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Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure staff inventoried and performed preventive maintenance on 2 of 6 adjustable electric treatment tables located in 2 of 6 (Room #3 and Room #5) treatment rooms in the outpatient Therapy department. Failure to inventory equipment and perform preventive maintenance could potentially result in the equipment failing to function when needed for the care and treatment of a patient, and may result in delayed care, treatment disruption, and patient harm. The Director of Therapies identified an average of 622 outpatient therapy visits per month from 01/2019 through 07/2019.

Findings include:

1. Observations during a tour of the Therapy department on 08/27/2019 at 09:42 AM, with the Director of Therapies, revealed the following therapy tables lacked a biomedical sticker to identify when the equipment was checked for electrical safety and received preventive maintenance:

Treatment room #3: Armedica adjustable electric treatment table-serial # 23424
Treatment room #5: Armedica adjustable electric treatment table-serial # 47847

2. A review of the policy, "Medical Equipment Management Plan," revised 03/2019, revealed in part, "...[Hospital A's] BioMed Department is responsible for the [Preventive Maintenance] Program and maintenance history of all medical equipment both scheduled and unscheduled...."

3. A review of Armedica adjustable electric treatment table's manufacturer's owners manual PN-03405, dated 11/28/11, revealed in part, "...The Armedica Treatment Tables are equipped with a maintenance free electric motor. The moving parts of the table should have a drop of oil placed on them approximately every six months...frequently check to make certain that all hardware (nuts, bolts, etc.) are properly adjusted and securely fastened...."

4. During an interview on 08/27/2019 at 01:30 PM, the Director of Therapies confirmed the adjustable electric treatment tables in treatment rooms #3 and #5 had not received preventive maintenance and that Hospital A's Biomedical department, scheduled to perform preventive maintenance on Therapy department treatment tables twice per year, failed to locate treatment tables #3 and #5 in their equipment inventory log and could not provide a date when the last preventive maintenance occurred.

Based on review of documents and staff interview, the Critical Access Hospital (CAH) Governing Board failed to ensure the CAH Bylaws were reviewed by the CAH Governing Board every three years as required in the CAH Governing Board Bylaws. Failure to review the CAH Governing Board bylaws every three years may result in the inability of the Governing Board to carry out their oversight of CAH operations. The CAH identified a census of 8 inpatients at the beginning of the survey.

Findings include:

1. Review of undated "Amended and Restated Bylaws of [Hospital]", revealed in part, "...These Bylaws will be reviewed at least every three years."

2. Review of Governing Board meeting minutes dated October 1, 2018 revealed in part, "...The most recent copy of the bylaws was distributed to the board of directors for review. The bylaws must be reviewed by the board of directors every three years and updated as needed. There will be a vote for approval at the December JRMC [Jones Regional Medical Center] Board Meeting...."

Review of Governing Board meeting minutes dated December 3, 2018 revealed the lack of approval of the Governing Board bylaws.

Review of Governing Board meeting minutes dated August 1, 2011 revealed the governing board approved the CAH Bylaws on August 1, 2011.

3. During an interview on 8/26/2019 at 4:00 PM, the Chief Nursing Officer (CNO) acknowledged the Governing Board failed to review and approve the CAH Bylaws every three years as required in the bylaws. The CNO further acknowledged the last review and approval of the CAH Bylaws by the governing board was August 1, 2011.

Based on observation, document reviews, and staff interviews in the Critical Access Hospital (CAH) failed to follow the facility policy to provide current "Consent for Treatment" forms for 1 of the 11 records reviewed in the Infusion Center. Failure to ensure patient "Consent for Treatment" forms are updated annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.The CAH administrative staff reported approximately 2,107 patient visits per year in the Infusion Center.


Findings included:


1. A review of 11 open records from January 2019 to August 2019 was conducted which revealed Patient #1 lacked a current "Consent for Treatment" dated within the last year. The most current consent found was dated 03/23/2018.

