HospitalInspections.org

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 Network hospital (Network Hospital D) staff assisted the CAH staff with the implementation of the CAH's Quality Assurance (QA) Plan. Failure to ensure the Network hospital staff participate in implementation of the CAH's QA plan could potentially result in the misdiagnosis of a patient and/or providing inappropriate or substandard patient care. The CAH's administrative staff reported a census of 5 patients upon entrance of the survey.

Findings include:

1. Review of the CAH "Iowa Critical Access Hospital Program Network Agreement", dated 5/1/03, revealed in part, "...Members of CAH's medical staff, mid-level practitioners, nursing staff, and administration participate in implementing the QA plan. The parties agree that [Network Hospital D's name], through participating members of its medical staff or other personnel designated by [Network Hospital D's Name], shall meet with CAH's QA representatives no less than on a semi-annual basis to provide objective oversight and assistance to CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy and to assist CAH to implement its QA Plan, to review findings under CAH's QA Plan, and to propose improvement plans and/or recommend corrective action."

2. Review of the documents "Quality and Planning Board Committee" meeting minutes for 9/16/20 to 6/16/21 revealed the meeting minutes lacked evidence that Network Hospital D staff participated in the CAH's QA meetings.

2. During an interview on 7/22/21 at 9:30 AM, the Chief Executive Officer (CEO) confirmed the CAH Quality meeting minutes lacked documentation that staff from Network Hospital D assisted the CAH staff with the implementation of the CAH's QA plan.

Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 Teleradiologist (Teleradiologist D) selected for review, received outside entity peer review by the Network Hospital to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review, prior to reappointment, affects the CAH's ability to assure physicians provide quality care to the CAH patients. The CAH administrative staff identified 28 Teleradiologists credentialed to provide Teleradiology Services through Teleradiology Entity A. The Director of Ancillary Services identified Teleradiology Entity A interpreted 786 images from 7/1/2020 to 6/30/2021.

Findings include:

1. Review of the CAH's network agreement, effective 5/1/03, revealed in part " ... The parties agree that [Network Hospital D], through participating members of its medical staff or other personnel designated by [Network Hospital D], shall meet with CAH's [Quality Assurance] representatives no less than on a semi-annual basis to provide objective oversight and assistance to CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy ...".

2. Review of a CAH agreement titled "Agreement for Peer Review Services", effective 7/10/14, revealed in part "... [Teleradiologist Entity A] will provide professional peer review services for the [CAH]."

3. Review of a CAH policy titled "Ongoing Professional Practice Evaluation (OPPE)," effective 7/1/20, revealed in part "... Ongoing Professional Practice Evaluation will be completed as part of the biennial reappointment process. ... During each credentialing period, radiologists will have at least one case per modality ([Magnetic Resonance Imaging], [Computerized Tomography], [Ultrasound], [Positron Emission Tomography], Nuclear Medicine, Diagnostic Radiology and Mammography) per quarter reviewed by an entity selected by [CAH]. The reports will be returned to [CAH] from the external entity quarterly and upon receipt will follow the same processes as that of other practitioners ... OPPE data will be collected by Credentialing Specialist per practitioner. Results will be provided to the Vice President of Patient Care for initial perusal. The results will then be provided to Professional Activities Committee (PAC) for review ... PAC will approve the reports as presented or take action as appropriate on a case by case basis ...".

4. Review of the credential file and external peer review for Teleradiologist D revealed the medical staff approved his reappointment to the Medical Staff on 8/11/20. The Board of Directors approved Teleradiologist D for reappointment to the Medical staff on 8/25/20. Teleradiologist D did not have any external peer results available for review prior to his reappointment.

5. During an interview on 7/20/21, at 9:50 AM, the Director of Ancillary services reported the CAH utilizes Teleradiology Entity A for overnight radiology image interpretation and identified Teleradiologist D recently interpreted an image.

6. During an interview on 7/21/21, at 9:00 AM the Credentialing Coordinator reported the CAH's Network Hospital conducts external peer review on all medical staff members except Radiologists, which in conducted by Teleradiologist Entity A. She reported the Director of Ancillary Services coordinates the peer review and she receives the results to send to the PAC committee for review. She reported she did not have any external peer review results for Teleradiologist D, from Teleradiology Entity A, conducted prior to his reappointment, as his volume reports showed he had not interpreted any radiology images.

7. During an interview on 7/21/21, at 12:50 PM, the Director of Ancillary Services reported the Lead Radiology Technician runs a report of each Radiologist quarterly and, if the report shows any volume of image interpretations, a sample is selected and sent to Teleradiology Entity A for external peer review and would run a report to look at Teleradiologist D's volume of service over the past year. The Director of Ancillary Services confirmed radiology image interpretations are not sent to the CAH's Network Hospital for external peer review.

