HospitalInspections.org

Based on observation, interview, and document review, the provider failed to maintain the following:
*Two of two, one liter bottles of eyewash buffered solution in the laundry room had expired June 2013.
*Six of six ceiling tiles in the small clean storage closet for one of one therapy area were stained, damaged, and/or bulged from leaks.
*One of one handwashing sink in the emergency room (ER) had caulking that had receded from the wall.
Findings include:

1. Random observations on 3/22/16 from 9:30 a.m. to 4:00 p.m. revealed:
a. Two bottles of buffered eyewash solution by the handwashing sink in the laundry room had expired June 2013. Interview with the laundry supervisor at the time of the observation confirmed that finding. She revealed she was not aware the solution had expired.

Review of a registered nurse/licensed practical nurse (RN/LPN) training conducted 9/2/15 revealed: "2. Eye washing stations and education was done with ____. Hands on demonstration done. We currently have eye washing stations in the Lab (laboratory), ER, NH (nursing home), Dietary, and utility room behind the ER." There was no information to show the training had included expiration dates. Nor did the training include the laundry location for an eyewash station.

b. Six lay-in ceiling tiles in the clean supply storage closet for the therapy area been damaged from what appeared to be water leaks. They were stained, damaged, bulged, and broken. Interview with the occupational therapist confirmed that finding. He stated he had put in a work order months ago to have them changed, but it had not been done.

c. The handwashing sink in the ER had caulking that had separated from the sink and wall. That dried and separated caulking left a gap approximately 1/8 to 1/4 inch around the sink basin.

d. Interview on 3/23/16 at 4:00 p.m. with the interim director of nursing confirmed she was unaware of:
*The expiration dates of the buffered solution or the eye wash station in the laundry.
*The damaged ceiling tiles in therapy.
*The dried and separated caulking around the ER handsink.

A policy on the upkeep of the facility had been requested but was not provided. There was a preventative maintenance log that had been started by the maintenance supervisor. But it did not include a review of floors, walls, and ceilings.

Based on interview and swing bed services review, the provider failed to have specific policies and procedures for patients who required swing bed services. Findings include:

1. Review of the provider's swing bed services program revealed no specific policies and procedures for activities, social services, and care conferences. There was no specific organized policy and procedure manual for patients who required swing bed services.

Interview on 3/23/16 at 1:45 p.m. with registered nurse C confirmed there were no specific policies and procedures related to activities, social services, or care conferences for patients who required swing bed services. Nursing policies and procedures applied to both inpatients and swing bed patients.

Based on observation, interview, and policy review, the provider failed to ensure medications had been properly secured in 4 of 15 medication blister packs. Findings include:

1. Observation and interview on 3/22/16 at 9:10 a.m. with registered nurse (RN) A regarding the medication room revealed:
*There was a metal box secured to the wall and required a key to open it.
*Inside of the metal box there had been fifteen medication blister packs containing hydrocodone and Tramadol, both used for pain relief (narcotic controlled medications).
*Of those fifteen narcotic controlled medications:
-Two hydrocodone blister packs contained a total of forty-eight pills. Two of those pills had slits through the packaging and had been re-taped on the back of the blister pack.
-Two Tramadol blister packs contained a total of fifty-nine pills. Twelve of those pills had slits through the packaging and had been re-taped on the back of the blister pack.
*RN A:
-Had been aware the staff were re-taping the blister packs to secure the medications inside of the packages if they had been slit open.
-Could not guarantee the medications in those blister packs with the re-taping had not been diverted (stolen) and replaced with other pills.
-Agreed that had not been a good practice and those pills should have been destroyed.

Interview on 3/22/16 at 2:30 p.m. with the pharmacist revealed she was not aware the staff had been re-taping pills inside of the above observed blister packs. She agreed that was not a good practice, and those medications should have been destroyed.

Interview on 3/23/16 at 11:20 a.m. with the interim director of nursing revealed she had:
*Been aware the staff were re-taping the blister packs to secure medications inside of the packages if they had been slit open.
*Agreed that was not a good practice.
*She could not guarantee the medications in those blister packs had not been diverted and replaced with another type of pill.

Review of the provider's August 2011 Medication Security policy revealed:
*Objective: "To insure that medications and biological's be secured in accordance with State requirements."
*No procedure for the staff to follow to ensure proper security of controlled medications inside of a blister pack.

A. Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained:
*For one of four randomly observed medication administrations for one patient (15) by one of one registered nurse (RN) (A).
*During blood sugar testing for one of one sampled patient (19) by one of one RN (A).
*During intravenous (IV) medication administration for one of one randomly observed patient (31) by one of one RN (B).
*For patient personal care items in two of two randomly observed shared patients' bathrooms (rooms 4 and 8).
Findings include:

1a. Observation on 3/22/16 at 9:00 a.m. with RN A during medication administration revealed:
*She had administered medications to patient 15.
*After she had administered those medications she had washed her hands.
*With those clean hands she had turned the water faucet off.

b. Observation on 3/22/16 at 11:00 a.m. with RN A during blood sugar testing for patient 19 revealed:
*She had checked patient 19's blood sugar.
*After completion of that task she had washed her hands.
*With those clean hands she had turned the water faucet off.

c. Observation on 3/22/16 at 2:00 p.m. with RN B during IV medication administration for patient 31 revealed:
*She had prepared and started an antibiotic for medication administration through patient 31's IV.
*After completion of that task she had washed her hands.
*With those clean hands she had turned the water faucet off.

d. Interview on 3/22/16 at 4:00 p.m. with RNs A and B revealed:
*They were not aware they had not used a barrier such as a paper towel when turning the water faucet off.
*They agreed that:
-Was not a good practice, and they should have used a paper towel or another form of a barrier to turn the water off.
-Process had created the potential for cross-contamination of bacteria to the patients.

Interview on 3/23/16 at 11:25 a.m. with the interim director of nursing (DON) confirmed the above processes had not been completed in a sanitary manner. She agreed those processes had created the potential for cross-contamination of bacteria to the patients.

Review of the provider's June 2010 Hand Hygiene policy revealed "When washing hands use a new disposable towel to turn off the faucet."

2a. Observation on 3/22/16 at 10:30 a.m. of room 4 revealed:
*The room had been shared by two patients.
*There had been one bathroom with a sink.
*On the left side of the sink was:
-A container to hold dentures.
-Two sharp edged razors.
-A can of shaving cream.
-Two containers of first aide ointment.
*On the right side of the sink was:
-One tube of perineal (area between the thighs) cleansing cream.
-One tube of lotion.
*The patients' personal care items were not marked.
*There was no identification indicating which items on the sink belonged to which patient in the shared room.

b. Observation on 3/22/16 at 10:45 a.m. of room 8 revealed:
*The room had been shared by two patients.
*There had been one bathroom with a sink.
*On the left and right sides of the sink were:
-Multiple bottles of lotion.
-An opened container with several cotton Q-tips inside of it.
-Two toothbrushes with the bristles resting directly on the countertop.
-A comb.
-A bottle of mouth wash.
-Two bottles of facial cleanser.
-A tube of petroleum jelly.
*The patients' personal care items were not marked.
*There was no identification indicating which items on the sink belonged to which patient in the shared room.

c. Interview on 3/22/16 at 4:10 p.m. with RNs A and RN revealed:
*Patients' personal care items should have been labeled with their names or bed number.
*Their expectations were to be able to identify which supplies belonged to an individual patient.

Interview on 3/23/16 at 11:15 a.m. with the interim DON/infection control nurse confirmed the above interview with RNs A and B.

Review of the provider's September 2014 Personal Care Products policy revealed "Every resident/patient will have their personal care products labeled with their initials and bed number for easy identification."



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B. Based on observation, interview, policy review, and record review, the provider failed to ensure:
*One of one patient whirlpool tub and/or chair were:
-Cleaned and disinfected according to their policy and procedure.
-Smooth and easily cleanable surfaces.
*All clean linens and all patients' clothing were handled in a manner to prevent soiling or spread of infection.
*Unapproved enzymatic cleaners and expired products were not used on all sterilized instruments from the emergency room (ER).
Findings include:

1. Observation and interview on 3/22/16 at 10:00 a.m. revealed housekeepers E and F would clean and disinfect the patient shower and whirlpool tub and chair throughout the day. "At the very least we always disinfect them at the end of the day." Housekeepers E and F confirmed they would:
-Fill an old patient water pitcher with Master Care whirlpool disinfectant "up to about one inch."
-Would "Then add water to about one inch down from the top of the pitcher."
-"Take the Johnny mop [toilet wand] and wash down all sides of the chair and whirlpool."
-"Leave it set ten minutes or more."
-"Fill the tub and run the jets until it is really foamy."
-"Drain and rinse until clear."

