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Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians periodically reviewed 3 of 3 applicable mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner. (Practitioners M, N and O)

The CAH administrative staff reported the volume of services provided by the selected mid-level providers for the month of April were identified as follows:
Staff M, Nurse Practitioner - 208 patients
Staff N, Physician Assistant - 105 patients
Staff O, Physician Assistant - 46 patients

Failure to ensure a physician periodically reviewed mid-level practitioners' patient medical records in conjunction with the mid-level practitioner could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of a facility policy titled "Mid-level Provider Practice Review", effective 9/2008, revealed in part "... The purpose of mid-level practice review is to promote the continuous improvement of the quality of care provided by the mid-level provider. The role of the Medical Staff in mid-level practice review is to provide evaluation of performance of the mid-level providers to determine whether medical care services are being provided in compliance with the applicable standards of care. ..." The policy defined the routine practice review included the physician review and signing of all medical records, one-on-one communication at the time of signing and an annual performance evaluation, at which time the supervising physician provides the mid-level provider with verbal communication on competency, quality of care and any needed corrective action.

2. During an interview on 5/9/18 at 1:10 PM, Staff Q, Medical Staff Coordinator, acknowledged the CAH lacked documented evidence of periodic patient medical record review for Practitioner M, N and O, in conjunction with their supervising physician. She reported the supervising physicians sign off on all their charts and perform an annual performance evaluation, in conjunction with the mid-level provider, but confirmed the performance evaluation does not include specific patient medical record review.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the mid-level practitioners participated in the periodic review of patient medical records, in conjunction with their supervising physician for 3 of 3 applicable mid-level practitioner. (Practitioners M, N and O).

The CAH administrative staff reported the volume of services provided by the selected mid-level providers for April 2018 are identified as follows:

Staff M, Nurse Practitioner - 208 patients
Staff N, Physician Assistant - 105 patients
Staff O, Physician Assistant - 46 patients

Failure to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records could potentially result in the mid-level practitioner misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of a Quality policy titled "Peer/Mid-level Review", approved 8/10/2016, revealed in part " Review of a facility policy titled "Mid-level Provider Practice Review", effective 9/2008, revealed in part "... The purpose of mid-level practice review is to promote the continuous improvement of the quality of care provided by the mid-level provider. The role of the Medical Staff in mid-level practice review is to provide evaluation of performance of the mid-level providers to determine whether medical care services are being provided in compliance with the applicable standards of care. ..." The policy identified the routine practice review included the physician review and signing of all medical records, one-on-one communication at the time of signing and an annual performance evaluation, at which time the supervising physician provides the mid-level provider with verbal communication on competency, quality of care and any needed corrective action.

2. During an interview on 5/9/18 at 1:10 PM, Staff Q, Medical Staff Coordinator, acknowledged the CAH lacked documented evidence of periodic patient medical record review of Provider M, N and O, in conjunction with their supervising physician. She reported the supervising physicians sign off on all their charts and perform an annual performance evaluation, in conjunction with the mid-level provider, but confirmed the performance evaluation does not include specific patient medical record review.

Based on documentation review and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the required group of professionals, including a mid-level provider and a physician, reviewed all patient care policies for 27 of 27 patient care departments. (Medical Imaging, Quality, Risk Management, Safety, Environmental Services, Nutrition, Pharmacy, Respiratory Therapy, Cardiac Services, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Staff, Clinic, Health Information Management, Medical/Surgical, Emergency Department, Surgery, Intensive Care Unit, Infection Control, Nursing, Obstetrics, Anesthesia, Laboratory, Diabetic Education, Infusion, and Wound Care)

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of CAH policy titled "Guidelines for Hospital/Department Policies and Procedures", dated reviewed 6-2017, revealed in part, ". . . Annually . . . The medical executive committee comprised of 5 physicians, the CEO, CNO, and Chief of Medical Staff Services, gives final approval for any policy, procedure or protocol that guides patient care. . . ."

