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Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Network Hospital staff reviewed the CAH's quality assurance plan and its implementation on an annual basis; had an active member on the Hospital Medical Staff Quality Committee and the Hospital Quality Council, in accordance with the Network Agreement for Quality Assurance.

Failure to ensure the Network Hospital staff reviewed the CAH's quality assurance plan and its implementation annually, in accordance with the Network Agreement for Quality Assurance, could potentially result in the quality staff of the CAH failing to identify and act on patient care related issues, potentially cause adverse patient outcomes.

Findings include:

1. Review of the Network Agreement, dated September 9, 2005, revealed the following in part, ". . . [Network Hospital] will B. 3. Review the Hospital Quality Improvement Plan and activities annually, and as indicated based on findings. 4. A Network Hospital representative will be an active member of the Medical Staff Quality Committee. 5. A Network Hospital representative will be an active member of the Hospital Quality Council..."

2. Review of CAH documentation revealed the lack of evidence showing the Network Hospital annually reviewed the CAH's quality assurance plan and its implementation of the plan per the Network Agreement. CAH documentation lacked evidence the Network Hospital had a representative on the Hospital Medical Staff Quality Committee and the Hospital Quality Council.

3. During an interview on 7/22/15 at 10:00 AM, Staff BB, a Health Care System Affiliate acting as the Interim Quality Manager, acknowledged the lack of documentation of the Network Hospital annually reviewing the CAH's quality assurance plan and its implementation per the Network Agreement. Staff BB did not attend Medical Staff Quality and Hospital Quality Council meetings, but was available to consult with hospital staff if concerns were identified with quality improvement.

Based on review of Board of Directors By-laws, Medical Staff By-laws, Board of Directors meeting minutes, Medical Staff meeting minutes, documents, and interview with staff, the Board of Directors (governing body) failed to ensure the Medical Staff as well as the Board of Directors themselves administered policies to determine and maintain quality health care at the Critical Access Hospital, (CAH). The CAH administrative staff reported a current census of 5 patients at the time of the survey and an outpatient case volume of 29,970 yearly.

The determination was evidenced by:

The Board of Directors failed to evaluate all contracted services, have a current list of all contracted services, document quality improvement information was reviewed, lacked oversight of CAH staff managed by Hospital B, (Network Hospital) without a contract and retain a complete organizational chart. Refer to C-241.

The Board of Directors failed to assure all policies and procedures were reviewed annually by the required group of professionals, a physician, midlevel and community member, and they always present during they were always present at the meetings. Refer to C-272.

The Board of Directors failed to ensure a current list of all contracted services was maintained. Refer to C-291.

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the quality of health care provided by practitioners to patients.

I. Based on review of the Critical Access Hospital (CAH) Board of Directors meeting minutes and staff interviews, the CAH failed to document an evaluation of all contracted services. The CAH administrative staff reported a current census of 5 patients at the time of the survey and an outpatient case volume of 29,970 yearly.

Failure to evaluate all contracted services provided to patients could allow contracted staff to provide the services without current qualifications and might result in patients receiving substandard care.

Findings include:

Review of the Board of Directors committee meeting minutes from 8/7/14 to 6/4/15 revealed a lack of documentation regarding the evaluation of the contracted services and if they were meeting the needs of the CAH.

During an interview on 7/22/15 at 1:00 PM, Staff F, Administrative Director confirmed the Board of Directors committee meeting minutes lacked documentation regarding the evaluation of the contracted services.


II. Based on review of the CAH Board of Directors meeting minutes and staff interviews, the CAH failed to present or document information regarding the Quality Improvement meeting minutes at the Board of Directors meetings for the board members consideration and evaluation. The CAH administrative staff reported a current census of 5 patients at the time of the survey and an outpatient case volume of 29,970 yearly.

Failure of the CAH Board of Directors to review and evaluate Quality Improvement meeting minute information could result in a decline in the CAH Quality Improvement program and delay in needed actions.

Findings include:

Review of the Board of Directors committee meeting minutes from 8/7/14 to 6/4/15 revealed a lack of documentation showing review and evaluation of the Quality Improvement meeting minutes by the board members.

During an interview on 7/22/15 at 11:05 AM, Staff H, Risk Management, Interim Quality Manager reported the Board of Directors meeting minutes lacked documentation showing the board members reviewed and evaluated the Quality meeting minutes.

During an interview on 7/22/15 at 10:00 AM, Staff F, the Administrative Director, confirmed the Board of Directors meeting minutes did not address Quality and Infection Control information.