8. During an interview on 7/22/21, at 9:20 AM, the Director of Ancillary Services reported the volume report for Teleradiologist D showed no image interpretations and acknowledged this would happen for all of the Teleradiologists from Teleradiology Entity A, as their interpretations are over read the next morning by a Radiologist from Radiology Entity B. The Director of Ancillary Services confirmed treatment decisions would potentially be made based on the initial image interpretation and there has been no external peer review conducted to ensure the appropriateness of diagnosis and treatment based on Teleradiology Entity A's services.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all patient care policies were reviewed annually by the required group of professionals, including a physician and mid-level provider, in accordance with facility policy, for 10 of 41 patient care departments including contracted services (Nuclear Medicine, PET Scan, Teleradiology, Dexa Scan (bone density scans), MRI, Diabetic Education, Enterstomal Therapy, Telemedicine, Sleep Study and the Hospital Clinic). Failure to ensure all patient care policies are reviewed annually could potentially result in the CAH staff failing to identify patient care needs not addressed in the CAH policies/procedures.

For the fiscal year 2020, the CAH administrative staff identified:

An average daily census of 4 patients
93-Nuclear Medicine tests (contracted)
2- PET Scans (contracted)
786-Teleradiology readings of x-rays (contracted)
220-Dexa Scans (bone density scans)
257-MRI tests
121-Diabetic Education patient visits
603-Enterstomal Therapy visits in the Wound clinic (contracted)
112-Telemedicine patient visits (contracted)
36-Sleep Studies (contracted)
17547- Hospital Clinic patient visits

Findings include:

1. Review of the policy "Policy and Procedure Protocol," revised 11/2020, revealed in part "Policies are developed and reviewed annually ... Each department will maintain current policies and procedures (facility-wide and department specific) ... All policies and procedures will be reviewed on an annual basis."

2. Review of the "Critical Access Hospital Oversight Committee (CAH)" meeting minutes, dated 8/11/20 through 5/11/21, revealed that the meeting minutes lacked documentation that the CAH staff annually reviewed the policies for Nuclear Medicine, PET Scan, Teleradiology, Dexa Scan (bone density scans), MRI, Diabetic Education, Enterstomal Therapy, Telemedicine, Sleep Study and the Hospital Clinic.

3. During an interview on 7/21/21 at 4:25 PM, the Chief Clinical Officer confirmed the CAH staff failed to annually reviwe all of the policies for Nuclear Medicine, PET Scan, Teleradiology, Dexa Scan (bone density scans), MRI, Diabetic Education, Enterstomal Therapy, Telemedicine, Sleep Study and the Hospital Clinic.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to create and maintain 1 of 1 list of contracted services which described the nature and scope of the services provided. The administrative staff identified a current census of 4 inpatients at the time of the survey. Failure to maintain a list of contracted services, including the delineation of the nature and scope of contracted services, could potentially result in the CAH's administrative staff failing to ensure the contracted services provided quality services to the CAH's patients and the contracted services met their responsibilities under the contracts.

Findings include:

1. Review of the undated "Current Patient Care Contracts" revealed the document listed the services provided at the CAH by a contracted company, but the list lacked a description of the nature and scope of the contract.

2. During an interview on 07/21/2021 at 11:105 AM, the Chief Executive Officer (CEO) confirmed the list of services provided at the CAH lacked a description of the nature and scope of each contracted service.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) nursing administrative staff failed to ensure the staff kept patient medical information secure from unauthorized access to patient information in 1 of 1 Dirty Endoscope Processing Room. Failure to keep patient medical information confidential could potentially result in unauthorized access of a patient's personal/medical information and potentially result in unauthorized release of personal information. The CAH's nursing administrative staff identified and average of 403 endoscopic (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract) procedures from July 1, 2020 to June 30, 2021.

Findings include:

1. Review of the policy "Safeguarding PHI," last reviewed 2/2020, revealed in part, "Medical records shall not be left unattended on the nurses' station desk or other areas where patients, visitors or unauthorized individuals could easily view the records."

2. Observation on 7/20/21 at 8:15 AM, during an tour of the Dirty Endo Processing Room with the Surgical Services Manager, revealed a binder with approximately 16 stickers with patient information in a drawer, allowing housekeeping access, and potentially allowing unauthorized personnel access to confidential patient information.

3. During an interview on 7/20/21 at approximately 8:15 AM with Surgical Tech B, verified housekeeping cleans this room daily after hours when medical staff is not present. The room can be accessed at any time, as the push button lock is no longer functioning.

4. During an interview at the time of the tour, the Surgical Services Manager acknowledged the binder contained patient information and that the housekeeping or other staff could have access to the information, without a legitimate reason to need to know the information.

