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At the time of the revisit on November 18, 2010, this deficiency was not corrected.

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Based on record review and interviews with hospital staff, the governing body failed to monitor and ensure care was provided in a safe environment. The Governing Body does not ensure hospital services provided to patients are evaluated with corrective actions taken when indicated.


Findings

1. On 11/18/2010 surveyors reviewed meeting minutes from Quality Assurance/Infection Control/Safety (QA/IC/S), Medical Staff and Governing Body since the visit on 07/16/2010 to present. The QA/IC/S report contained statistical data, but no analysis of the data collected. The meeting minutes did not reflect analysis of the data collected in the QA/IC/S reports. The meeting minutes did not reflect corrective actions were taken for the problems identified in the QA/IC/S report - findings that did not meet 100%.

2. The infection control portion of the minutes did not demonstrate an effective and ongoing infection control program with evaluation of the program or analysis, with corrective actions if problems identified.
a. Meeting minutes for August 17, 2010 recorded the hospital had two cases of MRSA (methicillin resistant staph aureus) in the emergency room and one inpatient case with four isolations for the month. The minutes did not contain evaluation/analysis as to whether the inpatient infection was nosocomial or if the appropriate antibiotics for the MRSA infections were ordered/administered. The data did not contain an evaluation the use of the isolation or if the hospital policies on isolation was followed.
b. Meeting minutes for November 16, 2010 also did not contain evaluation/analysis of data with corrective action if needed.
c. During the interview with the staff identified as responsible for the infection control program (Staff D)on the afternoon of 11/17/2010, she stated she did not have any prior experience with infection control and did not know how to set up an infection control program or what was needed. She stated she had attended only one class and they did not show her how or what to do.

3. On 11/18/2010 surveyors requested personnel files for eight contract employees. Eight of eight (Staff E,F,G,H,I,J,K,L) files did not contain current licenses, orientation to the facility/department, competencies, or evaluations. Review of Quality Assurance, Medical Staff, and Governing Body meeting minutes did not contain any review or oversight of contracted personnel. Surveyors spoke with the managers and administration responsible for these areas on the afternoon of 11/18/2010 no further information was provided

Based on policy and procedure manual review, review of hospital documents, and interviews with the radiology department manager and administration, the hospital failed to provide orientation, training, and oversight of the radiology services personnel. The hospital also failed to have documentation showing all the contract personnel operating the radiology equipment are qualified and trained.

Findings:

1. On the morning of 11/18/2010 surveyors were given radiology personnel files including contract magnetic resonance imaging (MRI), contract ultrasound, and contract mammography. EIght of eight contract personnel files did not contain current orientation, training, competency or evaluation. Eight of eight contract personnel (Staff E,F,G,H,I, J,K,L) files did not have complete immunization status or current licenses. This finding was discussed with Staff C on the afternoon of the survey. Staff C told surveyors there was no further information on the contract radiology personnel.

2. On the morning of 11/18/2010 surveyors were provided radiology policy and procedure. There was no documentation indicating who the Medical Staff or radiologist had deemed competent to provide radiology services. This finding was reviewed with Staff C. No further documentation was provided.

At the time of the revisit on November 18, 2010, this deficiency was not corrected.

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The hospital does not meet the Condition of Participation for Periodic Evaluation and Quality Assurance Review at CFR 485.641.

Based on record review and interviews with hospital staff, the hospital does not ensure that the quality assurance (QA) program evaluates patient care services to insure the health and safety of patients and provides this data to the Medical Staff and Governing Body. The hospital does not have a mechanism in place to analyze and evaluate the quality and appropriateness of services and treatments furnished by the staff at the CAH, with corrective action/follow-up when needed.

Findings

1. On 11/18/2010 surveyors reviewed meeting minutes from Quality Assurance/Infection Control/Safety (QA/IC/S), Medical Staff and Governing Body since the visit on 07/16/2010 to present. The QA/IC/S report contained statistical data, but no analysis of the data collected. The meeting minutes did not reflect analysis of the data collected in the QA/IC/S reports. The meeting minutes did not reflect corrective actions were taken for the problems identified in the QA/IC/S report - findings that did not meet 100%.

2. The infection control portion of the minutes did not demonstrate an effective and ongoing infection control program with evaluation of the program or analysis, with corrective actions if problems identified.
a. Meeting minutes for August 17, 2010 recorded the hospital had two cases of MRSA (methicillin resistant staph aureus) in the emergency room and one inpatient case with four isolations for the month. The minutes did not contain evaluation/analysis as to whether the inpatient infection was nosocomial or if the appropriate antibiotics for the MRSA infections were ordered/administered. The data did not contain an evaluation the use of the isolation or if the hospital policies on isolation was followed.
b. Meeting minutes for November 16, 2010 also did not contain evaluation/analysis of data with corrective action if needed.
c. During the interview with the staff identified as responsible for the infection control program (Staff D)on the afternoon of 11/17/2010, she stated she did not have any prior experience with infection control and did not know how to set up an infection control program or what was needed. She stated she had attended only one class and they did not show her how or what to do.

3. On 11/18/2010 surveyors requested personnel files for eight contract employees. Eight of eight (Staff E,F,G,H,I,J,K,L) files did not contain current licenses, orientation to the facility/department, competencies, or evaluations. Review of Quality Assurance, Medical Staff, and Governing Body meeting minutes did not contain any review or oversight of contracted personnel. Surveyors spoke with the managers and administration responsible for these areas on the afternoon of 11/18/2010 no further information was provided