III. Based on review of the CAH's Board of Directors' Organizational Chart and interview with staff, the CAH lacked a complete organizational chart listing all departments during the time of the survey. The CAH administrative staff reported a current census of 5 patients at the time of the survey and an outpatient case volume of 29,970 yearly.

Failure to have a complete organizational chart could result in ineffective communication to the proper departmental staff about identified concerns and corrective actions and staff not aware of the the Quality and Infection Control activities of the CAH.

Review of the Mercy Hospital of Franciscan Sisters Board of Directors' Organizational Chart revealed the document lacked the Infection Control and Quality departments and supervising staff.

During an interview on 7/22/15 at 10:00 AM, Practitioner A, a physician and Vice President of Medical Affairs at the CAH's Network Hospital acknowledged the CAH's organizational chart the Infection Control and Quality Improvement departments and their supervising staff.

Based on review of policies, meeting minutes and staff interview, the Critical Access Hospital (CAH) failed to ensure the required group of professionals, including a physician and a mid-level provider and a community member reviewed all patient care policies for 27 of 27 patient care departments. The departments included Laboratory; Diabetes Education/Dietary; Pharmacy; Health Information; Plant Operations; Routine and Preventative Maintenance/Biomed, Emergency Services; Environmental Services; Infection Control; Respiratory Therapy; Acute Care; Case Management; Rehabilitation Therapies; Out Patient Clinic; Magnetic Resonance Imaging; Food Services; Contractual Services Nuclear Medicine; Stereotactic Biopsy; Radiology Services; Pastoral Care; Admissions; Patient and Family Services; Cardiac and Pulmonary Rehabilitation; Wound Care; Echo; Sleep lab; and Ambulance Services. The CAH administrative staff reported a current census of 5 patients at the time of the survey and an outpatient case volume of 29,970 yearly.


Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to address and develop policies for changing patient care needs not addressed in the CAH policies and/or opportunities to update the policies as needed.

Findings include:

1. Review of the CAH policy titled "Critical Access Hospital Manual", dated 5/17/06, revealed in part, . . . "The CAH Advisory Council membership includes at least one physician who is a member of the Medical Staff, a mid-level practitioner on staff, a community member (may be a member of the CAH Board of Directors). Policies are reviewed annually by the CAH Advisory Council."

2. Review of the Critical Access Advisory Council meeting minutes revealed the following information on attendance at the meetings:
a. the community member was not present at the 3/21/14 meeting;
b. the midlevel provider was not present at the 5/12/14 meeting
c. the midlevel provider was not present at the 9/25/14 meeting;
d. the physician and midlevel provider were not present at the 12/11/14 meeting ;
e. the community member was not present at the 5/19/15 meeting; and
f. the physician and midlevel provider were not present at the 6/25/15 meeting.

3. During an interview on 7/22/15 at 3:15 PM, Staff F, Administrative Director, stated when the physician, mid-level provider or community member were not present at the annual policy and procedure review meeting, they review the information at a later date. These reviews, completed at a later date, were not documented showing when the review of the policies occurred. During the annual policy and procedure review, the department policy books are available to the staff reviewing these in the meeting. The meeting members only review new policies or revised policies at the meeting.

Based on review of the Director- Quality and Clinical Performance job description, Infection Control Plan, undated and staff interviews, the Critical Access Hospital (CAH) administration failed to ensure the designated Infection Control Preventionist was an employee of the CAH. The CAH utilized services of an Infection Control Preventionist employed by the Network Hospital. The CAH administrative staff reported a current census of 5 patients at the time of the survey and an outpatient case volume of 29,970 yearly.

Failure to ensure the Infection Control Preventionist was an employee of the CAH could place patients at higher risk for contracting infections or lack of treatment for communicable diseases if not identified during admission to the CAH and throughout the hospital stay.

Findings include:

1. Review of the CAH's Director- Quality and Clinical Performance job description , revised 6/1/2012, documented in part... "Titles of Direct Reports: Infection Control Practitioner. 7. Adheres to all safety, infection control and employee health policies and procedures. Attends required safety programs. Appropriately and consistently uses the personal protective equipment required for the job. Knows and can demonstrate departmental emergency procedures for fire, disaster and other emergency situations."

2. Review of Infection Control Plan documented in part... "Infection Control Function: The Infection Control Practitioner is responsible for the operation of the Infection Control Program. To integrate this program with overall hospital management, the Infection Control Practitioner reports to the Quality Services Department and also maintains a close working relationship with administration. The Infection Control Practitioner will also maintain a close working relationship with the Quality Services Department for quality assessment and improvement and patient relations functions..."

