and updated with any change of status of need.

Based on record review, interview, and procedure review, the provider failed to ensure:
*Thorough documentation had been completed for one of two obstetrical patients (7).
*Pediatric assessments had been completed for two of two pediatric patients (16 and 22).
Findings include:

1. Review of patient 7's medical record revealed:*She had been admitted to the emergency department (ED) labor room on 2/10/16 at 2:40 a.m.
*She had been in active labor.
*An ED nursing assessment had been initiated. That assessment revealed she had vaginal bleeding, her estimated date of confinement was 2/28/16, and the fetal heart tones (FHT) were 140 beats per minute.
*There was no record of:
-How much blood loss she had.
-A continuous record of the FHTs.
-An ongoing record of her continued labor.
-Any post-partum notes other than her transfer to another medical facility.

2. Review of pediatric patients 16 and 22's medical records revealed an adult assessment had been completed instead of a pediatric assessment.

3. Interview on 7/14/16 at 1:00 p.m. with the medical records manager confirmed the documentation was not complete for the above patients. She had completed chart reviews up until one month ago. The information from those reviews had been given to the director of nursing and administrator. She was not aware of any actions that had been taken from her chart reviews.

Review of the provider's revised August 2002 Charting/Documentation Timelines procedure revealed the procedure was in reference to swing bed patients only.

Based on interview, document review, and policy review, the provider failed to ensure all operations and departments of the critical access hospital (CAH) operations were part of the comprehensive quality assurance performance improvement (QAPI) program for the following:
*A review of patients' active and closed records.
*A review of the CAH's policies and procedures (P/P).
*A review of physicians' services.
*Evaluations of mid-level practitioners (such as physician assistants and nurse practitioners) by a medical doctor (MD)/doctor of osteopathy (DO).
*Evaluations of MD/DO diagnosis/treatment apart from those who worked at the facility.
*Reviews and evaluations of all contracted services.
*Direction, recommendations, and actions for each operation of all hospital departments' performance improvement (PI) plans.
*A complete annual utilization review of its total program.
Findings include:

1. Review of the last four 9/1/15, 12/22/15, 3/8/16, and 6/13/16 QAPI meeting notes revealed:
*Those who attended meetings regularly were:
-The medical director.
-The chief executive officer (CEO)/administrator.
-The QAPI coordinator.
-The director of nursing (DON) for the hospital.
-The pharmacist.
*Those who had only attended one meeting or none were:
-The registered dietician or dietary manager.
-Social services.
-Activities.
-Physical therapy.
-Human resources.
-Laboratory.
-Radiology.
-Central supply.
-Maintenance.
-Housekeeping.
-Home health.
-Trauma/ER.
-The health information manager.
-Swing bed.
-The board president.

The forms used for the QAPI agenda/meetings were from the South Dakota Foundation for Medical Care Quality Improvement Organizations. They were user friendly and outlined what should have been reported, and who would have that responsibility.

Interview on 7/13/16 at 11:00 a.m. with the QAPI coordinator revealed:
*The QAPI committee met quarterly.
*The QAPI committee promoted focusing on high risk, high-volume, and problem prone areas, but it did not create the projects.
*The department or area of review was not driven by the QAPI committee.
*The department or area of review was responsible to create their own projects, set their own goals and timelines, and monitor and set their own thresholds. The department or area of review was also responsible for reporting to the QAPI committee.
*The QAPI committee gave no recommendations or actions to the departments or areas of review.
*The quarterly reports were sent to the governing board for review. The board gave no feedback to the provider on their reports.
*Credentialing reviews such as MDs, DOs, certified nurse anesthetists, physician assistants, and nurse practitioners were not part of the QAPI committee.
*The provider's healthcare policy/procedures (P/Ps) were evaluated and reviewed by the administration but were not part of the QAPI committee.
*The provider's contracted services were not reviewed by the QAPI committee.
*The director of nursing (DON) monitored infection control and patient safety.
*She agreed there was no distinction for QAPI projects between long term care and acute care.
*She was aware not all departments or managers reported. She had asked several times for all of the above listed departments to report and had sent notices of the meetings.
*There had been no utilization review of the hospital.

Interview on 7/13/16 at 3:20 p.m. with the CEO/administrator revealed:
*She was aware not all departments or managers attended the QAPI meetings. About half of the departments heads were new in the past year and they may not know all of their duties yet.
*No one reviewed the contracted services when their contract was up for review.
*The QAPI meeting encompassed reports for both the long term care facility and the CAH.
-Some of those departments and/or areas overlapped both facilities and did not differentiate between the long term care and the CAH.
*An annual review had not been completed since she had been at the facility for over four years.
*The hospital had a strategic plan, but there was no periodic evaluation or utilization plan.