2. Review of CAH Medical Executive Committee meeting minutes, dated March 8, 2017, revealed in part, "As part of the required annual review of all policies and procedures, the physicians were asked for approval of all PRHC [Pella Regional Health Center] policies. All patient care departments are continually reviewing their policies and any changes to policies affecting patient care are taken to Med Exec at the time of revision. The approved policies include, but are not limited to: Medical Imaging, Quality, Risk Management, Safety, Environmental Services, Nutrition, Pharmacy, Respiratory Therapy, Cardiac Services, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Staff, Clinic, Health Information Management, Medical/Surgical, Emergency Department, Surgery, Intensive Care Unit, Infection Control, Nursing, Obstetrics. . . The above departmental policies were granted annual approval by the Medical Executive Committee. . . ."

The Medical Executive Committee meeting minutes lacked annual approval of patient care polices for Anesthesia, Laboratory, Diabetic Education, Infusion, and Wound Care.

Review of a document to Staff X, a mid-level provider, on April 19, 2017 revealed in part, "As part of our requirements as a Critical Access Hospital, attached for your review are the 1st quarter 2017 policy revisions/updates. If you approve, please sign the face sheet and return to me. If you have any questions or would like to review any specific policies, please let me know and I will forward them to you. . . ."

The document failed to include all patient care policies, and only addressed policy revisions/updates.

Review of a document titled "Policy Signature and Approval," revealed on 4/19/2017 Staff X signed approval for the first quarter policies submitted from the Medical Executive Committee.

3. During an interview on 5/10/18 at 10:05 AM, Staff Y, Registered Nurse/Clinic Director, stated the Clinic Administrative Council committee only looks at new policies or policies that need to have changes. If there are no changes or new policies, the policies were only reviewed by the Clinic Director.

During an interview on 5/10/18 at 12:50 PM, Staff Z, Medical Staff Coordinator, stated the annual policy/procedure review process included any pertinent changes in patient care policies were taken to the Medical Executive Committee for approval. Staff Z stated during the Medical Executive Committee the list of all policies/procedures were brought up on the computer and the Medical Executive Committee members were asked to globally approve all policies that were listed. Staff Z also acknowledged a mid-level provider does not attend the Medical Executive Committee. Staff Z stated quarterly the list of all policies/procedures that was approved at the Medical Executive Committee was sent to a mid-level provider and that mid-level provider reviewed the policies/procedures that were approved by the Medical Executive Committee. Staff Z confirmed the Medical Executive Committee members and the mid-level provider only looks at policies/procedures that have pertinent changes, not all policies/procedures.

I. Based on observation, document review, and staff interview, the critical access hospital (CAH) staff failed to ensure 4 of 4 observed male staff members (Certified Registered Nurse Anesthetist (CRNA) JJ, Surgeon KK, CRNA LL, and Surgeon MM) wearing skull caps completely covered their hair. Failure to cover all of a staff member's hair could potentially result in bacteria on the staff member's hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The CAH staff performed approximately 375 surgical procedures per month.

Findings include:

1. During an interview on 5/9/18 at approximately 10:00 AM, the Director of Surgery acknowledged the CAH followed the AORN (Association of peri-Operative Registered Nurses) guidelines for surgical attire.

2. Review of the AORN Guideline Essentials Surgical Attire Quick View, copyright 2017, revealed in part, "Head Covering ... Completely cover your hair, scalp, sideburns, and the nape of your neck with a hood or head covering.... Uncovered hair and skin can harbor bacteria that can be dispersed into the environment."

3. Observations during surgical procedures on 5/9/18 revealed the following:

a. At 09:00 AM, CRNA JJ (a nurse with advanced training in administering medications used to render patients unconscious for surgery) entered an operating room wearing a skull cap. The skull cap consisted of a cap covering CRNA JJ's forehead and central part of CRNA JJ's hair. The skull cap did not cover the lower approximately two inches of CRNA JJ's hair on the side of CRNA JJ's head and the back of CRNA JJ's hair.

b. At approximately 11:04 AM, Surgeon KK was in a surgical procedure wearing a skull cap. The skull cap consisted of a cap covering Surgeon KK's forehead and central part of Surgeon KK's hair. The skull cap did not cover the lower approximately one inch of Surgeon KK's hair on the side of Surgeon KK's head and the back of Surgeon KK's hair.

c. At approximately 11:04 AM, CRNA LL was in a surgical procedure wearing a skull cap. The skull cap consisted of a cap covering CRNA LL's forehead and central part of CRNA LL's hair. The skull cap did not cover the lower approximately one inch of CRNA LL's hair on the side of CRNA LL's head and the back of CRNA LL's hair.

d. At approximately 11:35 AM, Surgeon MM entered an operating room wearing a skull cap. The skull cap consisted of a cap covering Surgeon MM's forehead and central part of Surgeon MM's hair. The skull cap did not cover the lower approximately two inches of Surgeon MM's hair on the side of Surgeon MM's head and the back of Surgeon MM's hair.