3. During an interview on 7/22/15 at 1:10 PM, Staff I, RN, (Registered Nurse, Nurse Manager) stated the CAH utilizes Staff AA, (Healthcare System Affiliate, Infection Control Preventionist) employed at Network Hospital as the CAH's Infection Control Preventionist. The CAH did not have a contract or agreement with with Staff AA.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to develop a non-select menu for the regular and therapeutic diets. The administrative staff identified a census of 5 inpatients at the time of the survey. The Food and Nutrition Services Supervisor reported the dietary department served approximately 18 patient meals daily.

Failure to provide a planned menu for dietary staff to follow, when a patient is unable or chooses not to make their own selections, could potentially result in patients receiving inadequate or excess nutrients, impacting their health and nutritional status.

Findings include:

Review of a Patient Focus policy titled "Patient Meals and Snacks", approved 6/25/15, revealed in part "A patient receiving an oral diet will receive meals daily in accordance with each patient's dietary prescription . . . 5. Clinical nutrition associates . . . will gather patient preferences for patients receiving a "house diet" (non-select) in order to meet patients individual needs. 6. Patients who do not wish to select their own or are unable to make food choices will receive a pre-selected meal planned by Nutrition Services . . ."

During an interview on 7/20/15 at 11:00 AM, Staff A, Food and Nutrition Services (FANS)Supervisor, reported the department used a 7-day patient menu cycle and each patient received a daily self-select menu. She relayed if the kitchen did not receive selections back from the patient, a department employee would visit the patient to obtain selections or may call and see if nursing could obtain selections. Staff A reported the department did not have a planned non-select menu, in the event a patient declined to self select or unable to self select.

Review of available patient menus revealed select menus for a regular, cardiac and consistent carbohydrate diet, but lacked a planned non-select menu for any of the diet types.

Review of FANS policy and procedures revealed the lack of any guidance regarding meal selections for patients who had not completed a self-select menu, to ensure the patient received a nutritionally balanced diet.

During an interview on 7/20/15, at 12:00 PM, Staff B, a cook, reported if she did not have a menu filled out by the patient, she might ask Staff D, Clinical Dietitian or Staff A to obtain the patient selections. She relayed if neither of these individuals were available, she would pick some items to serve them. Staff B confirmed she did not have a planned non-select menu to refer to.

During an interview on 7/20/15, at 3:45 PM, Staff D reported the FANS department used to have a planned non-select menu utilized when a patient did not make their own selections, but did not think the department currently had one.

During an interview on 7/21/15, at 7:50 AM, Staff Z, Healthcare System Affiliate Food and Nutrition Services Director, acknowledged the department lacked a planned non-select menu and reported she could easily develop one from the current self-select menu options.

During an interview on 7/21/15 at 10:10 AM, Staff C, a cook, reported if a patient did not make their own menu selections she would visit the patient to obtain selections or have the nurse ask. She confirmed she did not have a planned non-select menu to refer to or any guidelines to assist in selecting an appropriate menu for a patient.

During a follow-up interview on 7/22/15, at 9:10 AM, Staff Z confirmed the policy titled "Patient Meals and Snacks" identified the availability of a planned non-select menu.

II. Based on staff interviews the CAH administrative staff failed to provide a qualified employee responsible for the operation of the Food and Nutrition Services Department. The administrative staff identified a census of 5 inpatients at the time of the survey. The Food and Nutrition Services Supervisor reported the department served an average of 18 patient meals daily.
Failure to ensure a qualified person manages the food service department could result in poor management and dietary practices impacting the health and nutritional status of the patients.

Findings include:

During an interview on 7/20/15 at 10:20, Staff A reported she became employed in her position approximately 5 months ago. She relayed she had several years of foodservice experience but confirmed she was not a Registered Dietitian and had not completed a Dietary Manager course. Staff A reported she planned to enroll in a Dietary Manager course this fall.

During a follow-up interview on 7/20/15, at 11:00 PM, Staff A reported she had periodic on-site assistance and oversight from Staff Y, Healthcare System Affiliate Food Service Manager and Staff Z Healthcare System Affiliate Food Service Director, to help her with the operation of the department. Staff A reported the current 7-day patient menu system was written by Staff Y and approved by Staff Z, and did not believe Staff D had a role in the menu system.