Review of the provider's March 2015 QAPI policy revealed:
*"All employees and departments will be involved in the QAPI process and meetings held at least quarterly."
*"All departments will be required to provide their QAPI projects and present them at the meeting. Or provide them prior to the meeting to the QAPI coordinator, who will then present them."

Based on record review, interview, and policy review, the provider failed to ensure two of six swing bed patients (2 and 4) had received the notice of patient's rights. Findings include:

1. Review of patients 2 and 4's swing bed records revealed no notice of A Patient's Bill of Rights.

Interview on 7/14/16 at 3:00 p.m. with the administrator confirmed all swing bed patients were to have received the notice of A Patient's Bill of Rights.

Review of the provider's revised June 2004 Patient Rights policy revealed a Patient's Bill of Rights was to have been presented to them to ensure that patient's and their families understood their rights and responsibilities.

Based on record review, interview, job description review, and policy review, the provider failed to ensure individual patient's activities were provided and documented in the electronic medical records for six of six sampled swing bed patients (1, 2, 3, 4, 5, and 6). Findings include:

1. Review of patients' 1, 2, 3, 4, 5, and 6's swing bed medical records revealed no documentation was present regarding any activities assessment or activities that had been provided.

Interview on 7/13/16 at 9:25 a.m. with the activities director revealed she:
*Provided a monthly calendar of activities scheduled Monday through Friday for swing bed patients.
*Those activities would have taken place at the connected nursing home.
*Was not aware she was to have completed an assessment of the patient's activity needs.
*Did participate in the care plan meetings but did not write any care plans regarding a patient's activity requirements.

Review of the provider's Activities Coordinator Job Description revealed the activities coordinator was to have:
*Participated in swing bed care plan meetings and provided a continued evaluation of activity programs for meeting patient's needs.
*Contacted new patients to complete activity assessments and introduce them to the activities program.

Review of the provider's revised March 2015 Activities for Swing Bed policy revealed:
*A certified activity coordinator was to be in charge of activities.
*The provider would have made available a variety of supplies and equipment adequate to satisfy the individual interests of the patient.
*The activity director was also responsible for care planning and implementation.

Based on record review, interview, licensed certified social worker (MSW) consultation review, and policy review, the provider failed to ensure six of six sampled swing bed patients (1, 2, 3, 4, 5, and 6) had an assessment for medically related, social, and discharge needs. Findings including:

1. Review of patient's 1, 2, 3, 4, 5, and 6's swing bed medical records revealed no documentation was present regarding:
*Medically related social services.
*Social needs.
*Discharge needs.

Interview on 7/13/16 at 8:50 a.m. with the social services director (SSD) revealed she:
*Had only been in the position for one month.
*Knew she was to provide the same services as she did for the nursing home residents.
*Was aware there was no documentation in the swing bed patients' medical records.

Review of the 6/15/16 licensed certified social worker's consultation revealed she had provided education to the SSD regarding the nursing home requirements including: care planning, admission process, and documentation in a resident's medical record. There was no documentation that any education or consultation had been done in regards to the swing bed patients.

Review of the provider's revised June 2004 Social Services Swing Bed policy revealed the SSD would complete the social services assessment on all residents. That assessment would have been within seven days of admission. The assessment would identify resident's psychosocial needs and ensure those needs were met.

Based on record review, interview, and policy review, the provider failed to ensure six of six sampled swing bed patient's (1, 2, 3, 4, 5. and 6) each had a comprehensive care plan. Findings include:


1. Review of patient 1, 2, 3, 4, 5, and 6's medical records revealed there were no comprehensive care plans documented. The care plans only addressed the patients' admission diagnosis. There was no care plan contributions from dietary, activities, social services, and discharge planning.

Interview on 7/14/16 at 3:00 p.m. during the exit interview with the administrator revealed she was not aware the swing bed patients care plans were not comprehensive. She agreed the care plans should have included the entire patient's needs.

Review of the provider's revised September 2004 Nursing Care Plans policy revealed:*An individualized nursing care plan would have been developed at the time of admission and kept current on each patient.
*The care plan was to have been reviewed daily and updated with any change of status or need.
*The care plan was to have been multidisciplinary including the needs and plans from all departments.