HospitalInspections.org

Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel biennially review the CAH's health care policies for 2 of 2 years (2020 and 2021) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH's ability to ensure treatment of CAH patients followed current policies, regulations, and standards of practice.

Findings include:

The policy "Patient Care Policies and Procedures," dated 04/2016, stated,
"POLICY: It is the policy of LAHS [Lisbon Area Health Services] to ensure patient care policies are consistent with applicable state and federal laws.
PROCEDURE: Patient care policy and procedure committee will meet at a minimum of annually or as needed.
Committee members consist of:
Physician
Mid-level . . .
The committee: . . .
C. Policies reviewed at least annually by policy & procedure committee . . ."

Review of the CAH's policies occurred on all days of the survey. On 11/29/21, a physician and nurse practitioner had reviewed the following policies: Ambulatory Care, Pain Clinic, Sleep Studies, and Self Harm. All other CAH policies lacked evidence of biennial review in 2020 and 2021 by a physician and physician assistant/nurse practitioner/clinical nurse specialist (the required members of a group of professional personnel).

Upon request on 07/13/22, the CAH failed to provide evidence a physician and a physician assistant/nurse practitioner/clinical nurse specialist biennially reviewed the CAH's policies in 2020 and 2021 except for the Ambulatory Care, Pain Clinic, Sleep Studies, and Self Harm policies reviewed on 11/29/21.

During interview on 07/13/22 at 9:50 a.m., an administrative staff member (#1) confirmed the CAH's physician and a physician assistant/nurse practitioner/clinical nurse had failed to review CAH's policies in 2020 and 2021 except for the Ambulatory Care, Pain Clinic, Sleep Studies, and Self Harm policies reviewed on 11/29/21.