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Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the evaluation of contracted services for 1 of 1 year (2019) reviewed. Failure to evaluate contracted services limited the CAH's ability to ensure the contracted services provided appropriate and quality patient care.

Findings include:

Review of the policy "Performance Improvement Plan" occurred on 02/11/20. This policy, revised 11/2016, stated, ". . . D. Structure/Design/
Deployment of Plan: . . . Roles/Responsibilities: The Performance Improvement Manager in collaboration with the management team under the supervision of the Administrator, Board of Directors, President/CEO [Chief Executive Officer] and the Medical Staff leadership have the overall responsibility to ensure quality patient care and safety and to continuously improve organizational performance that impacts patient care and safety. This leadership group administers a collaborative, organization wide, performance improvement process that systematically monitors and analyzes the level of performance of the processes of care and those services that support patient care and safety. . . ."

Review of the CAH's performance improvement committee meeting minutes occurred on 02/11/20. The 2019 quarterly minutes failed to include evidence of evaluation of the CAH's contracted services. Upon request on 02/11/20, the CAH failed to provide evidence of evaluation of contracted services.

During interview on 02/12/20 at 8:20 a.m., an administrative staff member (#1) confirmed the CAH had failed to evaluate contracted services.

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel review the CAH's health care policies for 1 of 1 year (2019) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH's ability to ensure the policies were current and followed regulations and standards of practice.

Findings include:

Review of the policy "Policies & Procedures: Development, Revision, & Deletion" occurred on 02/12/20. This policy, dated 04/2019, stated, ". . . Procedure: 1. All patient care policies are to be reviewed by the Policy Review Committee yearly
. . . 4. The Policy Review Committee will consist of at minimum . . . b. Advanced practice provider
. . ." The policy failed to define the advanced practice provider as a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Review of the CAH's policies occurred on all days of the survey. The policies lacked evidence of review in 2019 by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Review of the Policy Review Committee meeting minutes occurred on 02/11/20. The 2019 minutes lacked evidence of attendance by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Upon request on 02/12/20, the CAH failed to provide evidence a physician assistant/nurse practitioner/clinical nurse specialist reviewed the CAH's policies.

During interview on 02/12/20 at 7:45 a.m., an administrative staff member (#1) confirmed the CAH failed to have a physician assistant/nurse practitioner/clinical nurse specialist review the CAH's policies.