Housekeeper E stated "If the patient was on special precautions, I add extra disinfectant just to be sure."

During the above interview, Housekeeper F confirmed the whirlpool tub chair was pitted all over the surface. She stated she had told the director of nursing for the hospital about the cracked shower chair but not the whirlpool chair.

Review of the provider's undated housekeeping cleaning routines revealed "8. Shower and Tub: Clean after each use with disinfectant solution."

Observation and interview on that same day at 4:20 p.m. with certified nurse assistant (CNA) G confirmed the same process as housekeepers E and F had stated. She stated she had been taught by another bath aide how to disinfect the bathing room.

Observation and interview on 3/23/16 at 10:50 a.m. with CNAs H and I regarding the disinfection of the whirlpool tub and chair revealed:
*"Wet all surfaces of the tub and shower."
*"Use the pre-mixed solution in the wand and disinfect all surfaces and let it stand for ten minutes while we scrub all the surfaces with the scrubbing brush for the whirlpool."
*"Fill the tub and let the jets run for at least ten minutes, drain, and rinse clear."
*"We have both been taught by former CNAs or nurses how to clean and disinfect the tub."

Continued interview with CNAs H and I confirmed they were aware the tub chair was pitted but had not told anyone about the chair.

Review of the provider's May 2009 Cleaning Tub/Shower and Bathing Equipment policy revealed:
"3. Clean the tub/shower and bathing apparatus, water hose and scrub brush by using the appropriate cleanser.
4. All contact time per disinfectant cleaner label.
5. Rinse entire tub/shower, bathing apparatus and tub/shower chair thoroughly with clean water and allow to air dry."

Review of the provider's July 2011 Tub Cleaning - Integrity policy revealed:
"6. Rinse the chair and insides of the tub down with clean hot water from the shower wand before disinfecting.
7. Grasp the disinfectant wand and hold it so the nozzle is pointed inside the tub.
8. Apply disinfectant to all surfaces of the tub, chair and pads.
9. Scrub all areas with the long handled brush provided with the tub.
10. After all areas are thoroughly scrubbed, turn off the disinfectant valve.
11. After standard contact time per label direction on the disinfectant container, use the shower wand to rinse all areas."

Review of the provider's July 2014 Whirlpool Tub policy revealed it had a competency for cleaning the facility tub. The instructions were the same for the July 2011 policy.

Review of the provider's undated Proper Cleaning Procedures instructions posted on the cabinet in the tub room revealed:
*The instructions followed the July 2011 policy.
*The instructions also listed "7. Apply disinfectant (2 oz. Per gallon) to all surfaces of the tub..."

2. Observation on 3/23/16 at 1:25 p.m. of the clean supply/clean utility room revealed:
*A sink used for ER instrument decontamination.
*An Autoclave sterilizer.
*Numerous storage racks of E sized oxygen (O2) cylinders.
*An uncovered clean linen storage rack.
*A towel laid on top of the counter. On that towel intermingled were:
-A single sock.
-A pair of underwear.
-Cleaned instruments.
-Clean and folded patient clothes

Continued observation at the above time of the hallway revealed CNAs H and I held clean patients' clothing and linens next to their uniforms. They delivered those clean items uncovered and unprotected throughout the hallway to the patients' rooms.

Interview on 3/23/16 at 4:00 p.m. with the interim DON revealed she was not aware of the clean linen storage situation. Continued interview with the interim charge nurse confirmed she was aware of the clean supply/clean utility room with the autoclave, O2 storage, and uncovered clean linen.

Review of the provider's June 2013 Infection Control policy for the laundry department revealed no guidelines for delivering clean patients' clothing and linens from room-to-room.

3. Observation and interview on 3/23/16 at 2:00 p.m. with health unit coordinator (HUC) J revealed she:
*Was in charge of sterilization of the ER instruments.
*Used Speed-Clean as the cleaner for the third decontamination of ER instruments.
*Stated "It is used for cleaning the autoclave so it should be okay for the instruments."
*An opened Steris Hinge-Free one gallon container was stored beneath the sink. It had "Opened 10/27/14" written on the side.
*Confirmed they had not gone through a lot of sterilization supplies anymore since they used a lot of disposables.

