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Based on observation and interview, the Critical Access Hospital (CAH) staff failed to appropriately store and dispose of biological's. This deficient practice can lead to a hospital-wide infectious disease outbreak which can affect staff and patients. The findings are:

A. On 01/31/18 at 1:15 pm during observation a biohazard container (something that is used by hospitals and clinics to dispose of hazardous materials) was found in the Lab area of the CAH without a lid. Inside the biohazard container 4 vials of blood were found. There was no lid to the container which was placed near a sharps container.

B. On 01/31/18 1:15 pm during observation, the Lab Director was asked if it was appropriate for the biohazard container to be unopened with the blood vials. The Lab Director stated; "no, they should be placed in a biohazard bag for disposal and should not be kept in the front area of the lab without a lid." The Lab Technician who was present was asked to properly dispose of the vials by the Lab Director.

C. Record review of CAH Policy titled "Handling of Infectious and Regulated Medical Waste" dated 01/20/2017 Heading "Central Delivery System" #2 Medical Waste Clinical Unit Storage of Infectious Waste #2.4 indicates "The bags must be placed inside rigid biohazard containers and the lid must be closed."

Based on record review and interview, the Critical Access Hospital (CAH) failed to ensure that the responsibilities of the Doctor of Medicine or Osteopathy (MD / DO) were met. This deficient practice has the potential to affect patient care due to the MD / DO not completing his/her duties as the Medical Director of the CAH. The findings are:

A. On 01/31/18 at 2:20 pm record review reveals document title "EMERGENCY SERVICES AGREEMENT" dated 12/29/16, page 3 (c) states, "Group shall cause the Medical Director to maintain and submit to Hospital no later than the tenth (10th) calendar day of each month time reports in a form substantially similar to Exhibit 1.2(c) SAMPLE TIME AND ACTIVITY LOG".
Exhibit 1.2(c) contains the following information for the Medical Director to report:
1. Oversee operation of Emergency Department (E.D.)
2. Advise and Assist Hospital in review, development or revision of policies and procedures, protocols and guidelines for E.D.
3. Advise and assist Hospital in review, development or participate in utilization review activities.
4. Advise and assist Hospital in review, development or participate in risk management activities.
5. Advise and assist Hospital in review, development or participate in quality improvement activities or related to hospital initiatives.
6. Attend Hospital Medical Staff or Medical Staff Committee meeting or meeting with Hospital administration.
7. Advise and assist Hospital in review, development or participate in continuing education activities or community education programs.
8. Advise and assist Hospital in development or review forms and documents for use within the E.D.
9. Advise and assist Hospital in development, review, evaluate or participate in development of annual E.D. objectives and budgets.
10. Conference regarding E.D. equipment, scheduling or other operational matters.
11. Conference with Hospital regarding program policies and compliance.
12. Complaint management activities.

B. On 01/31/18 at 3:15 pm during an interview, the Administrator of the CAH stated that although the Medical Director reports to the Governing Board monthly, he does not provide any information similar to Exhibit 1.2(c). as described in the Emergency Services Agreement.

Based on observation, record review and interview, the Critical Access Hospital staff failed to safeguard patient record. 7 (P #22 through #28) out of 28 (P #1 through P#28) patients reviewed. This deficient practice has the potential for unauthorized people, such as other patients to view and use/share Protected Health Information (PHI). The findings are:

A. On 01/30/18 at 9:30 am, during observation in the Physical Therapy clinic, a stack of patient information was found in one of the physical therapy treatment rooms. A total of 7 patients P#22 through P#28 were identified in a stack of therapy documents. The door was unlocked and the patient's documents were unsecured and available to anyone who entered the room.

B. On 01/30/18 at 9:30 am during an interview, the Physical Therapy Clinic Director (PTCD)confirmed that these documents should not have been left in the physical therapy treatment room and should have been placed in a secure area.

C. Record review of the hospital's policy titled, "HIPPA (Health Insurance Portability and Accountability Act), Administrative, Technical and Physical Safeguards for [hospital name]" indicated "...v. File folders and papers containing PHI [Protected Hospital Information] should not be left where the contents are readily visible to unauthorized Workforce and should be put away when not in Use."

