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Based on observations, maintenance staff interview and record review, the facility failed to maintain minimum Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code) (C231).

2. On 9/11/12 at 8:15 a.m., the laboratory was toured with staff member C. The following supplies were noted to be outdated and readily available for use on patients:
-Ermine UA liquid control 2 x 5 ml expired 5/2012;
-Ermine UA diptube level 1 expired 5/2012;
-Coulter Act 5 diff. calibrator expired on 9/5/12;
-Glucose drink 100 gram 18 bottles expired on 5/2012;
-Chemistry Calibrator expired 9/1/12;
-Calibration Verification Control two boxes expired 9/2011;
-20 Evacuated container 500 ml expired 8/1/12;
-QuikLyte multi-symptom kit expired 8/8/12;
-Mucolex expired 1/2011;
-Diluents in a vial covered with Saran Wrap, without a date;
-Optimum glucose strips expired 2/28/12;
-Protocol Hema 3 solution, Fixative, and solution II expired on 10/2010;
-#3 sodium citrate for protime expired on 2/2012; and
-staff food items were stored with laboratory supplies in the small refrigerator.

At this time, the staff member C was interviewed regarding the schedule for checking for outdated supplies. Staff member C stated that she checks when she can but supplies are expensive. She stated she knew some of the supplies were expired but was still using the items.

At this time, the surveyor asked for policies and procedures for the laboratory. By the end of the survey, no policies or procedures were received.

3. On 9/10/12 at 9:30 a.m., the surveyor toured the kitchen with staff member G. The surveyor noted that the freezer door had a large accumulation of ice on the outside and a large accumulation of ice on the floor entering the freezer. Staff member C stated that the administration and maintenance were aware of this problem. (photos taken)

4. On 9/11/12 at 8:30 a.m., a facility staff member was interviewed regarding the maintenance and cleaning of the two auto-claves used by the hospital. The staff member stated that she cleans the steam auto-clave about every three months but does not keep a log of the cleaning schedule.

At this time, the manufacturer's manual was reviewed and documented that the auto-clave was to be cleaned monthly.

On 9/11/12 at 11:00 a.m., the DON was asked about the cleaning schedule for the dental auto-clave. The DON stated that there was not a cleaning record of the auto-clave and that she was not sure when or how often the machine was to be cleaned. At this time the manufacturer's manual was reviewed and documented that the auto-clave was to be cleaned daily, weekly and monthly.

The hospital did not provide documentation that the auto-claves were cleaned as per manufacturer's instructions.














23085


Based on observation and staff interviews, the hospital failed to properly store and discard expired supplies. The facility failed to maintain an appropriate schedule for cleaning the two autoclaves. The freezer in the kitchen had large accumulation of ice on the outside of the door and the entrance to the freezer. Findings include.

1. On 9/11/12 at 8:45 a.m., during the review of the medication room the surveyor observed the following expired supplies:
-6 light green top vacutainers with a manufacturer's expiration date of 8/2012;
-7 green top vacutainers with a manufacturer's expiration date of 6/2012;
-2 red top serum vacutainers with a manufacturer's expiration date of 8/2011;
-1 intravenous catheter 24 gauge with a manufacturer's expiration date of 6/2010;
-1 BBL culture swab plus with a manufacturer's expiration date of 7/2012;
-3 packages of Iodine swabsticks with a manufacturer's expiration date of 7/2012;
-2 packages of skin prep with a manufacturer's expiration date of 11/2011;
-1 package of skin prep with a manufacturer's expiration date of 4/2011;
-1 BD 22 gauge needle with a manufacturer's expiration date of 8/2010;
-2 packages of alcohol prep pads with a manufacturer's expiration date of 11/2011;
-3 packages of alcohol prep pads with a manufacturer's expiration date of 1/2012; and
-42 packages of alcohol prep pads with a manufacturer's expiration date of 3/2011.

Staff member I stated the night shift reviews the medication room once a month for expired supplies.