Consultation on 3/24/16 at 11:10 a.m. with the Speed-Clean product manager revealed the product was not designed to clean surgical or ER reprocessed instruments. She could not confirm if the product would leave a residue on the instruments, as it was not designed for that purpose.

Consultation on that same day at 11:25 a.m. with the Steris Healthcare representative revealed the Hinge-Free lubricant did not have an expiration date if it was kept sealed. Once opened it was good for twelve weeks.

A. Based on observation and interview, the provider failed to maintain the following items or areas in the kitchen:
-One of one handwashing sink was dirty and there were no supplies for handwashing in the dishwashing room.
-Three of six serving carts had melted tops or were broken.
-One of one incandescent light bulb was not shielded in the mop room/clean linen room.
-One of one wall behind and surrounding the garbage can in the dishwashing room was scratched, gouged, and chipped.
-One of one corner wall between the dishwashing room and the kitchen was scratched, gouged, and chipped down to bare metal.
Findings include:

1. Observation and interview on 3/22/16 from 8:00 a.m. to 8:45 a.m. with the certified dietary manager (CDM) revealed:
*The handwashing sink in the dishwashing room was blocked from use with serving carts of dirty dishes and a room tray cart.
*The basin of the handwashing sink was dirty and held two old rags and a green scrubber.
*There was no soap or paper towels.
*Three plastic rolling serving carts had melted or broken tops. The CDM confirmed those carts were no longer cleanable.
*The mop room had clean linens stored on the shelves. The bulb in the room was not shielded from breakage. The CDM was unaware the bulb must be shielded.
*The painted gypsum board wall behind the garbage can in the dishwasher room had gouges, scrapes, and holes and was uncleanable.
*The painted gypsum board corner wall between the dishwasher room and the kitchen was battered and damaged. The metal corner bracket beneath the gypsum board was visible.
*The CDM stated it was hard to get minor things done by the maintenance department.

Interview with kitchen employee D confirmed the above findings and stated the room became crowded after meals. He also confirmed he did not use that sink to wash his hands.

Continued interview at the above time with the CDM revealed another employee would try to unload the clean dishes, but there were times when the dishwasher worked the clean and dirty side. She could not confirm where they washed their hands between tasks.

No policy could be provided on the above identified concerns.

B. Based on observation, interview, testing, and document review, the provider failed to ensure one of one dishwasher met the sanitizing requirements for all dishes, cups, glassware, and silverware used by all patients. Findings include:

1. Observation on 3/22/16 from 8:00 a.m. to 8:45 a.m. in the dish room revealed:
*The final rinse temperature of the dishwasher was 148 degrees Fahrenheit (F). After four more trays were washed the final rinse temperature was 152 F.
*Testing of the chemical sanitizer after four additional trays revealed it read 0 ppm (parts per million), 10 ppm, 50 ppm, and 10 ppm.
*Interview with kitchen employee D at the time of the testing revealed he did not have any test strips for the dishwasher. He would write down the temperature indicated on the gauge outside the dishwasher, but did not know how to test the final rinse on the plate surface itself.
*The assistant dietary manager (DM) said they could use the test strips for the three compartment sink. The assistant DM was not aware it was a different chemical sanitizer for the dishwasher.
*The CDM then found temperature test strips from the dishwasher contractor company. Review of the temperature test strip after the final rinse revealed the sensor pad had not changed color to indicate the surface of the dish received at least 160 degrees F of hot water for sanitization.

Review of the dish machine temperature log for March 2016 revealed only three times the dishwasher gauge temperature reached 160 degrees F or higher.

Continued interview with the CDM and kitchen employee D revealed neither of them knew if the commercial dishwasher was set-up for hot water sanitizing or chemical sanitizing.

Review of the provider's June 2013 Dish Machine Temps policy revealed:
*"It is the policy of the Dietary Department to monitor all dishwashing temperatures to ensure that dishes are being properly cleaned and sanitized and that dish machine is working efficiently."
*"Minimum temperature is 120 degrees."
*"Sanitizer must be 50-100 ppm."

Review of the provider's May 2013 Dishwashing policy revealed:
*"Check dish machine temperature and record if needed."
*"Run through machine."
*"Use test strip on clean dishes while still wet if needed."