4. During an interview on 5/9/18 at approximately noon, the Director of Surgery acknowledged the AORN guidelines required the male surgical staff members to cover all of their hair, and the skull caps did not cover all of the male staff members' hair.

II. Based on observation, document review, and staff interviews, the CAH staff failed to ensure 2 of 2 observed staff members (Registered Nurse (RN) NN and RN OO) wore personal clothing items laundered in the hospital's laundry facility. Failure to launder personal clothing items in the hospital's laundry facility could potentially result in the clothing item becoming soiled with infectious material from a patient and if the staff launder the clothing item at home, potentially failing to remove or disinfect the infectious material on the clothing item, potentially transmitting the infectious material to another patient, who could develop a life threatening infection. The CAH staff performed approximately 375 surgical procedures per month.

Findings include:

1. During an interview on 5/9/18 at approximately 10:00 AM, the Director of Surgery revealed the CAH followed the AORN (Association of peri-Operative Registered Nurses) guidelines for surgical attire.

2. Observations during a surgical procedure on 5/9/18 revealed the following:

a. RN NN was in an operating room at approximately 9:38 AM. RN NN wore a cloth bouffant style hair covering.

b. RN OO was in an operating room at approximately 11:35 AM. RN OO wore a cloth bouffant style hair covering.

3. During an interview at 10:02 on 5/9/18, RN NN stated they owned the cloth bouffant style hair covering. RN OO wore the cloth bouffant style hair covering once, and then took the cloth bouffant style hair covering home to wash it after wearing it once. The CAH staff did not provide a method for RN OO to launder the cloth bouffant style hair covering in the hospital's laundry facility.

4. Review of the AORN Guideline Essentials Surgical Attire Quick View, copyright 2017, revealed in part, "If you wear personal clothing ... make sure it is covered completely by the scrub attire or has been laundered in a health care accredited facility." "Do not home launder your surgical attire."

5. During an interview on 5/9/18 at approximately noon, the Director of Surgery acknowledged the CAH allowed staff members to wear their own reusable cloth hair coverings. The staff members could only wear the reusable cloth hair covering once, and had to launder the reusable cloth hair covering in the staff members' personal laundry. The CAH did not provide access to a health care accredited laundry facility.



III. Based on observation and staff interview, the CAH staff failed to ensure 1 of 2 observed CRNA's (CRNA JJ) opened sterile packaging for needles in a way to ensure the sterility of the needle. Failure to open sterile packages appropriately could potentially result in contamination of the sterile fluid pathway, and potentially result in the patient developing a life threatening infection. The hospital's administrative staff identified an average of 375 surgical procedures per month.


Findings include:

1. Observations on 5/9/18 at 9:00 AM revealed CRNA JJ preparing medication to administer to a patient. CRNA JJ removed 4 needles and 4 syringes from his anesthesia medication storage cart. The packaging for the syringes and needles consisted of a plastic side and a paper side. CRNA JJ pushed against the plastic side of the packaging for the syringes and needles and pushed the syringes and needles through the paper side of the packaging.

2. During an interview on 5/9/18 at approximately noon, the Director of Surgery acknowledged the findings and acknowledged CRNA JJ could have contaminated the needles and syringes when pushing the needles and syringes through the paper packaging.


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IV. Based on document review, policy review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure health exams were regularly completed as part of their system to identify and prevent transmission of infections and communicable diseases. The problem was identified for 5 of 5 volunteers selected for review (Staff C, D, E, F and G).

Failure to identify infections and communicable diseases among volunteers could potentially result in the transmission of a communicable disease to patients.

Findings include:

1. Review of a CAH policy titled "Volunteers", revised 5/2017, revealed the CAH requires a health assessment, including, but not limited to, communicable disease history, TB screening and flu shot.