2. A review of the CAH policy,"Informed Consent", effective 03/2019, revealed in part that a signed "Consent to Treat" should be completed "annually".

3. During an interview on 8/26/2019 at 01:49 PM, Staff G acknowledged the Consent for Treatment for Patient #1 was dated 03/23/2018 and lacked a current annual update.

4. During an interview on 8/27/2019 at 08:50 AM, the Chief Nursing Officer (CNO) confirmed that the "Consent for Treatment" for Patient #1 was dated 03/23/2018 and lacked a current annual update.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to secure 1 of 1 Pharmacy and its contents from potential unauthorized access. Failure of CAH staff to secure the pharmacy and its contents could potentially allow an unauthorized person access to a variety of medications and place the CAH staff at harm from an intruder. The CAH's administrative staff reported approximately 120,000 doses of medications, including opioids, narcotics and other controlled drugs were stored in the pharmacy for patient use.

Findings include:

1. Observation during a tour of the pharmacy on 8/27/2019 at 9:46 AM with the Director of the Pharmacy and the Maintenance Manager, revealed the pharmacy had a dropped ceiling (secondary ceiling, hung below the main ceiling). The pharmacy's perimeter walls did not extend vertically, up to the main ceiling (or roof deck) in multiple areas and left a 5 foot vertical gap that could potentially allow an individual to remove ceiling tiles and gain unauthorized entry into the pharmacy. The following pharmacy perimeter walls did not extend to the main ceiling/roof deck and left an approximate 5 foot vertical gap between the main ceiling/roof deck and the dropped ceiling tiles and were located in areas without 24 hour staff supervision:

a. a 9 foot 10 inch shared wall with registration area
b. a 17 foot 9 inch shared wall registration hallway
c. a 24 foot shared wall with the nurses report room, nurses staff rest room, and nursing supervisor office

2. During an interview on 8/27/2019, at the time of the tour, the Director of Pharmacy reported he did not know if the perimeter pharmacy walls extended to the main ceiling (roofdeck) above the dropped ceiling. The Director of Pharmacy reported the pharmacy was staffed Monday through Friday 7:00 AM to 3:30 PM, approximately 42.5 hours per week. The pharmacy was not staffed approximately 125.5 hours per week.

3. During an interview at the time of the tour, the Maintenance Manager confirmed the pharmacy walls did not extend to the roof deck in the identified areas and it would be possible for an individual to remove ceiling tiles and gain access to the pharmacy. The Maintenance Manager expressed surprise the walls did not fully enclose the pharmacy.

4. Review of "ACCESS TO THE INTRA-HOSPITAL DRUG DISTRBUTION," dated 10/2015, revealed the policy failed to address all routes of access to the pharmacy, including access through the drop ceiling.




II. Based on observations, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy oversight of sample medications in 1 of 1 Diabetes Education provider-based clinic. Failure of pharmacy oversight in the dispensing of sample medications could result in outdated, recalled, or otherwise unusable medications being available for the Diabetes Education Coordinator to give to patients, as well as, the potential for theft of medications by unauthorized persons. The CAH reported the Diabetes Education clinic saw approximately 197 patients from 1/1/2019 to 7/31/2019.

Findings include:

1. Observation during tour of the Diabetes Education provider-based clinic on 8/26/2019 at 3:30 PM, with the Diabetes Education Coordinator, revealed a small refrigerator stored several sample medications. The sample medication refrigerator included 23 samples of a variety of medications used to treat diabetes.

2. During an interview, at the time of the tour, the Diabetes Education Coordinator reported she received sample medications, Physician I signed for the samples medications and the samples are entered on log sheets. The log sheets consisted of a separate sheet for each medication sample strength, and included documentation about the sample and a log of which patients received the sample. The Diabetes Education Coordinator reported the CAH pharmacist did not play a role in oversight of the sample medications in the clinic. The CAH pharmacist was aware the clinic stored and disbursed sample medications, but was not involved in monitoring the sample medications.