Based on observation, staff interviews, and record review done during September 10, 2012, the facility failed to meet the Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code. The facility emergency generator failed to pass a load bank test as required. The failure was deemed an Immediate Jeopardy which was abated on September 12, 2012 at 12:40 p.m. with the installation of a temporary portable generator. See the attached CMS form 2567 for specific Life Safety Code deficiencies and details.

Based on record review, policy review, and staff interviews, the facility governing body failed to assume responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. The facility governing body failed to ensure that providers employed at the facility were granted membership to the medical staff and privileges according to facility bylaws, rules, and regulations. Findings include:

1. On 9/10/12 at 2:30 p.m., the surveyor reviewed the governing board minutes for 2011 to the present. The minutes lacked documentation of the governing board responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. There was no documentation of the governing board annually reviewing the facility's policies, the review of the annual quality assurance program, and review of the pharmacy services.

2. The facility Medical Staff Bylaws, with the adoption date of 9/27/07 and the governing board approval date of 11/5/07, state that the qualifications for membership in the medical staff include:

Article 4 Medical Staff Appointment:
Section 4.1 reads "Except as otherwise specified herein, no person shall exercise clinical privileges in the Medical Center unless and until that person applies for and receives appointment to the medical staff or is granted temporary privileges as set forth in these bylaws."
Section 4.4 Duration of Appointment and Reappointment reads, "Except as otherwise provided in these bylaws, initial appointments to the Medical Staff shall be for the period of one year. Reappointments shall be for a period of up to two Medical Staff years.

3. During the review of the provider credential files, beginning 9/12/12 at 1:30 p.m., the surveyor noted that physicians L, M, and P had privileges last granted by the medical staff board and the governing board on 9/22/09. According to the Medical staff bylaws, Article 4 Medical Staff Appointment, Section 4.4 Duration of Appointment and Reappointment, "Reappointments shall be for a period of up to two Medical Staff years."

4. The surveyor noted during the review of the provider credential files, physicians M and O never were credentialed or privileged by the medical staff board or the governing board. According to Article 4 Medical staff Appointment, Section 4.1, " Except as otherwise specified herein, no person shall exercise clinical privileges in the Medical Center unless and until that person applies for and receives appointment to the medical staff or is granted temporary privileges as set forth in these bylaws."

5. On 9/12/12 at 2:30 p.m., staff member A and B, the ADON and CEO, stated they could not find documentation the above physicians were credentialed or granted privileges by the medical staff board or the governing board.

Based on staff interviews, the MD or DO failed to periodically review the policies governing the services provided in conjunction with the mid-levels. Findings include:

On 9/10/12 at 4:00 p.m., based on interviews with the CEO and the DON, the policies were not updated or reviewed by the MD or DO as part of the medical oversight function.

Based on staff interviews, the MD or DO failed to periodically review the patients' records, medical orders, and medical care services to the patients. Findings include:

On 9/10/12 at 4:00 p.m., based on interviews with the CEO and the DON, the patients' records have not been reviewed by the MD or DO.

Based on staff interview, the hospital failed to have mid-levels participate with a medical doctor in periodic reviews of the health records. Findings include:

On 9/12/12 at 11:30 a.m., staff member H, a nurse practitioner, was asked if he participated in the review of patients' medical records. He stated no.

Based on staff interview the hospital failed to have a group of professionals which developed and reviewed policies for the hospital. Findings include:

On 9/11/12 at 3:30 p.m., the CEO stated that there was not a group of professionals which included at a minimum one medical doctor, one mid-level, and one non-staff member to provide advice or guidance regarding the development of polices for the hospital.

23085


Based on observation, contract review, and staff and contracted staff interviews, the facility failed to ensure the pharmacy contract included all regulatory duties. The facility failed to ensure outdated medications were not available for patient use for 4 (#s 32, 22, 23, and 39) of 42 sampled patients. Findings include:

Pharmacy Contracted Services:

Upon review of the pharmacy contract, the contract did not include the following services:
-Review and revision of policies and procedures;
-Contribute with the periodic evaluation and quality assurance review program;
-Perform periodic reviews of patient records with a written status report about the review; and
-Notification of patient adverse drug reactions.