2. Review of the health information documents titled "Initial Volunteer Health Screening and TB evaluation" for Staff C, D, E, F and G, Volunteers, showed a section for self-identification of infectious disease history/immunizations and tuberculosis (TB) screening questions by the volunteer and documentation of TB test(s) given but failed to include an assessment by a qualified person to review their infectious/communicable disease status and perform a basic health exam to include a minimum of vital signs.

3. During an interview on 5/9/18, at 11:00 AM, Staff R, Human Resources Manager reported she thought the limited health assessment is all that is done for volunteers but would follow-up with the Occupation Health Coordinator and confirm this is the case.

4. During a follow-up on 5/10/18, at 7:55 AM, Staff O, Quality Coordinator reported she confirmed with the Occupational Health Coordinator the limited "Volunteer Health Assessment" is currently all that is completed.



V. Based on observations, policy review and staff interview, the facility failed to handle and serve food under sanitary conditions in order to reduce the risk of contamination and food-borne illness. The Critical Access Hospital (CAH) identified a census of 19 patients. The Certified Dietary Manager/Director of Support Services reported the department provides an average of 95 patient meals per day.

Failure to handle food in a sanitary manner could potentially result in the contamination of the patients' food and potentially cause food borne illness.

Findings include:

1. Observation on 5/7/18, from 11:30 AM to 12:27 PM, revealed Staff B, cook, assigned to prepare and serve hot food items at the noon meal. On 2 occasions, she handled a buttered hamburger bun with a bare hand and placed on the grill to warm for less than 1 minute. The surface of the bun she touched did not come in contact with the grill. Both buns were subsequently placed on a plate for service to patients. On one occasion, Staff B obtained a slice of cheese with a bare hand and placed on top of a cooked hamburger patty on the grill for a few seconds and placed the hamburger on a plate for service to a patient. On 3 occasions, Staff B used a bare hand to place the plate garnish (orange wedge/kale leaf) on plates for service to patients. The observation revealed Staff B did not wash her hands prior to any of the observations and touched a variety of surfaces, including but not limited to menu tickets, counter tops, refrigerator and freezer drawer handles, and uniform pants.

2. Observation on 5/8/18, from 11:15 AM to 12:00 PM, revealed Staff A, cook, assigned to prepare and serve hot food items at the noon. Staff A changed gloves 4 times during the observation, but failed to wash her hands prior to donning and removing the gloves on each occasion, and at one point, she wore the same pair of gloves for a period of 20 minutes and touched a variety of surfaces, including but not limited to, refrigerator and freezer drawer handles, menu tickets, a thawed raw steak package, garbage can lid, uniform pants, counter top, utensil drawer handle, cold table lid and microwave handle. During the observation, Staff A touched ready-to-eat food with the contaminated gloves, including 3 slices of bread, 4 slices of cheese, 1 hamburger bun, sliced deli meat and 5 plate garnishes (orange wedge/kale leaf) for service to patients.

3. During an interview on 5/9/18, at 12:30 PM, Staff S, Certified Dietary Manager/Director of Support Services, reported dietary staff are trained to minimize handling food and use a utensil when possible, otherwise, if touching food directly are to wear a glove. Staff S acknowledged all dietary staff receive training on food handling and glove use but confirmed his training failed to include washing hands prior to donning of glove for handling food and did not recall this being part of food safety education.

4. Review of a CAH policy titled "Hand Hygiene", reviewed 5/18/17, revealed in part "... When to wear gloves ... In the event of directly handling food ..."

5. Review of a CAH policy titled "Glove Usage", reviewed 5/18/17, revealed in part "... if you touch anything other than the food you are preparing, you must remove and discard those glove immediately ... you must wash your hands immediately after removing gloves ..."

6. The 2013 Food Code, published by the Food and Drug Administration, considered a standard of practice for the food service industry and adopted by the state to ensure the provision of safe food requires:

1. Food employees wash their hands immediately before engaging in food preparation, including before donning gloves for working with food in order to prevent cross contamination when changing tasks. Single-use gloves are to be used for only one task, such as working with ready-to-eat food, and used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

2. Food employees shall minimize bare hand contact with food and may not contact exposed, ready-to-eat food (a food subsequently subjected to a prescribed time and temperature pathogen kill step) with their bare hands and shall use suitable utensils or a single-use glove.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure the approved diet manual was readily available for medical, nursing and food service personnel as a reference when questions arose related to appropriate therapeutic diets, appropriate textures and appropriate food and/or fluids served to patients. The Certified Dietary Manager/Director of Support Services reported the food service department served approximately 95 patient meals daily.

