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Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on October 30, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.623, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on October 30, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on document review and staff interview, it was determined the Critical Access Hospital (CAH), failed to ensure a policy with rules for handling and disposition of biological's was developed. This failure has the potential to affect all patients receiving care in the CAH.

Findings:

1. A request for a policy regarding the handling and disposition of biological's, including disposal of expired supplies was requested on 10/30/19 at 9:00 AM, to the Chief Nursing Officer (E#1). On 10/30/19 at 4:00 PM, E#1 reported there was no policy to address the handling of hospital supplies related to expiration and disposition.

2. An interview with the Director of Patient Services/Infection Control (E#3) was conducted on 10/31/19 at 9:30 AM. E#3 reported it is known to all staff that all supplies should be checked for expiration dates and replaced as needed. E#3 agreed there is no written policy regarding the handling of biological's.

Based on observation, document review and staff interview, it was determined the CAH failed to ensure polices were developed and accurate regarding the type and use of disinfecting agents to control infection and communicable diseases of patients and personnel. This failure has the potential to affect all patients receiving care and staff and visitors in the therapy department.

Findings:

1. A tour conducted with the Director of Physical Therapy (E#4) on 10/29/19 at approximately 2:00 PM. E#4 was asked what is used to disinfect patient equipment, E#4 replied, "Well, the solution we started using had a very strong, bad odor so we are using these wipes", indicating disinfecting cloth wipe in a round container. I asked E#4 what they were supposed to use, and she indicated "Oxycide."

2. A request for a policy with instruction for staff regarding when, where, and how to use the Oxycide, was made on 10/29/19 at 4:30 PM. The policy supplied gave instructions for mixing the solution and use with the appropriate cloths, but no instructions for staff on when, where, or how the Oxycide should be used.

3. An interview was conducted with the Director of Patient Services/Infection Control (E#3) on 10/30/19 at approximately 3:30 PM. E#3 confirmed the physical therapy department should be using the Oxyicide solution and cloths for cleaning all surfaces and patient care equipment

Based on document review and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure their contract with the outside entity used to review the appropriateness of the diagnoses and treatment provided by each physician, included the extent and frequency of the outside review. This has the potential to affect all patients receiving care at the CAH (average daily in patient census of 6).

Findings include:

1. On 10/30/19 at 2:30 PM, the CAH's "Quality Program Book" was reviewed. The "External Peer Review Agreement" (effective 10/23/19) did not include the extent or frequency of outside reviews. This agreement is the contract between the CAH and the agency responsible for reviewing the appropriateness of the diagnoses and treatment provided by each physician, included the extent and frequency.

2. On 10/31/19 at 1:30 PM, an interview with the Quality Manager (E #2) was conducted. E #2 explained that the CAH uses the "External Peer Review Agreement" as their contract for third party review. E #2 confirmed that the contract did not include any agreement as to the extent and frequency of outside reviews.