During an interview on 7/20/15, at 3:45 PM, Staff D, a registered dietitian, reported she provides clinical services only for the hospital. She relayed Staff A is ultimately supervised and reports to Staff Z who holds responsibility for oversight of the FANS department.

During an interview on 7/21/15, at 7:50 AM, Staff Z reported she is employed by the CAH's Healthcare System Affiliate and does not have a management agreement or contract with the CAH for her services for the oversight of their FANS department. She reported she provides periodic onsite visits, but spends the majority of her time offsite and her office is located at the Network Hospital. Staff Z explained the FANS department had been managed by Staff D up until approximately 1 year ago, when her responsibilities changed to clinical only. Staff Z reported Staff Y provided onsite support and oversight at least monthly, with more frequent visits since the employment of Staff A and planned to enroll Staff A in a Dietary Manager course.

During a follow-up interview on 7/21/15, at 8:30 AM, Staff D reported she is a full-time employee of the CAH but spends one day a week off-site at the Network Hospital and also has responsibilities for clinical nutrition care, within the long-term care unit of the CAH. She relayed she had previously been responsible for the management of the FANS Department but those responsibilities ended approximately 2 years ago. She confirmed her current responsibilities included clinical nutrition only and she has no role in the oversight of the department, menu planning/approval or policy/procedure development/review.

During an interview on 7/22/15, at 8:00 AM, Staff A relayed she reports to Staff Y and Z and her performance evaluations are completed by Staff Y and Z. She reported she provides input on the performance evaluations for the front-line dietary staff, which are then finalized by Staff Y and Z.

During an interview on 7/22/15, at 9:10 AM, Staff F, Administrative Director, reported Staff Z held the ultimate responsibility for the FANS department and acknowledged the CAH did not have a contract or agreement for the provision of these services.

During an interview on 7/22/15, at 9:45 AM, Staff Z confirmed she is ultimately responsible for the CAH FANS Department and thought a small amount of time was allocated through the CAH payroll system, for her services.

During a follow-up interview on 7/22/15, at 11:30 AM, Staff F confirmed the CAH did not allocate any time, through their payroll system, for Staff Z's management responsibilities of the FANS department.

III. Based on document review and staff interviews the CAH administrative staff failed to ensure the Food and Nutrition Services policies and procedures reflected current practice and were approved by the medical staff and governing body. The administrative staff identified a census of 5 inpatients at the time of the survey. The Food and Nutrition Services Supervisor reported the department served approximately 18 patient meals daily.

Written policies and procedures provide guidance and consistency among staff and serves as a resource for staff in the provision of care. Failure to maintain consistency between Food and Nutrition Services policies and procedures could potentially result in confusion for staff and failure to perform the expected practices potentially resulting in negative outcomes to patients.

Findings include:

During an interview on 7/20/15, at 10:20 AM, Staff A reported she had recently given the FANS policy and procedure manual to administration for approval and provided the manual for review. The manual had a signature page in the front showing approval on 6/25/15.

During an interview on 7/20/15, at 4:30 PM, Staff F reported the current policies and procedures should be on-line and the FANS hard-copy policy manual may not be current. Staff F checked the on-line policy directory and found only 3 FANS policies.

During an interview on 7/21/15, at 10:20 AM, Staff A reported the manual provided at the survey entrance was an old policy manual and did not contain the current FANS policies. She relayed the current hard-copy policy manual lacked a label so did not realize what the notebook contained. Staff A confirmed the old policy manual went to Administration in June for approval and the new one did not.

During an interview on 7/21/15, at 10:20 AM, Staff Z reported she compiled the current policy manual to reflect current CAH practice and Staff A mistakenly provided the wrong manual. She acknowledged she did not know that the department policies had to go through the CAH approval process so the hard-copy manual had not been approved.

During a follow-up interview on 7/22/15, at 8:00 AM, Staff A confirmed she gave the old policy manual to administration for approval last month and did not perform any policy review prior to turning over the manual. She acknowledged she did not know about the other hard-copy manual or about the existence of the policies on-line, under the Patient Focus heading, which included policies that applied to the FANS department.

During a follow-up interview on 7/22/15, at 9:45 AM, Staff Z reported all the policy and procedures are developed through the Network Hospital and, if they are in the Healthcare System Affiliate format, the top right corner of the policy reflected which of the 3 Healthcare System Affiliates it applied to. She acknowledged a problem regarding policies and procedures, related to the old hard-copy manual being approved, the new hard-copy manual lacked approval and on-line policies in conflict with hard-copy policies. Staff Z reported the majority of the department policies are not on-line and confirmed the hard copy policies reflected current practice.