Meeting individual patient nutritional needs may include the use of therapeutic diets. Therapeutic diets refer to a diet ordered as part of the patient's treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet. Failure to ensure the facility has a diet manual readily available to medical, nursing and food service personnel could potentially result in an inappropriate patient diet order or inappropriate food and/or fluids served to patients.

Findings include:

1. During an interview on 5/7/18, at 2:40 PM, Staff U, Education Dietitian identified the designated CAH diet manual as the on-line version of the "Nutrition Care Manual", but believed it was only available to the dietitians.

2. During an interview on 5/8/18, at 7:50 AM, Staff T, Clinical Dietitian confirmed the designated CAH diet manual as the "Nutrition Care Manual", which had been approved by the medical staff, is only available to herself and Staff U. She confirmed medical, nursing or food service personnel lacked access to the diet manual to use as a reference. She reported the food service staff have a hard copy of a different diet manual available to reference in the diet office, but unsure if this manual had been approved by the medical staff.

3. Review of a CAH policy titled "Nutrition Care Manual", reviewed 5/17/18, revealed in part "... The Nutrition Services Department will use the Web-based Manual of of Clinical Dietetics" as published by the Academy of Nutrition and Dietetics ... To provide a references of current diet and nutrition information for use in nutrition care, To serve as a method of communication among physicians, nurses and dietitians regarding the types and amounts of food served to patients ... The manual may be viewed on www.NutritionCareManual .org ..."

A current diet manual approved by the dietitian and the medical staff shall be used as the basis for diet orders and for planning therapeutic diets. The diet manual shall be reviewed, revised and updated at least every five years. Copies of the diet manual shall be readily available to all medical, nursing, and food service personnel.

Based on observation, policy review, document review and staff interviews, the Critical Access Hospital (CAH) failed to secure and protect patient information from unauthorized users in 1 of 1 Health Information Management Department and 1 of 1 basement record storage areas. The CAH administrative staff identified approximately 7,500 patient medical records are stored in the Medical Records Department and approximately 11,988 patient medical records are stored in the basement record storage area.

Failure to secure the patient information could potentially cause a misuse of patient information and a loss of identity for the individual patients.

Findings include:

I. A tour through the Health Information Management (HIM) department on 5/8/18, beginning at 10:30 AM, identified the following concerns:

1. The department had 3 doors and during an interview, Staff H, HIM Manager, reported employees use their badge to obtain entrance. She acknowledged she did not know for sure who all had badge access, but reported all HIM staff had badge access and Environmental Services Staff (EVS) had access, because they clean in the area. Staff H reported the department staffed hours ran from approximately 7:00 AM to 4:00 AM on week days.

2. During an interview as part of the tour, Staff L, Records Analyst/HIM reported patient medical information is stored in 2 large cabinets in her office area. She acknowledged she had keys to the cabinets but does not lock them.

3. During an interview as part of the tour, Staff M, Patient Information Scanner/HIM reported patient medical information is stored in an unlocked closet and open shelves in her office area.

4. During an interview on 5/8/18, at 12:05 PM, Staff V, Infection Preventionist reported she spoke with the Environmental Services Manager who reported all Environmental Services staff (EVS) have access to the HIM department through the main entrance, as they are assigned to clean the bathroom, breakroom and hallway of the department.

During an interview on 5/8/18, at 1:00 PM, Staff N, Janitorial Tech/Environmental Services, confirmed she has access to the HIM department and used to clean in the department but the responsibility has been moved to second shift. She reported the only area she cleaned included the bathroom, breakroom and hallway but acknowledged she had access to the entire department.

During an interview on 5/8/18, at 3:30 PM, Staff I, J and K, Janitorial Techs/Environmental Services, each confirmed they had access to the HIM department and reported they cleaned the department after all the staff had left for the day, usually about 5:30 to 6:00 PM. The techs all confirmed they only clean the restroom, breakroom and hallway but acknowledged they have access to the entire area.