Review of the policy book for the dietary department revealed the following:
*"After reviewing all policies annually, please sign and date."
*The current CDM had not signed that she had reviewed the policies.
*The prior CDM had reviewed the policies on 12/2/13.




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C. Based on record review, interview, and policy review, the provider failed to ensure a nutritional screening process was in place to determine a patient's nutritional risk at the time of admission for fifteen of fifteen patients (3, 4, 5, 6, 7, 9, 10, 11, 12, 14, 16, 17, 18, 19, and 20). Findings include:

1. Review of patients 3, 4, 5, 6, 7, 9, 10, 11, 12, 14, 16, 17, 18, 19, and 20's medical records revealed no documentation to support nutritional screens had been completed at the time of their admission.



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2. Interview on 3/23/16 at 1:10 p.m. with the CDM revealed:
*When new patients were admitted the dietary department would be notified of their diet orders.
*She visited with a new patient within the first week to assess food likes and dislikes.
*Sometimes she used an initial nutritional history/assessment data collection form to record food likes and dislikes.
*The registered dietitian (RD) visited the facility once a month.
*The RD was supposed to visit with each new patient.
*She was not sure how the RD documented her visits with patients.
*She attended weekly and monthly team care meetings for swing bed patients.
*She agreed new patients should have been screened on admission to determine their nutrition at risk status.

Interview by telephone on 3/23/16 at 2:00 p.m. with the RD revealed:
*Since the provider went to computerized medical records she had not completed nutritional assessments with the hospital patients.
*She had requested help to use the new system, but that had not happened.
*She visited the facility once a month.

Interview on 3/23/16 at 1:50 p.m. with registered nurse C confirmed patients should have been screened on admission to determine if they were at nutritional risk.

Review of the provider's April 2013 Nutritional At Risk Residents policy revealed:
*The dietary department would monitor and identify any patients at risk for nutritional problems.
*The CDM would:
-Observe residents during meals and note any changes in appetite and ability to feed oneself.
-Report any changes to the charge nurse and to the weekly team care meetings.
-Notify the RD with any changes.
*The RD would:
-Evaluate the changes and provide nutrition advice to the CDM.
-Document the changing nutritional needs on her next scheduled visit.

Based on document review, interview, and policy review, the provider failed to ensure all contracted services including NightHawk (twenty-four hour radiologist service), the registered dietitian/licensed nutritionist (RD/LN), and the registered pharmacist (RPh) were reviewed at least annually by the quality assurance (QA) committee. Findings include:

1. Review of the QA committee notes from the last quarter of 2014 and all four quarters of 2015 revealed no documentation or review of the contracted services including NightHawk, the RD/LN, and the RPh.

2. Interview on 3/22/16 at 10:55 a.m. with the certified dietary manger revealed she had not reviewed the quality or effectiveness of the RD/LN services. She did not have a current copy of the RD/LN's license.

3. Interview on that same day at 1:45 p.m. with the interim director of nursing revealed she:
*Was also the QA coordinator.
*Stated neither she nor the QA committee reviewed the contracted services for the QA program.
*Relied on administration or each individual department manager to review their own contracted services and create and compile their own QA improvement process.
*Confirmed she did not have any reviews or reports from any department managers or administration in regards to their reviews or audits of contracted services.
*Was unaware if they had a full list of all contracted services for the hospital as requested by this surveyor.

4. Interview on that same day at 2:00 p.m. with the director of radiology revealed she had not reviewed the services provided by NightHawk.

Based on record review, interview, and policy review, the provider failed to:
*Transcribe a history and physical (H/P) for 2 of 12 sampled acute care patients (5 and 7) in a timely manner.
*Authenticate (validate) a H/P for 12 of 12 sampled acute care patients (2, 3, 5, 6, 7, 10, 13, 16, 17, 18, 19, and 20).
*Initiate discharge planning (D/C) for 11 of 12 sampled acute care patients (1, 2, 3, 4, 5, 6, 7, 9, 10, 11, and 15).
*Complete monthly progress notes for three of six swing bed patients (14, 17, and 18).
Findings include:

1. Review of patient 5's medical record revealed an admission date of 10/19/15. The H/P had not been completed by the physician until fifteen days after her admission on 11/2/15.

Review of patient 7's medical record revealed an admission date of 9/16/15. The H/P had not been completed by the physician until ten days after his admission on 9/16/15.

