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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.12 Governing Body.

Findings include:

1.The hospital failed to ensure anesthesiology service was available, as required. See A-0048.

1. The hospital failed to ensure that on-call /coverage for the needed services were available, causing delay in the care and treatment of the patients. See A-0067.

2. The hospital failed to ensure that the hospital has an institutional plan and budget. See A-0073.

3. The hospital failed to ensure the contracted services were evaluated as required. See A-0084.

The Immediate Jeopardies (IJs) were identified on 1/30/2024 at 42 CFR 482.12 Governing Body, due to: (1) the hospital's failure to ensure appropriate providers are available to provide necessary services for it's patients treatment; (2) the hospital's failure to ensure an institutional plan and budget exist. This impacted the availability of services and supplies necessary for patient care. The IJ's were announced 01/30/2024 during a meeting at 4:00 PM with the Chief Executive Officer, the Chief Financial Officer, the Chief Operational Officer. the Assistant Chief Executive Officer, the Risk Manager and the Manager of Quality. The IJs were not removed by the survey exit date of 1/30/2024.

Based on document review and interview, it was determined for 5 of 5 patients' (Pt. #11-Pt. #15) outpatient surgical procedures reviewed, the hospital failed to ensure anesthesiology service was available, as required.

Findings include:

1. On 1/23/2024, the hospital's "Bylaws Rules and Regulations" (approved 7/2022) was reviewed and included, " ... Article XI ... 11.3. Services. In addition to the departments of the Medical Staff, there shall be services within the department of the medical staff. The various services within the Medical Staff (e.g., anesthesiology service... The purpose of the services shall be to provide specialized care within the Hospital..."

2. On 1/24/2024, the coverage schedule for the anesthesia services were reviewed with E #4 (Director of Surgical Services). E #4 stated that on 1/22/2024, one elective outpatient orthopedic surgery case was canceled due to not having enough anesthesia providers. On 1/23/2024, four elective outpatient colonoscopies (examination of the colon) were also canceled.

3. On 1/24/2024, the operating room schedules on 1/22/2024 and 1/23/2024 were reviewed and indicated the following procedures were canceled due to lack of anesthesia services:

- On 1/22/2024, Pt. #11 was scheduled for outpatient right shoulder arthroplasty (removal of portions of the shoulder).

- On 1/23/2024, Pt. #12, Pt. #13, Pt. #14, and Pt. #15 were scheduled for colonoscopy (examination of the colon).

4. On 1/24/2024 at approximately 12:40 PM, an interview was conducted with E #4 (Director for Surgical Services). E #4 stated, "I received a call on Sunday (1/21/24) that there will not be enough anesthesiologists to cover for elective cases due to non-payment to the group. E #4 stated that this has causes delay and discomfort to patients." E #4 stated that the canceled cases were not rescheduled.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #1) clinical records reviewed, the hospital failed to ensure that the on-call /coverage for the needed services were available, causing delay in the care and treatment of the patient. This has the likelihood to cause serious harm to any patient seeking care and treatment in the hospital.

Findings include:

1. On 1/23/2024, the hospital's scope of services included the following, but not limited to: cardiovascular, ear/nose/throat surgery, gastroenterology, and neurosurgery.

2. On 1/23/2024, the on-call coverage from January 2023 through January 2024 was reviewed with the Quality Manager (E #3). E #3 stated the following services are no longer available at the hospital, and that's why no one is scheduled as on-call to provide consultation for the following: Vascular Surgery (since 4/8/2023); Urology (since 12/18/2023); ENT/Ear/Nose/Throat (since 10/2023); Oral and Maxillofacial Surgery (since 11/2023); and Neurosurgery (since 01/01/2024).

-There was also no gastroenterology consultation coverage/on-call on the following dates: 11/18/2023 through 11/19/2023 (2 days); 11/23/2023 through 11/26/2023 (4 days); 12/23/2023 through 12/31/2023 (9 days); and 1/1/2024 (1 day).

3. On 1/24/2024, the hospital "Bylaws Rules and Regulations" (approved 7/2022) included, " ... Article 2 ... 2.6 Consultations. Consultations shall be obtained through the written order of the Attending Practitioner. The consultation report shall include evidence of review of the patient's record by the consultant ... The Attending Practitioner ... shall obtain consultation in the following circumstances ... B. The diagnosis is unclear following standard diagnostic procedure ..."

4. On 1/25/2024, the clinical record for Pt. #1 was reviewed. On 1/19/2024, Pt. #1 was admitted to the hospital's intensive care unit for evaluation of angioedema (swelling under the skin) and suspect anaphylactic reaction:

-On 1/20/2024, the physician's progress notes included that CT (computerized tomography/imaging studies) indicated concern for thyroid malignancy. Recommendation was made to transfer Pt. #1 to another hospital with ENT/Ear/Nose/Throat for evaluation due to not having coverage for ENT. The notes indicated that Pt. #1 was at risk for further deterioration.

On 1/23/2024 (3 days after the needed consultation), Pt. #1 was able to speak with an ENT provider from another hospital to identify plan of care for Pt. #1.

5. On 1/23/2024 at approximately 12:30 PM, interviews were conducted with MD #1 (Pt. #1's Attending Physician) and MD #2 (Medical Oncologist). MD #1 stated that Pt. #1 had to be transferred because the patient needed an ENT consultation. MD #1 stated that the hospital does not have neurosurgery, vascular, urology, and ENT services causing delay in the care and treatment of patients. MD #2 stated, "There is lack of available services in the hospital to ensure that all patients receive comprehensive care, which affects the course of treatment of patients.