Based on documentation review and staff interviews the Critical Access Hospital (CAH) failed to maintain a complete list of contracted services describing the nature and scope of services provided. The CAH had about 17 contracts.

Failure to maintain a complete list of contracted services describing the nature and scope of services could result in a misuse or a failure to use these services as needed.

Findings include:

Review of the list of contracts provided by the CAH showed it lacked the following contracted services and their nature and scope of service:
a. Speech
b. Occupational Therapy
c. Emergency water and fuel
d. Dental
e. Hospice
f. Biomedical
g. Infection Control
h. Food and Nutritional Services Director

Review of the Fiscal Year 2015 Performance Improvement Plan updated 7/22/14 revealed in part... "A. Ensures that these programs address all departments and services (including contracts)..."

Review of the Medical/Executive Committee meeting minutes dated 1/29/15 revealed "Annual Review of Contracted Services- committee reviewed the list of clinical contracted services for Mercy Hospital. The committee approved the list."

During an interview on 7/22/15 at 1:00 PM, Staff F, Administrative Director acknowledged the CAH's current list of contracts approved on 1/29/15 by Medical Staff failed to list all the contracted services with their nature and scope of service.

Based on review of documents and administrative staff interview, the Critical Access Hospital (CAH) failed to develop and implement a annual Periodic Evaluation. The CAH lacked an annual Total Program Evaluation that included: 1) the number of patient served and the volume of services provided; 2) a sampling of open and closed records to determine the appropriateness of services offered; 3) review of all health care policies and procedures including updates, new policies and existing policies requiring no changes; and 4) results of the review and how they were used to implement changes Refer to C-331, C-332, C- 333, C-334 and C-335.

The CAH failed to develop and implement an effective quality assurance program.
The CAH's Quality Assurance/Improvement program lacked problem prevention, identification, identification of corrective actions, implementation of corrective actions, evaluation of corrective actions, and measures to improve quality on a continuous basis.
The CAH failed to evaluate all patient services; failed to have the network hospital review peer review files as an external entity; failed to identify concerns through quality review so that appropriate remedial actions could be developed and implemented so any remedial action could be taken and the outcome could be taken.

The accumulative effect of these deficiencies would suggest a system breakdown resulting in this condition level deficiency. Refer to C-336, C-337, C-340, C-342 and C-343.

Based on review of documents and administrative staff interviews the Critical Access Hospital (CAH) failed to develop and implement a periodic, annual, evaluation of its total program. The CAH administrative staff reported an average daily census of 4 inpatients and an out patient case volume of 29,970 annually.

Failure to development and implement a total program review could potentially result in the CAH failing to meet the needs of their inpatients, outpatients, and staff.

Findings include:

Review of the document titled Critical Access Hospital (CAH) Manual Program Overview, with a review date of 3/11 states in part...A CAH Program Evaluation will be done on an annual basis...

Review of the CAH's administrative documents lacked a annual Total Program Evaluation. The last available Total Program Evaluation was dated 9/25/08.

During an interview on 7/21/15/ at 2:20 PM, with Staff F, Administrative Director, revealed a lack of a annual Total Program Evaluation, with the Administrative Director stating she has not completed a annual Program Evaluation since she started in 2011, and she was not aware of the need to complete a Total Program Evaluation.

Based on review of documents and interview with administrative staff, the Critical Access Hospital (CAH) failed to complete an annual Total Program Evaluation that identified the number of patients served and the volume of services provided at the CAH. The CAH administrative staff reported an average daily census of 4 inpatients and an out patient case volume of 29,970 annually.

Failure to include the number of patients served and the volume of services in the annual Total Program Evaluation could potentially result in the CAH failing to meet the needs of their patients.

Findings include:

Review of the document titled Critical Access Hospital (CAH) Manual Program Overview, with a review date of 3/11 states in part...A CAH Program Evaluation will be done on an annual basis. The purpose of the evaluation is to determine whether the utilization of services was appropriate...Utilization of Services (Includes the number of patients served and the volume of services provided.)

Review of the CAH's administrative documents showed the CAH lacked a annual Total Program Evaluation, or other documents related to the number of patients served and the volume of service. The last available Total Program Evaluation for the CAH was dated 9/25/08.

During an interview on 7/21/15/ at 2:20 PM, with Staff F, Administrative Director, acknowledged a lack of documentation that included the number of patients served and the volume of services provided annually. Administrative Director stated she has not completed a annual Total Program Evaluation since she started in 2011.

