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Based on interview, document review, and review of the hospital's quality program, the hospital failed to develop, implement, and maintain a hospital-wide, data-driven quality assessment and performance improvement program that included systematic data collection, analysis, implementation of process improvement, and monitoring of those plans post implementation to ensure sustained improvements in clinical care with oversight of the hospital's Governing Body.

Failure to systematically collect and analyze hospital-wide performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

Interview, record review, and review of the hospital's quality documents showed the following:

1. Failure to develop and implement an ongoing and comprehensive quality program that involved all departments of the hospital and services.

Cross Reference C 1306

2. Failure to address outcome indicators related to patient health by not implementing corrective action plans for identified problems.

Cross Reference C 1311

3. Failure of leadership and governing body to provide oversight to ensure full implementation of the quality assessment and performance improvement (QAPI) plan that included and evaluated all hospital departments and services, collection and analysis of performance improvement data for all hospital quality indicators and included implementation of process improvement for indicators not meeting hospital goals.

Cross Reference C 1313

4. Failure to implement measures shown to be predictive of desired patient outcomes for identified performance improvement projects to ensure their effectiveness.

Cross Reference C 1315

5. Failure to use measures to analyze and track hospital performance.

Cross Reference C 1319

6. Failure to ensure that the Quality Assessment Performance Improvement (QAPI) program received reports and tracked process improvement for quality indicator data.

Cross Reference C 1325

Due to the cumulative effect of deficiencies cited under 42 CFR 485.641, the Condition of Participation for Quality Assessment and Performance Improvement Programs was NOT MET.
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Based on interview, document review, and review of the Critical Access Hospital's (CAH) quality program, the hospital failed to develop and implement an ongoing and comprehensive quality program that involved all departments of the hospital and services.

Failure to develop and implement a comprehensive quality program that involves all departments and services risks poor patient outcomes and limits the hospital's ability to provide high quality care.

Findings included:

1. Review of the hospital's document titled, "2023 Quality Assurance Performance Improvement Plan", no number, last reviewed on 03/16/22, showed that the purpose of the Quality plan is to support a district wide approach to plan, measure assess and improve organizational performance.

2. Review of the hospital's quality meeting minutes from January 2023 through January 2024 showed Infection Prevention had no report out to Quality for 2023.

3. On 03/07/24 between 5:50 PM and 6:56 PM, Surveyor #7 and the Quality Manager reviewed the Quality meeting minutes for all of 2023. The review showed hospital departments including but not limited to: Infection prevention and Surgical Services had no report out to Quality for 2023. During the review Staff #701 stated it had been difficult to get staff participation in the Quality Program that that this was a continuing process to get appropriate projects and report outs.

4. On 03/15/24 between 9:00 AM and 9:47 AM, Surveyor #7 interviewed the Quality Manager (Staff #701), who verified Infection Prevention had not reported out to Quality in 2023.
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Based on interview and review of the Critical Access Hospital's (CAH) quality program and quality documents, the hospital failed to implement, monitor, and evaluate performance improvement action plans.

Failure to implement corrective action plans for identified problems and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.


Findings included:

1. Document review of the hospital's Quality Plan titled, "2023 Quality Assurance Performance Improvement Plan (QAPI)", no number, last reviewed on 03/16/23, showed that throughout all components of the QAPI planning will be the focus on patient outcomes, critical measures, system process. The QAPI committee will study and act upon findings and monitor the actions implemented to show the implemented actions work.

2. On 03/07/24 between 5:50 PM and 6:56 PM, Surveyor #7 and the Quality Manager reviewed the Quality meeting minutes for all of 2023. The review showed the following:

a. In January falls were identified as increased.

b. In May 2023 the Performance Improvement Snapshot identified several PI projects listed by department. Among the PI projects were Falls, to decrease the number of falls and Better drug library, to decrease medication errors.

c. In August 2023 Pharmacy introduced medication safety as a PI project to decrease intravenous infusion errors. Documentation of the project showed the start date as 01/10/22 and completion date of 04/24/23.

d. Surveyor #7 found no evidence that any data was collected, aggregated, or analyzed for falls, medication errors or IV medication errors.

3. On 03/07/24 between 5:50 PM and 6:56 PM, Surveyor #7 and the Quality Manger (Staff #701) reviewed the quality minutes and PowerPoint slides. At the time of the review, Staff #701 verified the following there was no documentation of data collection and analyzation for falls, medication errors or IV medication errors. Staff #701verified that the PI project related to IV medications had a start date of 01/10/22 over a year ago and there was no data reported through Quality.
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Based on interview, document review, and review of the hospital's quality and performance improvement program, the hospital's leadership and governing body failed to provide oversight to ensure full implementation of the quality assessment and performance improvement (QAPI) plan.