3. During an interview on 8/26/19, at 4:30 PM, the Director of Pharmacy confirmed he knew the Diabetes Education provider-based clinic stored sample medications. However, the Director of Pharmacy did not provide oversight for the medications.

4. Review of a CAH policy "Sample Medications," reviewed October 2018, revealed in part, "Prescription samples throughout [CAH] ... are handled in compliance with ... federal and state laws regarding prescription drugs." The policy failed to include a requirement for the pharmacy staff to provide oversight for drug samples dispensed to patients of the CAH's provider-based clinic.

5. During an interview on 8/28/2019 at 11:30 AM, the Chief Nursing Officer confirmed, while the Director of Pharmacy knew sample medications were used in the Diabetes Education provider-based clinic, the pharmacy failed to create a policy including how the pharmacy would provide oversight of the sample medications stored in the CAH's Diabetes Education provider-based clinic.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical services staff failed to change the enzymatic cleaning solution, Getinge Clean PowerCon Triple Enzyme Detergent Concentrate, when cleaning endoscopes in the Surgical Services unit. Failure to change the enzymatic cleaning solution could potentially result in the enzymatic cleaning solution failing to fully clean the endoscope, potentially failing to remove all of the biological material from the prior patient, and potentially result in the CAH staff transmitting the biological material to another patient, potentially causing a life-threatening infection. The CAH's administrative staff identified the surgical staff performed approximately 1,289 in the last year.

Findings include:

1. During observations of a demonstration endoscopy cleaning on 08/26/19, at 1:15 PM, Sterile Processing Aide (SPA) E revealed SPA E reused the same water and enzymatic cleaning solution, Getinge Clean PowerCon Triple Enzyme Detergent Concentrate, multiple times when cleaning endoscopes. SPA E further stated that SPA E would use the same water and detergent for multiple endoscopes until the water was cold.

2. Review of 2019 Association of periOperative Registered Nurses (AORN) guidelines for manual cleaning of flexible endoscopes revealed in part, "Manual cleaning sholud be performed using a freshly prepared cleaning solutions...repeated use of cleaning solutions decreases the amount of active ingredients and reduces cleaning efficacy."

3. During a follow-up interview on 08/28/19 at 9:45 AM, SPA E confirmed that surgical services staff follows the AORN guidelines. SPA E acknowledged should change the water and enzymatic detergent for every endoscope.



II. Based on observation and staff interviews, the Critical Access Hospital (CAH) surgical services staff failed to remove 1 of 2 outdated Getinge Clean PowerCon Triple Enzyme Detergent Concentrate from the Decontamination Room in the Surgical Services unit. Failure to remove outdated enzymatic cleaning product from the CAH's supplies could potentially result in staff using the expired items for cleaning surgical instruments, potentially causing infection. The CAH's administrative staff identified the surgical staff performed approximately 1,289 in the last year.

Findings include:

1. Observations on 08/26/19, at 12:45 PM, under the instrument cleaning sink in the Decontamination Room of the Surgical Services unit, revealed the following:

a. 1 of 2 bottles of Getinge Clean PowerCon Triple Enzyme Detergent Concentrate (used to pre-clean surgical instruments) which expired 06/2018.

2. During an interview at the time of the observation, Sterile Processing Aide E verified the Getinge Clean PowerCon Triple Enzyme Detergent Concentrate had expired on 06/2018.



III. Based on observation, document review and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure surgical staff sanitized their hands before and after glove use during 1 of 1 observed surgery (Patient #2). Failure to ensure surgical staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially cause bacterial and other staff causing the cross contamination of bacterial and/or other infectious contaminants which could cause severe patient illness and/or death. The CAH's administrative staff identified the surgical staff performed 1205 surgical procedure in 2018 and 752 surgical procedures from January 2019 to July 2019.