1. On 9/11/12 at 12:00 p.m., staff member A, the DON, stated that the pharmacist that has a contract for the hospital does not come into the hospital. "I have never seen him here." Staff member A stated that the pharmacist does not review medications, storage of medications, or patient charts. The pharmacist only provides medications to the hospital thru the pharmacy in town.

2. On 9/11/12 at 2:00 p.m., the surveyors reviewed the contract for the pharmacist. In general, the contract pharmacist will provide the facility with medications for the patients, and stock medications. The contract did not state the pharmacist would provide the above mentioned services for the facility.

3. On 9/11/12 at 1:55 p.m., the contracted pharmacist stated the facility staff fax the orders to the pharmacy. The pharmacist puts the order in the computer. The computer and pharmacist review the new order for allergies, medication to medication reaction, medication to food reaction, duplicates, right amount, route, and method of administration, and appropriate use of the medication.

The contracted pharmacist stated he would answer policy and procedure questions from the DON and ADON via e-mail.

The contracted pharmacist stated he was not notified of a patient's adverse drug reaction. The pharmacist stated he was not part of the periodic evaluation and quality assurance review program.

The contract pharmacist stated when they first started their services, the facility providers did not want the pharmacy to review patient records. The facility providers asked the contract pharmacy to start reviewing the patient records around October of 2011. The contract pharmacist stated he reviewed all the in-patient records in October of 2011 and April of 2012. The contracted pharmacist stated the report was turned into the previous DON.

4. The facility's pharmacy policies identify a contracted pharmacy that no longer used by the facility.

5. On 9/11/12 at 3:45 p.m., the surveyors asked for the contracted pharmacist report for 10/2011 and 4/2012. By the end of the survey on 9/12/12 at 4:00 p.m., the surveyors had not received the contracted pharmacist report for 10/2011 and 4/2012.

6. On 9/11/12 at 3:45 p.m., staff member B, the CEO, stated the contracted pharmacy does not provide the above mentioned services for the facility.

7. On 9/12/12 at 11:30 a.m., staff member D, the DON, stated he does not report any adverse drug reactions to the contracted pharmacist.


Expired Supplies:
1. On 9/11/12 at 8:45 a.m., during review of the medication room refrigerator, the surveyor observed the following multi-dose vials of mediations:
-1 Novolin R multi-dose vial with an open date of 6/1/12;
-1 Novolin R multi-dose vial with an open date of 6/20/12; and
-1 tuberculin, Purified Protein Derivative multi-dose vial with no open date. The multi-dose vials should have been disposed 28 days after the open date. The multi-dose vials were given to staff member I.

2. At 9:00 a.m., the surveyor observed the following outdated medications for 4 (#s 32, 33, 34, and 39) of 42 sampled patients:
-1 bottle of Ear drops for resident #32, with the manufacturer's expiration date of 12/2011;
-1 bottle of Ear drops for resident #33, with the manufacturer's expiration date of 1/2012;
-1 bottle of Nyamyc - Nystatin topical powder for resident #39, with the manufacturer's expiration date of 2/2012; and
-1 tube of Proctosol - HC 2.5% for resident #34, with the manufacturer's expiration date of 12/2011.

The above medications were given to staff member I. Staff member I stated the night shift reviews the medication room once a month for expired medications.

3. On 9/11/12 at 1:57 p.m., the contracted pharmacist stated he reviews the medication room once a year for expired medications.

23085


Based on record review, and staff and contracted staff interviews, the facility failed to report adverse drug reactions to the contracted pharmacist. Findings include:

1. During review of the incident report binder, the surveyors noted forms labeled Medication Error Reports. The forms lacked documentation of the facility notifying the contracted pharmacist of medications errors.