Based on interview, and record review, the facility failed to gather basic operational data for the Quality Assurance program from the following departments: dietary, housekeeping, laundry services, pharmacy, and infection control. By not conducting basic surveillance and data collection of these basic process areas, the facility could not assure the effectiveness of the day to day function of these areas. The findings are:

A. On 01/30/18 at 9:15 am during a interview with the facility's kitchen cook, when asked if he knew the temperature of the hot water in the sinks in the food preparation area. He replied, "No."

B. On 01/30/18 at 9: 20 am during interview, the Infection Control Nurse was asked if she knew what the temperature of the hot water in the sinks in the food preparation area were and and if she tracked that data. She stated, "I have not tracked that data. I did speak with him [the facility's cook] about the processes in the kitchen. I visit here once a month." She was asked if she monitored the temperature of the rinse water in the laundry. She stated, "I have not."

C. On 01/30/18 at 1:30 pm during interview, the facility Pharmacist was asked how often he spoke to patients and staff regarding medication and other related education. He stated, "I have been part time and I have not had time to talk to patients and staff." He was asked what he reported to Quality. He stated, "I am not sure what goes to Quality." He was asked if he had met with the quality person to discuss Pharmacy issues. He stated, "I am new and have not had that conversation yet."

D. On 01/30/18 at 2:15 pm during interview, the staff member in charge of the laundry was asked if he knew the temperature of the rinse cycle in the washing machines. He stated, "I know we need the rinse temperature between 160 and 180 degrees Fahrenheit [as recommended by the manufacturer and infection control standards]. But we do not test that." He was asked if the contractor for the maintenance of the washing machine checked the temperature of the water during monthly maintenance. He checked the maintenance records and no data for measuring the temperature was found.

E. On 01/30/18 at 1:10 pm during interview, Housekeeper (Staff #15 ) was asked if she knew what personal protective equipment she should wear while working with the agents she used. She answered, "Gloves?" She was asked how would she find out to be sure. "I am not sure."
She was asked if she had the Material Safety Data Sheet (MSDS) data sheet from the manufacturer for each agent. She went to the closet and produced the data sheet for the agent she was using. She was wearing only gloves. She was asked if she ever interacted with the Infection Control Nurse. She stated, "No. I have not."

F. On 01/30/18 at 3:15 pm during interview the hospital quality manager was asked to produce documents of surveillance in the kitchen, laundry and housekeeping. She was unable to provide that data.

G. Record review of the MSDS data sheet supplied by the manufacturer for the disinfectant she was using required: a face shield or eye protection, gloves and a gown to cover exposed skin on the arms.

H. The facility manager in charge of housekeeping and laundry was not available for interview during the survey due to illness.

I. Record review of the hospital's policy titled, "Utilization Management Plan" dated 07/31/17 indicated the following:
"Purpose: The purpose of the Utilization/Care Coordination Plan includes:....To assure the continuity of care. Address over/under utilization and scheduling of care..."

J. Record review of the hospital's quality indicated no data for water temperatures or regular testing for temperatures.



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Based on record review and interview, the facility failed to plan for the discharge of 3 (P#5, P#6, and #14) of 21 (P#1 - 21) Patients. Without discharge planning patients are not likely to continue their recovery.
The findings are:

A. Record review of the electronic medical record for Patient #6 indicated he was admitted on 01/28/18 and was discharged to home on 01/30/18. No notes from the Nurse Discharge Planner were found for the 3 days of the stay. No plans were found for post discharge care.

B. Record review of the electronic medical record for Patient #5 indicated she was admitted 01/27/18 and discharged on 1/31/18. One note was found by the discharge planner during the 4 day stay. No plans were found for post discharge care.

C. Record review of the medical record for Patient #14 indicated the patient was admitted on the 01/05/18 and transferred on 01/08/18 to inpatient Skilled Nursing Care. No discharge planning notes were found for this stay. No plans were found for post discharge care.

D. On 01/30/18 at 3:00 pm during interview, the Director of Patient Care was asked to describe the discharge planning process. She stated, "Planning begins on admission to the hospital. Planning notes should describe the changes in patient status throughout the hospital stay. It should include plans for post discharge care if needed." She confirmed that P #5 , 6 and 14 did not have any planning notes during their stay or discharge care notes?

E. Record review of the hospital's policy titled, "Utilization Management Plan" dated 07/31/17 indicated the following:
"Purpose: The purpose of the Utilization /Care Coordination Plan includes:....To assure the continuity of care. Address over/under utilization and scheduling of care..."