Findings include:

1. Review of CAH "Hand Hygiene Policy," revised 11/2019, revealed in part. "...Indications for hand washing include.... before and after removing gloves..."

2. Review of CDC guidelines revealed, in part, "...Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves...."

3. Observations on 8/26/19, beginning at 11:33 AM during Patient #2's surgery to repair an umbilical hernia repair and remove a mass from Patient #2's chest, revealed the following:

--11:33 AM Registered Nurse (RN) B, RN C and Certified Registered Nurse of Anesthesia (CRNA) F donned non-sterile gloves and did not perform hand hygiene. The antimicrobial soap was easily available on the anesthesia cart and at the nurse's desk.

--11:38 AM RN B and RN C did not perform hand hygiene after removal of non-sterile gloves.

--11:58 AM RN C donned unsterile gloves and did not perform hand hygiene.

--12:00 PM RN C removed non-sterile gloves and did not perform hand hygiene, prior to leaving the Operating Room (OR) for sterile supplies.

--12:01 PM RN B donned unsterile gloves and did not perform hand hygiene.

--12:18 PM RN C donned unsterile gloves and did not perform hand hygiene.

--12:19 PM RN C removed non-sterile gloves and did not perform hand hygiene, prior to leaving the OR for sterile supplies.

--12:20 PM RN C removed non-sterile gloves and did not perform hand hygiene.

--12:31 PM MD A removed sterile gloves and did not perform hand hygiene, prior to leaving the OR.

--12:32 PM CRNA F changed non-sterile gloves and did not perform hand hygiene.

4. During an interview on 08/26/2019 at 3:05 PM, Director of Operating Room and Outpatient Services confirmed that hand hygiene policy was based on CDC guidelines. The Director of Operating Room and Outpatient Services unaware the CAH policy directed staff to perform hand hygiene before gloves are put on and after gloves are removed.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the periodic evaluation of its total CAH program included the number of patients served and the volume of services provided at the CAH for 16 of 19 services provided (Nutrition/Diabetic Education, Pharmacy, Rehabilitation Services, Sleep Study, Cardiac Rehabilitation, Dietary, Wound Clinic, Anesthesia, Magnetic Resonance Imaging [MRI], Nuclear Medicine, Infusion, Laboratory, Imaging, Respiratory Therapy, Surgery Clinic, and Urology Clinic). Failure to include the number of patients served and the volume of services provided at the CAH could potentially result in the CAH failing to meet the needs of their patients. The CAH staff identified a current census of 8 inpatients at the beginning of the survey.

Findings include:

1. Review of the CAH policy "Annual Review of Critical Program/Policies and and Procedures," revised 10/2013, revealed in part, "...To include, but not limited to review of the total program evaluation, utilization of services, review of services provided under contract, medical record review open and closed, performance improvement activities, and review of network agreements. The utilization of CAH services, including at least the number of patients served and the volume of services."

2. Review of document "JRMC [Jones Regional Medical Center] Update," dated 12//14/2018, revealed the annual program evaluation lacked documentation of the number of patients served and the volume of services for Nutrition/Diabetic Education, Pharmacy, Rehabilitation Services, Sleep Study, Cardiac Rehabilitation, Dietary, Wound Clinic, Anesthesia, MRI, Nuclear Medicine, Infusion, Laboratory, Imaging, Respiratory Therapy, Surgery Clinic, and Urology Clinic.