The following are examples of Medication Error Reports found in the incident report binder:

On 2/14/11, the staff reported on the Medication Error Report, patient #38's Ritalin 5 mg count was not accurate. The Ritalin count was 14 when the book showed 15. The ADON and provider were notified. The form lacked documentation of the pharmacist being notified.

On 4/8/12, the staff reported on the Medication Error Report, patient #34 received a dose of Percocet 5/325 mg at 10:00 a.m. and then another dose at 12:00 p.m. The order was for Percocet 5/325 mg by mouth every 6 hours. The form lacked documentation of the pharmacist being notified.

On 6/14/12, the staff reported on the Medication Error Report, patient #38 received an extra dose of Ritalin. The night shift nurse pre-poured all the patient's night medications. During the medication pass, there was a change in nurses. Patient #38 received 2 doses of Ritalin at bedtime. The facility notified the provider and the DON. The form lacked documentation of the pharmacist being notified.

2. On 9/11/12 at 1:55 p.m., the contracted pharmacist stated he was not notified of patients' adverse drug reaction.

3. On 9/12/12 at 11:30 a.m., staff member D, the DON, stated he does not report any adverse drug reactions to the contracted pharmacist.

Based on observation and staff interview, the hospital failed to maintain sanitary conditions in the kitchen. Findings include:

On 9/10/12 at 9:30 a.m., the kitchen was toured with the dietary manager staff member G. Staff member G did not have a hair net on during the entire tour of the kitchen. Staff member G stated she was helping to prepare food for lunch. During the tour, the surveyor observed an unidentified kitchen staff member preparing food items. This staff member did not wear a hair net.

The surveyor at 9:45 a.m., asked the DM if hair nets were required in the kitchen and she stated yes but just forgot.

Based on staff interview, the hospital failed to have a group of professionals which reviewed the hospital policies annually. Findings include:


On 9/11/12 at 3:30 p.m., the CEO stated that there was not a group of professionals which annually reviewed the policies of the hospital. The CEO stated there was no documentation he could provide to prove the policies were reviewed annually.

Based on staff interview, it was determined that the CAH failed to assure that protective aprons used in radiology were checked for safety. The findings included:

On 9/12/12 at 1:00 p.m., staff member E, the radiology department manager, stated she had not checked the protective aprons for safety, since they were purchased in 2008.

On 9/12/12 at 1:30 p.m., the surveyor asked for the policy on checking protective aprons for the safety of the patients.

The surveyors did not receive the policy by the end of the survey.

23085


Based on staff interview and review of the list of contracts for services, the facility failed to provide the nature and scope of services for each listed contract. Findings include:

During the entrance conference with staff member B, CEO, on 9/10/12 at 9:45 a.m., the survey team provided staff member B with a list of requested documents and information that included the scope and severity of services. During this time, staff member B stated the facility did not have a ready list of contracted services.

During the survey, the facility gave to the surveyors a list of 5 contracted services. Each contracted service had a listing of additional contracts. No documentation of the scope of services was provided to the surveyors.

Based on record reviews and staff interview, the hospital failed to maintain records that were complete and systematically organized for 6 (#s 1, 2, 8, 11, 19, and 26) of 42 records reviewed. Findings include:

1. On 9/10/12 at 2:30 p.m., the following medical records were reviewed and lacked the following information:

Patient #8 was admitted to the facility on 8/8/12 and discharged on 8/9/12. The medical record was not organized and the following documentation could not be located:
-patient rights;
-advance directives;
-discharge planning; and
-discharge summary.

Patient #11 was admitted to the hospital on 8/23/12 and discharged on 8/28/12. The medical record was not organized and the following documentation could not be located:
-social service assessment;
-activity assessment;
-patient rights; and
-advance directives.

Patient #19 was admitted to the facility on 10/28/09 and discharged on 4/27/11. The medical record was not organized and the following documentation could not be located:
-activity assessment;
-patient rights;
-advance directives; and
-discharge planning.

Patient #26 was admitted to the facility on 5/20/10 and discharged on 9/17/11. The medical record was not organized and the following documentation could not be located:
-nursing assessment;
-social service assessment;
-patient rights; and
-discharge planning.