Based on review of documents and administrative staff interview the Critical Access Hospital (CAH) failed to complete an annual Total Program Review that included a representative sample of both active and closed clinical records since September of 2008. The CAH administrative staff reported an average daily census of 4 inpatients and an out patient case volume of 29,970 annually.

Failure to complete the annual Total Program Review and include a representative sample of both active and closed clinical records could potentially result in the CAH failing to meet the needs of their inpatients and outpatients.

Findings include:

Review of the document titled Critical Access Hospital (CAH) Manual Program Overview, with a review date of 3/11 states in part...A CAH Program Evaluation will be done on an annual basis. The evaluation will include the following: Record Review (Representative sample of both active and closed clinical records.)
Review of the CAH's administrative documents lacked a annual Total Program Evaluation. The last available Program Evaluation was dated 9/25/08.

During an interview on 7/21/15/ at 2:20 PM, with Staff F, Administrative Director, revealed a lack of a annual Total Program Evaluation, with the Administrative Director stating she has not completed a annual Program Evaluation since she started in 2011.

Based on review of documents and administrative staff interviews the Critical Access Hospital (CAH) failed to complete the annual Total Program Evaluation and failed to annually evaluate, review,and revise the CAH's health care policies as needed. The CAH administrative staff reported an average daily census of 4 inpatients and an out patient case volume of 29,970 annually.

Failure to complete an annual Total Program Evaluation annually evaluate, review, and revise the CAH's health care policies could potentially result in the CAH failing to meet the needs of their inpatients and outpatients.

Findings include:

Review of the document titled Critical Access Hospital (CAH) Manual Program Overview, with a review date of 3/11 states in part...A CAH Program Evaluation will be done on an annual basis. The purpose of the evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and if any changes are needed. The evaluation will include the following: Health Care Policies Evaluation and Review

Review of the CAH's administrative documents showed the CAH lacked a annual Program Evaluation. The last available Program Evaluation was dated 9/25/08.

During an interview on 7/21/15/ at 2:20 PM, with Staff F, Administrative Director, revealed a lack of a annual Program Evaluation, with the Administrative Director stating she has not completed a annual Program Evaluation since she started in 2011. An addition interview on 7/22/15 at 3:15 PM, with Staff F, revealed only new or revised policies are reviewed by the Medical Staff Committee annually.

Based on review of documents and administrative staff interviews the Critical Access Hospital (CAH) failed to conduct an an Annual Program review to develop and implement a periodic, annual, evaluation of its total program; and to determine whether the utilization of services was appropriate, established policies were followed, and any changes were made as needed. The CAH administrative staff reported an average daily census of 4 inpatients and an out patient case volume of 29,970 annually.

Failure to develop and implement a total program review could potentially result in the CAH failing to meet the needs of their patients and making policy changes as appropriate.

Findings include:

Review of the document titled Critical Access Hospital (CAH) Manual Program Overview, with a review date of 3/11 states in part...A CAH Program Evaluation will be done on an annual basis. The purpose of the evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and if any changes are needed. The evaluation will include the following:
1. Utilization of Services (Includes the number of patients swerved and the volume of services provided.)
2. Record Review (Representative sample of both active and closed clinical records.)
3. Health Care Policies Evaluation and Review
4. Patient Satisfaction and Customer Feedback.

Review of the CAH's administrative documents showed the CAH lacked a annual Total Program Evaluation. The last available Total Program Evaluation was dated 9/25/08.

During an interview on 7/21/15/ at 2:20 PM, with Staff F, Administrative Director, revealed a lack of a annual Total Program Evaluation, with the Administrative Director stating she has not completed a annual Total Program Evaluation since she started in 2011.

Based on review of documents and interview with administrative staff, the Critical Access Hospital (CAH) failed to develop, evaluate, and implement an effective Quality Assurance Program that to evaluate and improve the quality and appropriateness of patient care to improve quality on a continuous basis including all the services offered at CAH. The CAH identified 25 of 27 departments reported quality measures.

Failure to have an effective quality assurance program that included involvement of all of the CAH's departments to improve quality on a continuous basis could result in failure to ensure patient care problems were identified, monitored, addressed, and improved in each patient care area through the efforts of all involved departments.