During an interview on 5/10/18, at 9:10 AM, Staff H, confirmed the office doors within the HIM department are not locked when the staff leave at the end of their day and acknowledged if anyone came in after hours, they would have access to unsecured patient records.

II. Observation on 5/10/18, 8:50 AM, accompanied by Staff H and Staff O, Quality Coordinator revealed the basement HIM storage area is accessed by an employee badge and was a large open room with multiple open shelves holding old patient medical records, along with records from human records, hospice, long-term care, finance, cardiac rehab, etc. During an interview at the time, Staff H and O reported they were not sure who had access the area besides HIM staff except Staff O reported the volunteers had access to the area, because they had supplies stored there.

During an interview on 5/10/18, at 9:10 AM, Staff H confirmed that patient records should not be accessible to all employees and employees in departments such as volunteers, EVS, Material Management and the Print Shop should not have access to personal health information.

Review of a CAH policy titled "Security File," reviewed 1/2012, showed the purpose of the policy included the need to prevent and/or limit access and identified all patient medical records are restricted access and should be safeguarded from tampering, loss and inadvertent destruction.

Review of a CAH policy titled "Access to Facility Computing Systems and Electronic Medical Records", reviewed 5/2018, revealed in part " ... access to facility computing systems shall be strictly controlled and given to an individual only on a job function need-to-know basis ... " The CAH failed to ensure a similar policy to address access to paper patient records to limit access to those employees who needed the information to perform their job functions.

Review of CAH badge access reports for the HIM department and basement HIM storage area revealed 90 employees from departments such as Material Management, Environmental Services, Print Shop, Finance, Nutrition Services, Public Relations, Volunteer Services, Information Systems, Central Sterile, Human Resources, Bio Tech Contractors and Siemens Contractors had 24/7 access to the areas.

Based on document review, policy review and staff interviews, the Critical Access Hospital (CAH) failed to ensure 8 of 8 active, 1 of 1 visiting/consulting physicians and 2 of 2 teleradiology physicians selected for review, received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital from an appropriate entity. (Practitioners A, B, C, D, E, F, G, H, I, K and L). The CAH identified 44 active, 37 visiting/consulting physicians and 72 teleradiology physicians.

Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff reported the volume of services provided by the selected physicians for the month of April were identified as follows:

Practitioner A - 625 patients
Practitioner B - 400 patients
Practitioner C - 306 patients
Practitioner D - 946 patients
Practitioner E - 11 patients
Practitioner F - 101 patients
Practitioner G - 340 patients
Practitioner H - 370 patients
Practitioner I - 9 patients
Practitioner K - 12 patients
Practitioner L - 6 patients

Findings include:

1. Review of the CAH's network agreement revealed it did not contain an arrangement for the completion of outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital.

2. Review of a CAH policy titled "Medical Staff Professional Practice Evaluation," reviewed and revised April 2018, revealed the process for "Ongoing Professional Practice Evaluation" (OPPE) and defines the criteria for events that trigger OPPE, for the purpose of the identification of professional practice trends that may impact quality of care and patient safety and requires at least one chart annually. The policy revealed in part " ... External review may be considered for OPPE if: lack of expertise among medical staff to review a specific specialty, cases where a conflict of interest among practitioners prevent unbiased peer review ... " The policy also revealed the process for "Focused Professional Practice Evaluation" (FPPE) and defines the monitoring methods and criteria that trigger FPPE, for the purpose of evaluation of a practitioner's professional performance and /or competence in an effort to provide safe, high-quality care. The policy revealed in part " ... External review may be considered if: after internal review has been completed and it is felt additional review is necessary or if internal peer review would not be fair and objective, or lack of expertise among the medical staff regarding the care or procedure in question, or cases where a conflict of interest among practitioners prevent unbiased peer review ... " The policy failed to identify the need for an outside entity peer review to evaluate the appropriateness or diagnosis and treatment for all physicians and a regular basis.

