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Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure garbage was properly disposed. This failure has the potential to affect all patients and staff at the facility.

Findings include:

Observation on 07/18/18 at 11:30 AM revealed two (2) open garbage dumpsters, located outside the kitchen area of the hospital. Garbage bags full of refuse and empty cardboard boxes were visible inside the dumpsters.

Interview on 07/19/18 at 3:15 PM, the Dietary Director (DD) stated that garbage taken out of the kitchen area was placed in carts and transported to the dumpster outside the kitchen area and the lids of the dumpster were required to be closed.

Interview on 07/19/18 at 3:20 PM, the Housekeeping Supervisor (HS) stated that the housekeeping department transports garbage to the dumpster outside the kitchen area and the dumpster lids were required to be closed. The HS further stated that he did not know if the facility had a policy related to proper disposal of garbage.

Review of the facility policy titled, "Housekeeping trash handling and proper disposal of regulated trash and handling and disposal of contaminated waste," not dated, revealed the facility required housekeeping staff to transport garbage to the dumpsters located outside the service area of the hospital. In addition, the policy required the facility staff to "maintain a sanitary and safe environment at the facility by ensuring trash is properly bagged."

Based on observation, and staff interview, the facility failed to ensure that the air conditioning units, the fire extinguisher control unit next to the stove, the fluorescent light above the salad bar table, and the sprinkler system pipe in the kitchen were clean. Failure to ensure the kitchen was clean has the potential to contaminate food.

Findings include:

On 7/17/18 at 3:20 PM, a tour of the kitchen with the dietary manager revealed the following:

- The two-ceiling mounted air conditioner units were covered with fuzzy gray particles.
- The gas stove fire extinguisher control unit mounted on the wall next to the stove was covered with thick fuzzy gray particles and the top of the box had an oily thick film.
- The two-bulb fluorescent light mounted above the salad bar table was covered with fuzzy gray particles, in addition, the two light tubes had multiple, too numerous to count, black spots that appeared to be dead insects.
- The sprinkler system piping that traversed across the room was coated with gray fuzzy particles. Part of this piping system was over the food preparation areas.

Interview on 07/17/18 at 3:40 PM, the Dietary Manager stated that they had cleaned the food preparation areas but had failed to notice the ceiling and air exchange units.

Based on policy review, and CEO interview, the facility failed to have the Physician assistant (PA-C), the Nurse Practitioner (NP), and Clinical Nurse Specialist (NP-C), also referred to as mid-level practitioners, participate in developing and periodically review the policies governing the services the Critical Access Hospital, (CAH) provides. This was true for all policies reviewed. Failure to include the midlevel practitioners in the development of the facility's policies has the potential for policies to be out-of-date and inconsistent with State standards of practice requirements.

Findings include:

The facility was in the process of updating all the policies in the facility. Some of the policies were in paper format and some had been put on the "S" drive of the computer. None of the policies reviewed, either in paper or electronic format, had documentation to show the mid-level practitioners were involved in the development of the policies.

Interview on 07/19/18 at 9:30 AM, the Chief Executive Officer (CEO) stated that the policies and procedures had not been updated and no mid-level practitioners were involved in developing and reviewing the policies per regulation.

Based on policy review and interview, the facility failed to have the Critical Access Hospital (CAH) professional health care staff review the health care policies on an annual basis. This included all policies reviewed. Failure to have professional healthcare staff review policies annually has the potential for policies to be out-of-date and inconsistent with updated State or Federal regulations.

Findings include:

The facility was in the process of converting the health care policies from paper copy to electronic copy. The paper copies reviewed had signature sheets with various dates in 2015. The most recent electronic policies found were several swing-bed policies dated 9/2016. There was no indication the professional health care staff had reviewed any of the polices in the past year.

Interview on 07/19/18 at 9:30 AM, the Chief Executive Officer (CEO) stated that the policies and procedures had not been reviewed and updated in the past year.

Based on interview, and review of hospital documentation, it was determined the facility failed to ensure laboratory services were provided under a current Clinical Laboratory Improvement Act (CLIA) certificate or waiver for all tests performed and meet the laboratory requirements specified in 42 CFR Part 493 for one of two locations, the remote location. Failure to maintain a current CLIA certificate has the potential for inaccurate lab values and inability to provide services needed to meet the needs of the patients.

Findings include:

Review of the facility's CLIA certificate at the remote location showed the expiration date was 05/10/18.

Interview on 07/19/18 at 9:30 AM, the Chief Financial Officer 2(CFO2) stated that she was aware of the expiration of the CLIA certificate on 05/10/18. The CFO2 stated that the facility attempted to get information related to the renewal of the certificate from the state agency prior to the expiration of the CLIA certificate. However, CFO2 stated that the hospital's Laboratory Director (LD) was not informed by the state agency that a six (6) month extension for the CLIA certificate was granted until 07/17/18.

Interview on 07/19/18 at 10:05 AM, The LD2 stated that the hospital was aware of the CLIA certificate's expiration date prior to 05/10/18. The LD2 stated that she attempted to contact the state agency by telephone prior to the expiration of the CLIA certificate. However, the LD2 stated that the state agency did not return her phone call. The LD2 further stated that she contacted the state agency through electronic mail on 07/17/18 and received a response from the state agency on 07/17/18 informing the hospital of the extension of the CLIA certificate until 11/10/18 due to the agency's inability to conduct a survey of the facility's laboratory before 05/10/18.