3. During an interview on 8/27/2019 at 8:30 AM, the Chief Nursing Officer (CNO) verified the annual program evaluation lacked the number of patients served and the volume of services provided. The CNO acknowledged the annual program evaluation lacked documentation of the number of patients served and the volume of services for Nutrition/Diabetic Education, Pharmacy, Rehabilitation Services, Sleep Study, Cardiac Rehabilitation, Dietary, Wound Clinic, Anesthesia, MRI, Nuclear Medicine, Infusion, Laboratory, Imaging, Respiratory Therapy, Surgery Clinic, and Urology Clinic.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 19 of 19 patient care services provided (Inpatient Nursing, Emergency Department, Surgery, Nutrition/Diabetic Education, Pharmacy, Rehabilitation Services, Sleep Study, Cardiac Rehabilitation, Dietary, Wound Clinic, Anesthesia, Magnetic Resonance Imaging [MRI], Nuclear Medicine, Infusion, Laboratory, Imaging, Respiratory Therapy, Surgery Clinic, and Urology Clinic). Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided at the CAH. The CAH staff identified a current census of 8 inpatients at the start of the survey.

Findings include:

1. Review of the CAH policy "Annual Review of Critical Program/Policies and and Procedures," revised 10/2013, revealed in part, "...To include, but not limited to review of the total program evaluation, utilization of services, review of services provided under contract, medical record review open and closed, performance improvement activities, and review of network agreements...."

2. Review of document "JRMC [Jones Regional Medical Center] Update," dated 12//14/2018, revealed the annual program evaluation lacked documentation the CAH staff reviewed a sample of both active and closed clinical records for Inpatient Nursing, Emergency Department, Surgery, Nutrition/Diabetic Education, Pharmacy, Rehabilitation Services, Sleep Study, Cardiac Rehabilitation, Dietary, Wound Clinic, Anesthesia, MRI, Nuclear Medicine, Infusion, Laboratory, Imaging, Respiratory Therapy, Surgery Clinic, and Urology Clinic.

3. During an interview on 8/27/2019 at 8:30 AM, the Chief Nursing Officer (CNO) verified the annual program evaluation lacked documentation the CAH staff performed a review of a sample of both active and closed records for Inpatient Nursing, Emergency Department, Surgery, Nutrition/Diabetic Education, Pharmacy, Rehabilitation Services, Sleep Study, Cardiac Rehabilitation, Dietary, Wound Clinic, Anesthesia, MRI, Nuclear Medicine, Infusion, Laboratory, Imaging, Respiratory Therapy, Surgery Clinic, and Urology Clinic.

Based on review of the Performance Improvement Plan, Performance Improvement minutes/activities, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate 4 of 8 contracted patient care services (Anesthesia, Surgery Clinic, Urology Clinic, and Echocardiogram). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

The CAH administrative staff identified the contracted staff provided care from January 1, 2019 to July 31, 2019 to 225 Anesthesia patients, 204 Surgery Clinic patients, 127 Urology Clinic patients, and 24 Echocardiogram patients.

Findings include:

1. Review of the "Performance Improvement Plan," dated 6/2019, revealed in part, "To objectively and systematically monitoring measures, and pursue opportunities to improve patient/client outcomes...The scope of the performance improvement program includes all departments, committees, and services, including the medical staff...."

2. Review of the Performance Improvement Reports from August 28, 2018 through July 23, 2019 revealed the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve performance improvement for Anesthesia, Surgery Clinic, Urology Clinic, and Echocardiogram.

3. During an interview on 8/27/2019 at 11:15 AM, the Director of Operations acknowledged the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve performance improvement for Anesthesia, Surgery Clinic, Urology Clinic, and Echocardiogram.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 tele-radiologists selected for review (Physician H) received outside entity peer review by the appropriate entity, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. Failure to ensure all medical staff members received outside entity peer review by the appropriate entity, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified Physician H provided care to 337 patients from 1/1/2019 through 8/27/2019.

Findings include:

1. Review of the CAH network agreement, updated December 3, 2018, revealed in part, "The credentialing process will be initiated ... forwarded to personnel at [Hospital A] for completion ... The process will include review of the medical/surgical services as they relate to appropriateness of diagnosis and treatment ... "

2. Review of the "Credential Agreement," with the CAH network hospital, effective January 1, 2015 revealed in part " ... [Network Hospital] will asses [CAH] for the following services ... External peer evaluation ..."

