Bringing transparency to federal inspections
Tag No.: C0331
Based on review of available information and interview with the administrator revealed that the hospital had not carried out or arranged for an evaluation of the hospital program.
Findings were:
Review of the hospital Quality Improvement program and interview with the hospital administrator revealed that there had been new staff members and the committee had not completed the annual review for the facility; and the lack of an annual review for the calendar year 2010 was confirmed by the administrator.