2. Review of patient 2's medical record revealed an admission date of 2/28/16. The H/P had been completed on 2/28/16. There was no signature by the physician to authenticate that H/P as of 3/23/16.

Review of patient 3's medical record revealed an admission date of 12/26/15. The H/P had been completed on 12/29/15. There was no signature by the physician to authenticate that H/P as of 3/23/16.

Review of patient 5's medical record revealed an admission date of 10/19/15. The H/P had been completed on 11/2/15. There was no signature by the physician to authenticate that H/P as of 3/23/16.

Review of patient 6's medical record revealed an admission date of 10/28/15. The H/P had been completed on 10/28/15. There was no signature by the physician to authenticate that H/P as of 3/23/16.

Review of patient 7's medical record revealed an admission date of 9/16/15. The H/P had been completed on 9/16/15. There was no signature by the physician to authenticate that H/P as of 3/23/16.

Review of patient 10's medical record revealed an admission date of 7/16/15. The H/P had been completed on 7/16/15. There was no signature by the physician to authenticate that H/P as of 3/23/16.

3. Review of patients 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, and 15's medical records revealed:
*No documentation to support D/C planning had:
-Been initiated upon admission.
-Occurred during their stay in the facility.
-Occurred until the day of discharge from the facility.

Interview on 3/23/16 at 10:00 a.m. with RN C revealed:
*She had been aware the patients' H/Ps had not been completed and authenticated in a timely manner.
*The H/Ps should have been completed and authenticated within forty-eight hours of the patient's admission to the facility.
*The quality assurance (QA) team had been aware of that issue for some time.
*The physicians attended the QA meetings and had been informed that the H/Ps were not getting authenticated and completed in a timely manner.
*She confirmed:
-There was no D/C planning for patients upon their admission to the facility.
-D/C planning was not reviewed with the patients until the day of their discharge from the facility.

Interview on 3/23/16 at 11:45 a.m. with the interim director of nursing confirmed the above interview with RN C.



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4. Review of H/P reports revealed:
*Patient 13's H/P had been dictated on 4/14/15 and signed by the physician on 9/9/15.
*Patient 16's H/P had been dictated on 2/1/16 and had not been signed by the physician as of 3/23/16.
*Patient 17's H/P had been dictated on 6/17/15 and signed by the physician on 9/9/15.
*Patient 18's H/P had been dictated on 10/22/15 and had not been signed by the physician as of 3/23/16.
*Patient 19's H/P had been dictated on 2/9/16 and had not been signed by the physician as of 3/23/16.
*Patient 20's H/P had been dictated on 1/12/16 and had not been signed by the physician as of 3/23/16.

5. Review of physicians' progress notes revealed:
*Patient 14 had a progress note dated 8/26/15. The next progress note had been dated 11/4/15.
*Patient 17 had a progress note dated 8/26/15. The next progress note had been dated 11/4/15.
*Patient 18 had a progress note dated 12/30/15. The next progress note had been dated 3/2/16.

Review of the provider's January 2016 Intermediate Swing Bed Admission policy revealed swing bed patients would be seen by the physician at least once every thirty days.

6. Review of patient 12's medical record revealed:
*He had been discharged on 7/13/15.
*A physician's progress note for a 7/8/15 visit had been dictated on 3/8/16.
*His discharge summary had been dictated on 3/8/16.

7. Review of the provider's 2011 Medical Staff By-Laws revealed a patient's medical record should have been completed at time of discharge including progress notes, final diagnosis, and dictated discharge summary.

Review of the provider's 4/1/15 Electronic Documentation, Orders, and Authentication policy revealed:
*"The author of health information reports, orders, or documents will review and authenticate his or her own reports or entries in a timely manner."
*"The legal business record is finalized within 30 days following service and is archived in the Meditech system in the eChart."

Based on patients' record review and interview, the provider failed to ensure a yearly program was in place to review all of the patients served and the services they provided. Findings include:

1. Interview on 3/23/16 at 9:30 a.m. with the administrative assistant revealed:
*There had been no formal committee in place to review the provider's services on an annual basis.
*They would have reviewed all of their services provided every three years.
*The last review of their services they provided for their patients had been in 2012.
*There was no annual review to ensure the:
-Services they provided had been delivered in a timely manner.
-Length of stay and medical necessity had been appropriate for any of the patients admitted.

The provider had no policy or procedure in place for the staff to follow to ensure a utilization review had occurred annually.