During an interview on 5/9/18, at 1:10 PM, Staff Q, Medical Staff Coordinator, acknowledged their network hospital does not perform the CAH's outside entity peer review. She reported they have used their network hospital in the past but entered into a contract with CIMRO Quality Healthcare Solutions in 2010, due to a lawsuit claiming a conflict of interest with the use of their network hospital. Staff Q reported they do not seek out external peer review for all of their physicians since they do a lot of internal peer review. She reported they only seek external peer review if they lack a CAH physician staff with the expertise in a specialty area or if a conflict of interest may prevent an unbiased opinion.

Review of the external peer review results Staff Q provided from July 2016 through August 2017 revealed only 3 of the selected physicians received an external peer review on at least 1 of their patients.

Based on review of documents, the medical record, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the activity coordinator developed and implemented an activity program in the multidisciplinary care plan for 2 of 2 open swing bed patients (Patient #1 and #2 ) and 2 of 4 closed swing bed patients (Patient #3 and #5). Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient could potentially impede the patient's progression for attaining or maintaining the highest practicable level of well being. The Medical Surgical/ Intensive Care Unit (ICU) RN Director identified a census of 2 swing bed patients at the time of the survey and approximately 171 swing bed patients a year.

Findings include:

1. Review of the policy "SWING BED ACTIVITIES," revised 5-2-15, revealed in part, "The facility will provide for an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well being of each patient. Patients will be helped so they can participate in social and diversional activities..."

2. Review of the policy "RESIDENT ASSESSMENT and CARE PLAN SWING-BED PROGRAM," revised 3-2017, revealed in part, "Purpose: To provide ongoing assessment and care planning so that appropriate care and services are provided for each swing-bed resident." "Care plans will be ... updated daily Monday - Friday..."

3. Review of the job description for the "Activities Assistant," revised March 2018, revealed in part, " JOB DUTIES: ... Encourage patients to participate in activities. Assists patients to and from activities. Documents appropriately on patient participation records and other appropriate documents. Reviews residents' participation as needed in case of significant change."

4. Review of open medical records revealed:

a. A physician's order for swing bed services for Patient # 1 on 5/5/18. Staff W, designated activity assistant, completed the activity assessment on 5/5/2018. Patient #1's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

b. A physician's order for swing bed services for Patient #2 on 5/3/2018 . Staff W completed the activity assessment on 5/4/2018. Patient # 2's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

5. Review of closed medical records revealed:

a. A physician's order for swing bed services for Patient #3 on 3/8/2018. Staff W completed the activity assessment on 3/9/2018. Patient # 3's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

b. A physician's order for swing bed services for Patient #5 on 4/9/2018. Staff W completed the activity assessment on 4/9/2018. Patient #5's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

6. During an interview on 5/8/2018 at 3:00 PM Staff W acknowledged she was responsible for completing an activity assessment within 5 working days of swing bed patient admission. Staff W said in addition to activity calendars there were a variety of activities available for patients at their hospital. Staff W acknowledged she failed to develop an activity care plan and said she was not aware that this was her responsibility. Staff W said she met with nursing staff following her assessment and verbally shared the patient's activity preferences. Staff W said it was nursing and other staff that provided the activities that were chosen by the patient. Staff W acknowledged that she did no followup documentation after the initial activity assessment.

7. During an interview on 5/8/2018 at 2:50 PM the Medical Surgical/ICU Nurse Manager said Staff W was responsible for completing an activity assessment and she knew Staff W offered swing bed patient's a variety of activities and gave each patient an activity calendar. The Medical Surgical Nurse Manager acknowledged she was not aware an activity care plan was required and verbalized there was no documentation of activities that were provided or that the patient participated in. The Medical Surgical Nurse Manager said any staff can do activities and that activities are offered daily by the nursing staff.

8. During an interview on 5/10/2018 at 7:55 AM the Medical Surgical Nurse Manager acknowledged the open and closed records identified lacked an activity care plan and progress notes as part of the patient's interdisciplinary care plan to be reviewed by the interdisciplinary team at care plan conferences.

9. During an interview on 5/10/2018 at 9:15 AM, the Chief Nursing Officer (CNO) said they did not have a policy for swing bed activity care plans. The CNO acknowledged she was new to the CNO role and was not aware of the CAH Activity regulatory requirements.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients. The CAH staff identified a current census of 19 at the start of the survey.

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of CAH policy titled "Visitor Policy," reviewed 11-2017, revealed in part, "Visitation rights include the right to receive the visitors designated by the patient, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend...."