Interview on 07/19/18 at 10:00 AM, the Chief Executive Officer (CEO) stated that he was not aware of the expiration of the CLIA certificate at the remote location on 05/10/18. The CEO stated that CFO2 was the acting CEO at the time there was communication with the state agency regarding the expired CLIA certificate.

Based on record review, and staff interview the facility failed to ensure comprehensive assessments were completed for 3 of 3 inpatient swing-bed patients (Patients) (P)7, P8, and P9, residing in the remote location facility. Failure to conduct comprehensive assessments on swing-bed patients has the potential for residents' needs to go unmet.

Findings include:

The Critical Access Hospital (CAH) merged two facilities in November 2017. The merger resulted in a remote location from the main hospital located about 15 miles away. The remote location provided inpatient and swing-bed services to the patients. The merger also had created issues with medical records in that there were two different electronic record programs. The records at the remote location were being archived and not available for review in the main hospital location. P7, P8, and P9 were swing-bed patients in the remote location.

Record/P7
- P7 was admitted to the facility on 06/2/16.
- The record lacked evidence of a current or historic comprehensive assessment.

Record/P8
- P8 was admitted to the facility prior to 01/01/16
- The record lacked evidence of a current or historic comprehensive assessment.

Record/P9
- P9 was admitted to the facility prior to 01/01/16
- The record lacked evidence of a current or historic comprehensive assessment.

Interview on 07/20/18 at 10:30 AM, the Director of Nursing (DON) stated that the remote facility's policy and procedure for completing comprehensive assessments was different from the one used at the main facility and was not sure what it said. The DON also revealed that there may be paper assessments completed for swing-bed patients, but these were never provided during the survey. The staff member who did the assessments was gone, and she was not sure if there was a policy for comprehensive assessments or if they had to be completed for swing-bed patients.

Based on medical record review, and staff interview, the facility failed to complete a comprehensive assessment for two of two patients (Patient)(P)5, P6, in a swing-bed in the main facility and three of three patients P7, P8, and P9, who were in a swing-bed at the remote location.

Findings include:

Record/P5
- P5 was admitted to a swing-bed on 06/17/15 at the main hospital location.
- The facility completed a comprehensive assessment on 06/19/15.
- The record lacked documentation that the facility had completed an assessment since the admission assessment.

Record/P6
- P6 was admitted to a swing-bed on 05/02/17 at the main hospital location.
- The facility completed a comprehensive assessment on 05/03/17.
- The record lacked documentation that the facility had completed an assessment since the admission assessment.

Record/P7
- P7 was admitted to a swing-bed on 06/02/16 at the remote location of the facility.
- The record lacked documentation that the facility had completed a comprehensive assessment and any assessment for the previous 12 months.

Record/P8
- P8 was admitted to a swing-bed sometime prior to 01/01/16 at the remote location of the facility.
- The record lacked documentation that the facility had completed a comprehensive assessment and any assessment for the previous 12 months.

Record/P9
- P9 was admitted to a swing-bed sometime prior to 01/01/16 at the remote location of the facility.
- The record lacked documentation that the facility had completed a comprehensive assessment and any assessment for the previous 12 months.

Interview on 07/19/18 at 1:30 PM, the Case Manager (CM) for the main hospital swing-beds stated that an annual assessment for P5 and P6 had not been completed and the CM was not aware of the annual requirement.

Interview on 07/20/18 at 10:30 AM, the Director of Nursing (DON) for the remote location searched the medical records for the three swing-bed patients P7, P8 and P9. The DON was not able to find the comprehensive assessments and concluded that the facility also had not completed the annual assessment as required.

Based on medical record review and staff interview, the facility failed to develop, review, and revise comprehensive care plans for 5 of 5 swing-bed patients, (Patient)(P)5, P6, P7, P8 and P9. Failure to develop a care plan with an interdisciplinary team and periodically review and revise the care plan has the potential for patient's goals to go unmet.

Findings include:

Record/P5
- P5 was admitted to a swing-bed on 06/17/15 at the main hospital location..
- The record showed that the facility had developed initial admission care plans, but lacked evidence that an interdisciplinary team had formulated a comprehensive care plan.

Record/P6
- P6 was admitted to a swing-bed on 05/02/17 at the main hospital location.
- The record showed that the facility had developed initial admission care plans, but lacked evidence that an interdisciplinary team had formulated a comprehensive care plan.

Interview on 07/19/18 at 1:30 PM, the Case Manager for the main hospital swing-beds stated that the interdisciplinary team had met but there were no care plans developed.

Record/P7
- P7 was admitted to a swing-bed on 06/02/16 at the remote location of the facility.
- The record lacked evidence that an interdisciplinary team had formulated a comprehensive care plan.

Record/P8
- P8 was admitted to a swing-bed sometime prior to 01/01/16 at the remote location.
- The record lacked evidence that an interdisciplinary team had formulated a comprehensive care plan.

Record/P9
- P9 was admitted to a swing-bed sometime prior to 01/01/16 at the remote location.
- The record lacked evidence that an interdisciplinary team had formulated a comprehensive care plan.

Interview on 07/20/18 at 10:30 AM, the Director of Nursing (DON) for the remote location did a medical record review and was not able to find comprehensive assessments or comprehensive care plans based on interdisciplinary team review for any of the three patients, P7, P8, and P9.