Based on observation, document review, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 Vision Care Outsource Provider Technicians (Technician A), who performed the role of first assistant, during cataract procedures performed by Ophthalmologist C, were qualified to assist in surgical procedures, according to the Medical Staff bylaws and CAH policies. The administrative staff identified Technician A assisted with 178 cataract procedures from 7/1/20 to 6/30/21. Failure to ensure the qualifications of all individuals providing assistance to surgical procedures of CAH patients could potentially result in the performance of care beyond their capabilities and placing the patient at risk for surgical complications and potential harm.

Findings include:

1. Review of the CAH Policies and Procedures Credentialing Addendum to the Bylaws", approved by the CAH Board of Directors on 7/16/21, revealed in part "... A practitioner or member of the specified professional personnel staff providing clinical services in the hospital by virtue of medical staff membership or otherwise shall be entitled to exercise only those clinical privileges specifically granted by the governing body pursuant to the procedures set forth in these Bylaws ...".

2. Review of a document titled "Agreement for Mobile Cataract Services," dated 1/2/18, revealed in part "... [Vision Care Outsource Provider Entity C] agrees to ... Provide items necessary to perform cataract surgery ... Provide technician during the procedure to monitor the proper performance of the instrumentation and supplies and if necessary, scrub for surgical procedures ...".

3. During an interview on 7/20/21 at 3:50 PM, the Surgery Manager reported Ophthalmologist C works with a contracted service through Vision Care Outsource Provider Entity C to perform cataract procedures for CAH patients. She explained that part of the contracted service includes a technician for the procedure that assists with equipment settings/operation and performs as a surgical scrub technician. The Surgery Manager verified the surgical staff do not have access to Vision Care Outsource Provider Technician A's scrub technician's privileges.

4. During an interview on 7/21/21 at 9:00 AM, the Credentialing Coordinator reported she did not have a credential file for Vision Care Outsource Provider Technician A.

5. During an interview on 7/22/21 at 8:25 AM, the Surgery Manager reported a Vision Care Outsource Provider Technician with Entity C is present for all cataract procedures, performed by Ophthalmologist C. The technician scrubs in for the surgical procedure and monitors equipment function and performs the role of a scrub technician. The Surgery Manager reported Vision Care Outsource Provider Technician A has assisted Ophthalmologist C with all of the cataract procedures over the past year. The Surgery Manager recalled Technician A reported he received training as a surgical scrub technician training, but confirmed the Surgery Manager did not have any documentation of his training or privileges indicating what procedures the CAH's governing body had approved the technician to perform.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate and report patient care related data, including contracted services, offered at the CAH for 5 of 31 inpatient/outpatient services ( Dexa Scan (bone density), Ultrasound, MRI, Dietician, and Diabetic Education) and 7 of 10 contracted services (Nuclear Medicine, PET Scan, Echocardio Scan, Teleradiology, Enterstomal Therapy, Telemedicine, and Sleep Study). Failure to evaluate and report all patient care services could potentially result in the CAH staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved patient care services. For the fiscal year 2020, the CAH administrative staff identified:

An average daily census of 4 inpatients,
220-Dexa scans,
840-ultrasound exams,
257-MRI tests,
27-dietician visits,
121-diabetic education visits,
93-Nuclear Medicine tests,
2-PET Scans,
252-Echocardio Scans,
786-Teleradiology readings,
603-Wound and Enterstomal Therapy patient visits,
112-Telemedicine patient visits, and
36-Sleep Studies

Findings include:

1. Review of the CAH "Quality Plan Reporting and Improvement Focus [QAPI]," approved 06/16/2021, revealed in part, "The Avera Quality Plan provides a systematic, coordinated, multidisciplinary, and continuous approach to improving performance focusing upon the processes and systems that affect delivery of service and patient outcomes ... all facilities will participate in and report data on Avera initiatives ... At the end of the quality cycle, a summary of the effectiveness of the quality program will be sent to the Avera Health Board of Directors ... "

2. Review of the "Avera Holy Family Performance Excellence Council" meeting minutes, from 7/23/20 to 6/11/21, revealed the meeting minutes lacked documentation the CAH staff evaluated and reported quality improvement data related to improved patient care services, including inpatient/outpatient services (Dexa Scan (bone density), Ultrasound, MRI, Dietician, and Diabetic Education) and contracted services (Nuclear Medicine, PET Scan, Echocardio Scan, Teleradiology, Enterstomal Therapy, Telemedicine, and Sleep Study).

3. During an interview on 7/21/2021 at 3:25 PM, the Chief Executive Officer (CEO) verified the CAH Performance Excellence Council meeting minutes lacked evidence that the council members received and evaluated quality improvement data related to the improvement of patient care for inpatient/outpatient services of Dexa Scan, Ultrasound, MRI, Dietician, and Diabetic Education and contracted services of Nuclear Medicine, PET Scan, Echocardio Scan, Teleradiology, Enterstomal Therapy, Telemedicine, and Sleep Study.