Failure to include and oversee the quality and performance of all patient care services, departments, and locations risks provision of improper or inadequate care, adverse patient outcomes, and limits the hospital's ability to provide high quality clinical care and improve patient outcomes.

Findings included:

1. Document review of the hospital's Quality Plan titled, "2023 Quality Assurance Performance Improvement Plan (QAPI)", no number, last reviewed on 03/16/23, showed the District Board of Commissioners has the ultimate responsibility for the Quality Plan. The Quality Council will include a representative from the Board of Commissioners.

2. On 03/07/24 between 5:50 PM and 6:56 PM, Surveyor #7 and the Quality Manager reviewed the Quality meeting minutes for all of 2023. The review showed a representative from the Board of Commissioners was only present at 4 of the 9 meetings for 2023.

3. At the time of the review Staff #701 verified the Board representative had been active at less than half of the meetings. Staff #701 advised she had spoke with the representative and was assured they would be attending more meetings in 2024.
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Based on interview and review of the Critical Access Hospital's (CAH) quality program and quality documents, the hospital failed to implement and assess measures to improve patient outcomes.

Failure to implement measures to improve outcomes limits the hospitals ability to decrease potential harm to patients and improve organizational performance.

Findings included:

1. Document review of the hospital's Quality Plan titled, "2023 Quality Assurance Performance Improvement Plan (QAPI)", no number, last reviewed on 03/16/23, showed the following:

a. "The plan is intended to provide a framework of guiding principles for all participants in the provision of care. The structure will set the expectation and encourage all to participate proactively in the improvement process. The Quality plan facilitates the identification of key functions of the organization; the assessment of the quality, safety and appropriateness of these functions, and the generation of measurable improvements".

b. 51 PI projects were introduced in 2023.

2. Surveyor #7 found no evidence that measures were implemented after a pi project was introduced.

3. At the time of the review Staff #701 verified there was not a PI project that had been introduced with measures to improve patient outcomes. Staff #701 stated that this has been a struggle and that it is a continuing effort to gain participation from the stakeholders.
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Based on interview and review of the Critical Access Hospital's (CAH) quality program and quality documents, the hospital failed to analyze or track performance goals based off benchmarks set by Performance Improvement projects.

Failure to analyze and track performance limits the hospital's ability to make appropriate changes to processes and improve the patient services provided.

1. On 03/07/24 between 5:50 PM and 6:56 PM, Surveyor #7 and the Quality Manager (Staff #701) reviewed the Quality meeting minutes for all of 2023. The review showed the following:

a. The July Quality Councill slide Deck showed the OB workflow PI project. Surveyor #7 found no benchmark, no process plan steps, and no metrics.

b. The August Quality Council slide Deck showed the Drug library PI project for medication safety. Surveyor #7 found no benchmark and no measurement data.

2. Surveyor #7 found no evidence that benchmark measures were set for the Process Improvement projects and no tracking or analyzing of data was documented.

3. At the time of the review Staff #701 verified there was no measurement on progress of PI projects tracked in Quality or any committee that reported through Quality.
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Based on interview, document review, and review of the hospital's Quality Improvement Program Plan, the hospital failed to ensure that the quality improvement committee received reports and tracked process improvement for quality indicator data as directed by its quality improvement program plan.

Failure to systematically collect, analyze, assess, and monitor quality care indicator data limits the hospital's ability to formulate action plans for improvement and reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. Document review of the hospital's Quality Plan titled, "2023 Quality Assurance Performance Improvement Plan (QAPI)", no number, last reviewed on 03/16/23, showed the following:

a. The Quality plan supports district wide strategic approach to plan design, measure, assess and improve organizational performance.

b. A guiding principle is to assess performance with objective and relevant measures.

c. The QAPI manager, with input and oversight from the districts QAPI council, will provide the primary monitoring for Process Improvement (PI) projects.

2. On 03/07/24 between 5:50 PM and 6:56 PM, Surveyor #7 and the Quality Manager reviewed the Quality meeting minutes for all of 2023. Surveyor #7 found no evidence of quality indicator data.

3. At the time of the review Staff #701 verified there was no data tracked through Quality. Staff #701 further advised the individual departments track their data and that the reporting process to QAPI had been an issue that they are continuing to address.
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