Patient #1 was admitted to the facility on 3/28/12. The medical record was not organized and the following documentation could not be located:
-monthly drug review;
-activates assessment; and
-care conference.

Patient #2 was admitted to the facility on 2/17/12. The medical record was not organized and the following documentation could not be located:
-social service assessment;
-activities assessment; and
-patient rights notice.

2. On 9/10/12 at 3:30 p.m., the DON stated that the medical records are not organized well and there was a change over in staff. The DON stated that a lot of the needed information could not be located.


23085

Based on staff interviews, the hospital failed to ensure a staff member was responsible for maintaining records and ensure that the records are accurate, accessible and systematically organized. Findings include:

During an interview on 9/11/12 at 8:15 a.m., staff member K, the medical records manager, stated to the surveyor that she was new to the job. Staff member K stated she was not aware that all the medical records needed to be accurate with signatures, times, and dates. She stated that she was aware that the current charts were not organized well.

The surveyor asked staff member K if she tracked any records that were 30 days and 60 days past due for completion of all required documents. Staff member K said "I did not know I needed to do that."

The surveyor asked staff member K if she reviews any medical records for accuracy. staff member K said no.

On 9/12/12 at 3:30 p.m., during the exit conference, the CEO stated that the medical records department was lacking for a long time.

Based on record reviews and staff interview, the hospital failed to have complete medical records with dated and timed signatures for all entries by health care professionals for 4 (#s 1, 19, 26, and 32) of 42 sampled records. Findings include:

1. On 9/10/12 at 2:30 p.m., the review of the following records showed the omission of dated and/or timed signatures:

Resident #19's record lacked a dated or timed signature for:
-physician progress notes;
-nutritional assessment; and
-nursing assessment.

Resident #26's record lacked a dated or timed signature for:
-history and physical;
-diet order;
-nursing assessments; and
-pain management assessment.

Resident #1's record lacked a timed signature for hospice physician orders dated 6/22/12.

Resident #32's record laced a timed midlevel progress note dated 6/20/12.

2. On 9/10/12 at 3:30 p.m., staff member A, the DON, stated that all entries should be dated, timed and signed.


23085

Based on document review and staff interview, the facility failed to meet the condition of participation for the completion or arrange for the completion of the Periodic Evaluation and Quality Assurance Review. Findings include:

1. During the review of the provided documentation beginning on 9/12/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included;
-The periodic evaluation itself (C-0331),
-Evaluation of the utilization of the Critical Access Hospital services (C-0332),
-A representative sample of open and closed clinical records (C-0333),
-The Critical Access Hospital's policies and procedures (C-0334),
-Evaluation to determine whether the utilization of services was appropriate, established policies and procedures were followed, and if changes were needed (C-0335),
-Evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. (C-0336)
-All patient care services and other services affecting patient health and safety are evaluated (C-0337),
-The quality and appropriateness of the diagnosis and treatment furnished by a physician at the hospital are evaluated by a hospital in the network, a Quality Improvement Organization, or other qualified entity (C-0340),
-The findings of the evaluations were considered and corrective actions taken, if necessary (C-0341)
-The facility takes the appropriate remedial action to address deficiencies found through the quality assurance program (C-0342),
-The facility documents the outcome of all remedial action (C-0343).

2. During an interview with staff member B, the CEO, on 9/10/12 at 2:30 p.m., staff member B stated the last program evaluation he could find was dated 2008.