2. Observations where registration of outpatients occurred included the following:

a. During tour of the Pella Family Practice Clinic on 5/8/18 at 2:30 PM with Staff Y, Clinic Director, revealed a sign labeled "Your Patient Rights" posted at the entrance of the clinic. The sign contained information informing the patients of their rights as a patient at the CAH. The posted Patient Rights sign failed to include patient visitation rights.

b. During an interview on 5/10/18 at 10:25 AM, Staff AA, Clinic Receptionist, stated at the time of patient registration, the clinic receptionist would give the patient the "Notice of Privacy Practice" if the patient would ask for it. Staff AA confirmed the clinic receptionist would not give patients information on their patient visitation rights at the time of their registration.

c. During an observation on 5/10/18 at 10:25 AM, Staff AA registered Patient #7 for a clinic visit. During the registration process, Staff AA failed to provide Patient #7 with their visitation rights.

d. During tour of the Knoxville Clinic on 5/9/18 at 9:00 AM with Staff BB, Clinic Manager, revealed a sign labeled "Your Patient Rights" posted at the entrance of the clinic. The sign contained information informing the patients of their rights as a patient at the CAH. The posted Patient Rights sign failed to include patient visitation rights.

e. During an interview on 5/9/18 at 9:00 AM, Staff BB verified the sign labeled "Your Patient Rights" posted at the entrance of the clinic failed to include patient visitation rights.

f. During tour of the Knoxville Physical Therapy/Occupational Therapy/Speech Therapy Clinic on 5/9/18 at 9:15 AM with Staff DD, Therapy Manager, revealed the lack of patient visitation rights available to therapy patients.

g. During an interview on 5/9/18 at 10:25 AM, Staff CC, Therapy Admitting Clerk, acknowledged the therapy admitting clerk would not give therapy patients information on their patient visitation rights at the time of their registration.

h. During tour of the Pella Physical Therapy/Occupational Therapy/Speech Therapy Clinic on 5/9/18 at 1:25 PM with Staff DD, revealed a sign labeled "Your Patient Rights" posted at the entrance of the clinic. The sign contained information informing the patients of their rights as a patient at the CAH. The posted Patient Rights sign failed to include patient visitation rights.

i. During an interview on 5/9/18 at 1:25 AM, Staff DD verified the sign labeled "Your Patient Rights" posted at the entrance of the clinic failed to include patient visitation rights.

j. During tour of the Emergency Department registration area on 5/9/18 at 4:40 PM and interview with Staff FF, Patient Access, revealed a Patient Rights brochure available at the registration desk. Staff FF stated Patient Access staff registered outpatients, inpatients, and observation patients after 4:30 PM. Staff FF stated at the time of patient registration, the Patient Access staff would give inpatients, observation patients, and emergency patients the Patient Rights brochure but would not give other outpatients the Patient Rights brochure.

k. During an observation on 5/9/18 at 4:40 PM, Staff FF registered Patient #8 as an outpatient Laboratory patient. During the registration process, Staff FF failed to provide Patient #8 with their visitation rights.

l. During an interview on 5/9/18 at 4:40 PM, Staff EE, Chief Nursing Officer (CNO), verified the Patient Rights brochure failed to include patient visitation rights.

3. During an interview on 5/10/18 at 10:10 AM, Staff GG, Office Coordinator, stated at the time of outpatient registration, the office coordinator would give the patient HIPAA [Health Insurance Portability and Accountability Act] information. Staff GG confirmed the office coordinator would not give patients information on their patient visitation rights at the time of their registration.

During an interview on 5/10/18 at 10:45 AM, Staff HH, Patient Registrar, stated at the time of inpatient and outpatient registration, the Patient Registrar would give the patient the Patient Rights brochure. Staff HH confirmed the Patient Registrar would not give patients information on their patient visitation rights at the time of their registration.

During an interview on 5/9/15 at 3:15 PM, Staff II, Director of Medical/Surgical/Intensive Care Unit stated at the time of admission, the admitting nurse would go over the "Patient Rights and Responsibilities" as displayed on the television set during the admission process. Staff II verified the Patient Rights and Responsibilities information displayed on the television set failed to include patient visitation rights as stated in the CAH's "Visitor Policy" and what is required in the regulations.