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Tag No.: C0304
Based on review of medical records, the Critical Access Hospital (CAH) failed to ensure that two (2) of three (3) consent forms reviewed were properly completed.
Findings include:
Sixteen (16) medical records were selected at random from a list of discharges from January 1, 2012, though July 31, 2012, and reviewed along with five (5) inpatient medical records for a total of 21 medical records.
Three (3) medical records reviewed contained a Do Not Resuscitate consent form. All three (3) consent forms had been signed, witnessed, timed and dated. On two (2) of the three (3) consents, the two (2) parts of the form requiring completion, prior to being signed, were found to be blank.
Tag No.: C0307
Based on review of medical records, the Critical Access Hospital (CAH) failed to ensure that 18 of the 21 medical records reviewed had all entries in the medical record timed.
Findings include:
Sixteen (16) medical records were selected at random from a list of discharges from January 1, 2012, though July 31, 2012, and reviewed along with five (5) inpatient medical records for a total of 21 medical records.
18 of the 21 medical records reviewed had entries that had not been timed when entered in the medical record. This included progress notes and/or handwritten history and physical examinations.
Tag No.: C0331
Based on review of the Critical Access Hospital's (CAH's) policies and procedures and minutes of the Medical Staff meetings, the facility failed to ensure that a formal evaluation of its total program is carried out at least once a year.
Findings include:
Review of the facility's policies and procedures revealed that the facility had not developed policies and procedures for an annual evaluation specifying how the CAH was to conduct the evaluation, who is responsible for conducting the evaluation, and what information is to be included in the evaluation.
Review of the minutes of the facility's Medical Staff meetings for the past year revealed that the CAH had looked at the volume of patients, lengths of stays, financial reports, and had reviewed policies and procedures. While the facility had performed various requirements of the annual evaluation at different times during the past year, the CAH had not conducted a review and compiled a report designated as the Annual Evaluation of its total program to encompass all aspects of the evaluation during a specified time period.
Tag No.: C0332
Based on review of the Critical Access Hospital's (CAH's) policies and procedures and minutes of the Medical Staff meetings, the facility failed to ensure that a review of the utilization of CAH services, including the number of patients served and the volume of services, was part of an annual evaluation.
Findings include:
Review of the CAH's policies and procedures and minutes of the Medical Staff meetings revealed that there was no yearly program evaluation performed by the facility that included all the CAH services, the number of patients served and the volume of services provided.
Tag No.: C0333
Based on review of the Critical Access Hospital's (CAH's) policies and procedures and minutes of the Medical Staff meetings, the facility failed to ensure that a review of both active and closed medical records was performed as part of an annual evaluation.
Findings include:
Review of the CAH's policies and procedures and of minutes of the Medical Staff meetings revealed that there was no yearly program evaluation performed by the facility which included a review of medical records that were representative of the services furnished by the CAH, the method of selection of the records to be reviewed, the criteria to be utilized in the review of the records, and the person(s) responsible for the review.