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Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the surgical services, central processing department and ambulance services was incorporated into the overall CAH quality assurance/performance improvement (QAPI) program. This had the potential to affect all patients receiving surgical services from the CAH.

Findings include:

During an interview on 6/21/18, at 8:48 a.m. with the surgery technician (ST) stated there is no QAPI for the central processing area. The ST stated I just make sure everything is clean.

During an interview on 6/22/18, at 10:27 a.m. with the director of quality improvement (DQI) stated central processing should have their own quality improvement project and should be incorporated into the CAH's QAPI program. The DQI stated central processing had not reported to the DQI in the last year.




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On 6/19/18, at 1:00 p.m. the ambulance manager stated he had a current QAPI plan dated 9/2017, which included monitoring of outdated medications in the ambulance stock. He stated he was unsure if the ambulance QAPI was brought to the hospital wide QAPI.

On 6/20/18, at 9:10 a.m. the Director of Quality Improvement (DQI) stated she was unaware of what QAPI plan ambulance services was currently working on. She stated she has not received anything from the manager. DQI-A stated she had not brought any QAPI plans to the hospital wide QAPI. Further QAPI stated she had requested information from the surgical services director regarding QAPI plans, and had not received any information about what the department had been working on. She stated she had informed the chief nursing officer (CNO) and the administrator of the lack of information from surgical services.

On 6/22/18, at 9:30 a.m.. the CNO stated she had recently become aware of surgical services QAPI plans had not been given to the DQI in order to bring the information forth to the hospital wide QAPI. The CNO indicated she had not spoken with the director of surgical services as of the time of the survey. The CNO did confirm she was aware ambulance services QAPI had not been brought forth to the hospital wide QAPI.

On 6/22/18, at 10:20 a.m. the hospital administrator stated he had recently become aware surgical services QAPI plans were not provided for the hospital wide QAPI. He indicated he did not have a current plan to ensure surgical services provided their current QAPI to the DQI. He further stated he was aware of ambulance QAPI plans had not been received by the DQI, and he indicated he had been working with the ambulance manager to improve the communication.

The CAH's Quality Assurance Performance Improvement Plan dated 2018 indicated department managers and service supervisors are expected to develop/maintain departmental quality improvement plan, determine annual aims and project criteria, and identify quality projects including a least one special department quality project on an annual basis.

Based on document review and interview the critical access hospital (CAH) failed to have an agreement and/or contract with an outside provider of water in the event of an emergency or disruption of the water supply. This had the potential of affecting all patients and services provide at the CAH.

Findings include:

In review of the CAH's water policy, "Swift County-Benson Health Services Emergency Potable Water", last revised 3-17-18, it stipulated: "Swift County Benson Health Services will provide a safe, potable water supply at all times. Should the city water supply be contaminated or the flow has stopped during an all hazards situation the hospital will have an alternate source of clean safe water to continue essential facility operations". This document contained a formula which enumerated the amount of potable and non-potable water required in the event of a disruption of service.

The CAH did not have an contract and or an agreement with an outside agency which agreed to provide the necessary amount of water needed.

In an interview on 6/19/18, at 1:30 p.m., the Maintenance Manager confirmed the CAH did not have an agreement with an outside agency who would provide the required amount of water specified in the CAH's water policy.
On 6/21/18 at 8:50 the Chief Executive Officer, (CEO) confirmed there was not any written agreement or contract.