Findings include:

Review of the Network Agreement for Critical Access Hospital Between Mercy Hospital of Franciscan Sisters and Covenant Medical Center, Inc., dated and signed 9/9/2005 and related supporting documentation stated in part... 3. Covenant will review Hospital Quality Improvement Plan and activities annually, and as indicated based on findings. The network hospital and the CAH lacked documentation to support this....
5. A Covenant representative will be an active member of Hospital Quality Council. The network hospital and the CAH lacked documentation to support this....
6. Covenant representative will provide support and consultation for risk management issues. The network hospital and the CAH lacked documentation to support this.

During a phone interview on 7/22/15 at 10:00 AM, Staff BB Health care System Affiliated Risk Manager/Interim Quality Director revealed the network hospital failed to complete a hospital Quality Improvement Plan, provide documentation of onsite visits or input provided at CAH Quality Council Meeting minutes, and lacked documentation of for risk management issues at the CAH.

Review of the CAH's Quality Council Meeting minutes dated to August 21, 2014 to July 15, 2015 revealed the following information.

--The CAH lacked reports concerning problem prevention and identification, corrective action taken, and outcome of effective action from the following departments: Laboratory; Diabetes/Dietary/Clinical Nutrition; Pharmacy; Health Information; Plant Operations; Routine & Preventive Maintenance/BioMed; Emergency Services; Environmental Services; Infection Control; Respiratory Therapy; Acute Care; Case Management/Utilization Review; Out Patient Clinic; Rehab Therapies to including PT and Speech; Contractual Services (Nuclear Med, Stereotactic Biopsy); Radiology; Pastoral Care; Admissions; Patient & Family Services; Cardiac & Pulmonary Rehab; Wound Care/Ostomy Care; Echo & Sleep Lab; and Ambulance Services.

--The CAH lacked reports on issues involving patient care from the following departments: Respiratory; Utilization Review; Rehab therapies; Environmental Services; Infection Control; Health Information; Nuclear medicine; Plant Operations; and Ambulance Services.

--The CAH lacked reports about changing quality monitors from the following departments: Respiratory; Utilization Review; Rehab therapies; Environmental Services; Infection Control; Health Information; Radiology; Nuclear medicine; Emergency Services; Plant Operations; Echo/Sleep lab; and Ambulance Services.

Based on review of documents and administrative staff interview the Critical Access Hospital (CAH) failed to ensure that the Food Service and Magnetic Resonance Imaging (MRI) Service participated in the quality assurance program of the CAH and reported to the quality council.

Failure to ensure all departments of the hospital participated in quality assurance program could potentially result in patient problems within the food service and MRI areas not reported and/or addressed through the quality assurance program of the CAH.

Findings include:

A review of the Quality Council Meeting minutes dated August 24, 2014 to July 15, 2015 revealed departments of the hospital reported quality assurance findings on a quarterly rotation basis. Review of the meeting minutes revealed they lacked reporting from the Food Service Department and the Magnetic Resonance Imaging (MRI) departments of the hospital.

During an interview on 7/22/15 at 2:30 PM, with Staff F, Administrative Director revealed that the Quality Council Meeting minutes lacked reports from Food Service and MRI.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Medical Staff Executive Committee reviewed the outside entity peer review for 5 of 8 active physicians and 1 of 6 courtesy physicians, selected for review during the time of re-credentialing the physicians and received outside entity peer review performed by the Network Hospital to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH in accordance with the CAH's agreement with the Network Hospital. (Physicians B, C, D, E, F, and G) The CAH credentialed 8 active physicians and 6 courtesy physicians.

Failure to ensure all medical staff members received outside entity peer review and the results were available to the Medical Staff Executive Committee at the time of re-credentialing affected the CAH's ability to assure all of the physicians provided quality care to their patients.

Findings include:

1. Review of CAH policy titled "Medical staff policies, Peer Review", dated 11/13/14, revealed in part, ". . . Definitions: External review; The process of evaluating patient care, reviewing standards of medical care and evaluating qualifications or professional health care providers by qualified peer consultants who are not members of the Hospital Medical Staff. Composition: The committee shall be comprised of the Chair, Active Medical Staff of the 3 respective hospitals..."

Review of the "Peer Review Services Agreement" dated 10/6/2011 revealed in part... "The Peer Review Agreement is by and between the Mercy Hospital of Franciscan Sisters, Inc., an Iowa non-profit corporation (Mercy) and Hospital B, Network Hospital."

Review of the Network Agreement, dated September 9, 2005, revealed the following in part, ". . . [Network Hospital] shall participate in the performance review and the credentialing/privileging: re-credentialing/re-privileging process of practitioners, which includes chart review. . . ."

2. Review of credential files for Practitioners B, C, D, E, F and G revealed no outside entity peer review information was available to the committee at the time of the re-credentialing process.