6. On 1/24/2024 between approximately 2:09 PM and 2:30 PM, interviews were conducted with E #2 (Assistant Chief Executive Officer) and MD #3 (Chief Medical Officer). E #2 stated that the hospital is trying to recruit physicians to cover on-call/coverage for the hospital. However, it is still not enough. MD #3 admitted being unaware of the hospital lacking services other than ENT.

Based on document review and interview, it was determined that the hospital failed to ensure an institutional plan and budget. This has the potential to affect the hospital's operation and ability to provide the required safe and quality care for all patients.

Findings include:

1. On 1/25/2024 at approximately 9:30 AM, the hospital presented a document including the forecasted budget for fiscal year 2024. The forecasted budget did not include capital expenditures for at least a 3-year period. The provided budget was not approved by an agency at the time of review.

2. On 1/25/2024 at approximately 9:30 AM, the hospital provided a document including an email dated 1/02/2024, from the hospital's Chief Legal Officer to the hospital's Chief Executive Officer and Financial Officer, which included, " ...requested financial documents from you all (hospital's administration staff) for the last couple of months ...has not received ...These documents are essential for our bank, and (bank) have been hounding us for a while now ...(hospital) have significant financial issues that (hospital) are trying to resolve ..."

3. On 1/25/2024 at approximately 9:40 AM, an interview with the Assistant Chief Executive Officer (E #3) was conducted. E #3 stated the hospital is without an approved institutional plan and budget for the 2024 fiscal year.

4. On 1/30/2024 at approximately 10:30 AM, Director of Pharmacy (E #32 ) was interviewed. E #32 stated that on January 17, 2024, a request to order Rophylac (used to prevent autoimmune response to Rh positive blood patients) was in low quantity (only five remaining vials). E #32 stated that Rophlylac was not requested until January 22, 2024, because the hospital is on credit hold with Cardinal (pharmaceutical vendor). E #32 stated that Rophylac is ordered based on request from the blood bank supervisor who knows when available vials are low. Use of Rophylac can be unpredictable, and can be used up when quantities are low.

5. An email from E #32 to the pharmaceutical vendor on 1/22/2024 indicated, " ... Was wondering if you might be able to advise us - account has been blocked/frozen pending the payments towards past due for the month ..." Response from the pharmaceutical vendor on 1/22/2024 indicated, "Hi (E #32), They just reopened the account, not sure if you can order via (OE/order express) of if it has to update overnight for OE to work."

6. On 1/30/2024 at approximately 11:00 AM, E #36 (Blood Bank Specialist) stated that on the following dates, blood products were low in quantity to fill a PAR (Periodic Automatic Replacement) level and were not replenished/delivered because the hospital is on credit hold: January 17, 2024 (need 3 units of B- positive packed red blood cells/RBC and one unit of platelet); January 18, 2024 (needs seven units A-positive RBC and three units of B-positive RBC) ; January 19, 2024 (needs three units B-positive RBC).

7. On 1/30/2023 an email from Versiti (blood bank vendor) dated 1/16/2023 to the hospital was reviewed. The email indicated, "Good morning (E #14 /Chief Financial Officer) ... As we did not receive payment yesterday, we have discontinued service and supply as of midnight until we do. Please advise your blood bank staff of this as we did get a request for product ... which was denied ..."

8. On 1/30/2024 at approximately 11:15 AM, the Director of Central Supply (E #37) was interviewed. E #37 stated concerns of a possible depletion of supplies due to continuing to provide CRRT (Continuous Renal Replacement Therapy for (Pt. #20). Currently the hospital has a 3-day supply. I have been made aware by phone from Baxter (the vendor) the requested supplies will not be delivered due to "credit hold". E #37 stated "I have escalated the request for the supplies to the comptrollers, but I don't know when it will be received."

Based on document review and interview, it was determined for 10 of 10 contracted services, the hospital failed to ensure the contracted services were evaluated as required.

Findings include:

1. On 1/25/2024 at approximately 11:30 AM, the hospital's contracted service contracts were reviewed. The 10 contracted services reviewed were the following: Fresenius (Dialysis), VRAD (Virtual Teleradiology), VRAD (Health agreement), Aramark (Housekeeping/Dietary), SOS (Security), Shared Medical (Mobile PET Service), Teleneurology, G & G Anesthesia, Versiti (Blood supply) and Pulmonology Locum tenens.

2. On 1/25/2024 at approximately 12:30 PM, the hospital's document titled, "Omnibus Action by Written Consent of the Sole Member of (hospital company)" (11/18/2023) was reviewed and indicated, "... RESOLVED, the new Governing Body shall have all duties and responsibilities normally granted to the Governing Body pursuant to CMS (Centers for Medicare & Medicaid Services) Conditions of Participation ...".

3. On 1/25/2024 at approximately 2:00 PM, the Quality Assurance and Performance Improvement (QAPI) meeting minutes from January 2023 to January 2024 were reviewed. The meeting minutes did not include evaluation of the hospital's contracted services.

4. On 1/25/2024 at approximately 2:45 PM, an interview with the Quality Manager (E #3) was conducted. E #3 stated that the hospital did not have a process for evaluating contracted services nor were the contracted services reviewed during the hospital's QAPI meetings.