Based on document review and staff interview, the facility failed to complete or arrange for the completion of a periodic evaluation of it's total program. Findings include:

During the review of the facility provided documentation beginning 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review of the total program. The documentation was requested on arrival at the facility. No documentation was provided.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the last program evaluation he could find was dated 2008.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the utilization of CAH services, including at least the number of patients served and the volume of services. Findings include:

During the review of the facility provided documentation beginning on 9/12/12, the surveyor failed to locate or receive documentation of the completed required periodic evaluation and Quality Assurance Review of the utilization of CAH services, including at least the number of patients served and the volume of services.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the last program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included a representative sample of both open and closed clinical records. Findings include:

During the review of the facility provided documentation beginning on 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included a representative sample of both open and closed clinical records.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the review of the hospital's health care policies. Findings include:

During the review of the facility provided documentation beginning on 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the review of the hospital's health care policies.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

On 9/12/12 at 11:30 a.m., staff member H, a FNP, stated he had not been involved in reviewing or updating policies for the hospital.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the utilization of services was appropriate, the established policies were followed, and if changes were needed. Findings include:

During the review of the facility provided documentation beginning on 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that determined whether the utilization of services was appropriate, the established policies were followed, and if any changes were needed.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to create and maintain an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. Findings include:

During the entrance conference with staff member B, the CEO, on 9/10/12 at 9:45 a.m., the survey team provided staff member B with a list of requested documents and information that included a copy of the facility QA plan that included the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

The survey team received a copy of the current QA plan on 9/11/12 at approximately 10:00 a.m. There was no documentation of;
- Ongoing monitoring and data collection;
- Problem prevention, identification and data analysis;
- Identification of corrective actions;
- Implementation of corrective actions;
- Evaluation of corrective actions; and
- Measures to improve quality on a continuous basis.

There were no QA committee meeting minutes to review or reports from the facility departments.

According to an interview with staff member C, the laboratory director, she stated she was not part of the QA.

Staff member E, the radiology department manager, was interviewed on 9/10/12 at 1:30 p.m. She stated she was part of QA. Staff member E stated she reviewed the number of X-Ray retakes.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation of all patient care services and other services affecting patient health and safety are evaluated. Findings include:

During the review of the facility provided documentation beginning on 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review which included the appropriate utilization of services, the established policies were followed, and if any changes were needed.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the critical access hospital (CAH) are evaluated by a member of a hospital network, a QIO, or an appropriate and qualified entity identified by the State rural health care plan. Findings include:

During the review of the facility provided documentation beginning on 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by a member of a hospital network, a QIO, or an appropriate and qualified entity identified by the State rural health care plan.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the requirement that CAH staff considered the findings of the evaluations, including any findings or recommendations of the QIO, and took corrective action if necessary. Findings include:

During the review of the facility provided documentation beginning on 9/10/12, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the requirement for the hospital staff to consider the findings of the evaluations, including any findings or recommendations of the QIO, and take corrective action if necessary.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to take appropriate remedial action to address deficiencies found through the quality assurance program. Findings include:

During the entrance conference with staff member B, CEO, on 9/10/12 at 9:45 a.m., the survey team provided staff member A with a list of requested documents and information that included a copy of the facility QA plan showing the CAH took appropriate remedial action to address deficiencies found through the QA program.

The survey team received a copy of the current QA plan on 9/11/12 at approximately 10:00 a.m. There was no documentation that all patient care services and other services affecting patient health and safety were evaluated.

There were no QA committee meeting minutes to review or reports from the facility departments covering the evaluation of all patient care services and other services affecting patient health and safety. There was no documentation that remedial actions were taken to address deficiencies identified in the quality assurance program. There was no documentation indicating the individual responsible for implementing remedial actions to correct deficiencies identified by the quality assurance program.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.

Based on document review and staff interview, the facility failed to document the outcomes identified by the QA plan. Findings include:

During the entrance conference with staff member B, CEO, on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information, including the outcome of all remedial action by the QA plan.

The survey team received a copy of the current QA plan on 9/11/12 at approximately 10:00 a.m. There was no documentation that all patient care services and other services affecting patient health and safety were evaluated.

There were no QA committee meeting minutes to review, or reports from the facility departments covering the evaluation of all patient care services and other services affecting patient health and safety. There was no documentation of the outcomes of any remedial action.

During an interview with staff member B, CEO, on 9/10/12 at 2:30 p.m., staff member B stated the program evaluation he could find was 2008.