3. During an interview on 722/15 at 4:100 PM, Staff F, Administrative Director stated she attends the Medical Staff Executive committee and the external entity peer review information was not evaluated by the committee when determining the re-appointments for the providers.

4. During an interview on 7/22/15 at 4:00 PM, Practitioner A, Health Care System Affiliate, Vice President of Medical Affairs stated during the outside entity peer review process, Hospital C, (another affiliate hospital) attends the meetings and is part of the outside entity peer review.

Based on review of documents and interview with administrative staff, the Critical Access Hospital (CAH) failed to ensure that any concerns identified by 25 of 25 departments were discussed, evaluated, and documented in the minutes of the Quality Council meetings so remedial action warranted can be initiated.

This failure resulted in the lack of the CAH to ensure any remedial action determined by the departments or the Quality Council occurred. This failure resulted in the CAH's inability to ensure patient received the best quality of patient care services.


Findings include:

Review of Quality Council Meeting minutes dated August 21,2014 to July 15, 2015 revealed the following departments reported on a quarterly basis: Laboratory:Diabetes/Dietary/Clinical Nutrition; Pharmacy; Health Information; Plant Operations; Routine & Preventive Maintenance/BioMed; Emergency Services; Environmental Services; Infection Control; Respiratory Therapy; Acute Care; Case Management/Utilization Review; Out Patient Clinic; Rehab Therapies to include PT and Speech; Contractual Services (Nuclear Med, Stereotactic Biopsy); Radiology;
Pastoral Care; Admissions; Patient & Family Services; Cardiac & Pulmonary Rehab;
Wound Care/Ostomy Care; Echo & Sleep Lab; and Ambulance Services. Review of the Quality Council Meeting minutes and documentation from the reporting departments showed the documents lacked documentation of any concerns identified so there was no remedial action initiated.

During a phone interview on 7/22/15 at 10:00 AM, Staff BB, Health Care System Affiliate Risk Management/Interim Quality Director revealed she failed to attend Quality Council Meetings at the CAH. Staff BB received copies of the agenda and the meeting minutes at the Subcommittee Committee of the Board-Quality and Patient Safety Committee and lacked documentation of input or actions taken as a result of the Quality Council Meeting minutes of the CAH and lacked any knowledge of concerns identified and/or planned remedial action.

During a interview on 7/22/15 at 2:30 PM, Staff F, Administrative Director of the CAH, revealed after reviewing the Quality Council Meeting Minutes from August 21, 2014 to July 15, 2015, there was a lack of concerns identified by reporting departments and no remedial action was initiated or taken.

Based on review of documents and interview with administrative staff, the Critical Access Hospital (CAH) failed to document any remedial action taken for concerns identified in the Quality Council Meeting Minutes.

Failure to take remedial action for concerns identified could potentially result in a lack of improvement in processes effecting patients and patient care.

Findings include:

Review of Quality Council Meeting minutes dated August 21,2014 to July 15, 2015 revealed the following departments reporting on a quarterly basis: Laboratory; Diabetes/Dietary/Clinical Nutrition; Pharmacy; Health Information; Plant Operations; Routine & Preventive Maintenance/BioMed; Emergency Services; Environmental Services; Infection Control; Respiratory Therapy; Acute Care; Case Management/Utilization Review; Out Patient Clinic; Rehab Therapies to include PT and Speech; Contractual Services (Nuclear Med, Stereotactic Biopsy); Radiology; Pastoral Care; Admissions; Patient & Family Services; Cardiac & Pulmonary Rehab; Wound Care/Ostomy Care; Echo & Sleep Lab; and Ambulance Services. Review of the Quality Council Meeting minutes and documents of the reporting departments, showed the documents lacked any concerns identified and therefore lacked any initiation of remedial actions.

During a phone interview on 7/22/15 at 10:00 AM, Staff BB, Health Care System Affiliate Risk Management/Interim Quality Director revealed she failed to attend Quality Council Meetings at the CAH. Staff BB receives copies of the agenda and the meeting minutes at the Subcommittee Committee of the Board-Quality and Patient Safety Committee; and lacked any knowledge/documentation of remedial action taken related to concerns identified through the quality process.

During a interview on 7/22/15 at 2:30 PM, Staff F, Administrative Director of the CAH, reported the following information. After reviewing the Quality Council Meeting Minutes from August 21, 2014 July 15, 2015, the documentation lacked identification of concerns and any remedial action planned as no concerns were identified through the quality process.