3. Review of a CAH policy "Routine Clinical Peer Review Process," revised 4/2019, revealed in part " ... Each physician ... credentialed at [CAH] providing care incident to inpatients, emergency or surgery patients will have one external peer review performed per credentialing cycle. The external review is performed by a physician from our network hospital ..."

4. Review of Physician H's credential file revealed the medical staff approved re-appointment on 2/27/2019 and the governing body approved re-appointment on 4/1/2019. Review of external peer review completed for Physician H revealed a peer review summary completed by the contracted radiology group.

5. During an interview on 8/27/19, at 3:45 PM the Chief Nursing Officer reported the CAH received peer review from the contracted radiology group for all of the tele-radiologists.

The Chief Nursing Officer confirmed the CAH failed to obtain external peer review for Physician H from their network hospital.

I. Based on review of policies, patient medical records, and staff interview, the Critical Access Hospital (CAH) swing bed staff failed to develop and implement a comprehensive activities care plan for 4 of 4 open swing bed patient medical records (Patient #3, Patient #4, Patient #5, Patient #6) and 1 of 1 closed swing bed patient medical record (Patient #7). Failure to develop and implement a comprehensive activities care plan that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified a census of 4 swing patients at the beginning of the survey and an average of 11 swing bed patient admissions per month from 01/2019 through 07/2019.

Findings include:

1. Review of nursing policy, "Nursing Care Plan," effective 06/2019, revealed in part, "...Swing bed patient care plans will include the comprehensive assessment, the psychosocial assessment, and an activity assessment...The swing bed patient Care Plan includes input from a qualified acdtivities professional...."

2. Review of 4 of 4 (Patients #3, #4, #5, #6) open and 1 of 1 (Patient #7) closed swing bed patient medical records on 08/27/2019 revealed the following information:

a. Patient #3 was admitted to swing bed services on 08/24/2019. The Activity Coordinator completed an initial assessment for Patient #3 on 08/26/2019. Patient #3's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

b. Patient #4 was admitted to swing bed services on 08/20/2019. The Activity Coordinator completed an initial assessment for Patient #4 on 08/21/2019. Patient #4's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

c. Patient #5 was admitted to swing bed services on 08/12/2019. The Activity Coordinator completed an initial assessment for Patient #5 on 08/15/2019. Patient #5's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

d. Patient #6 was admitted to swing bed services on 08/16/2019. The Activity Coordinator completed an initial assessment for Patient #6 on 08/20/2019. Patient #6's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

e. Patient #7 was admitted to swing bed services on 06/06/2019 was discharged on 06/19/2019. The Activity Coordinator completed an initial assessment for Patient #7 on 06/11/2019. Patient #7's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

3. During an interview on 08/28/2019 at 01:45 PM, the Acute Care Manager acknowledged the lack of activities care plans for Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7.



II. Based on policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure qualified staff directed group, individual, and independent activities provided to swing-bed patients. Failure to ensure a staff member with experience or education in recreational therapy directed swing-bed activities designed to meet the patients' interests and encourage independence and interaction could potentially impede patients' progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified a census of 4 swing-bed patients at the beginning of the survey and an average of 11 swing-bed patient admissions per month from 01/2019 through 07/2019.

1. Review of policy, "Nursing Care Plan," revised 06/2019, revealed in part, "...Swing bed patient care plans will include the comprehensive assessment, the psychosocial assessment, and the activity assessment...The swing bed patient Care Plan includes input from a qualified activities professional...."

2. During an interview on 08/26/2019 at 03:31 PM, the Activities Coordinator verified failure to complete a recreational therapy qualifications course. The Activity Coordinator revealed supervision by the Social Worker since assuming the Activities Coordinator position two years ago.

3. During an interview on 08/27/2019 at 11:05 AM, the Social Worker acknowledged responsibility for supervision of the Activities Coordinator and confirmed no experience or education in recreational therapy.