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Based on observation, record review and staff interviews, the Critical Access Hospital failed to provide a safe and secure environment for the provision of patient care.

The findings documented on the accompanying Life Safety Code survey demonstrated that the Condition of Participation for Physical Plant and Environment was NOT MET

Cross Reference: Tag C231

Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the accompanying Critical Access Hospital Life Safety Code Survey, ASE Shell ID #Z8TL21.

Based on observation, record review and staff interviews, it was determined that the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements resulted in an unsafe healthcare environment.

Reference: 42 CFR 485.627(a) Standard: Governing Body or Responsible Individual
The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment

Findings:

Due to the scope and severity of deficiencies detailed under the Conditions of Participation for Physical Plant and Environment, and for Periodic Evaluation and Quality Assurance Review, the Condition of Participation for Organizational Structure was NOT MET.

Cross-Reference: Tags C0220, C0231, C0330, and C0337.

Based on staff interviews and review of the hospital's quality assurance program and quality assurance documentation, it was determined that the facility failed to meet the requirements for the Condition of Participation for Hospital Wide Periodic Evaluation and Quality Assurance Review.

Failure to develop and implement an effective quality assurance program that included correction of previously-cited deficiencies, including a serious Life Safety Code deficiency, impaired the facility's ability to provide quality care in a safe environment.

Findings:

Due to the citation of repeat deficiencies, including the serious Life Safety Code deficiency related to the Essential Electrical System and detailed accompanying Life Safety Code survey, the Condition of Participation for Periodic Evaluation and Quality Assurance Review was NOT MET.

Cross Reference: Tag C0337

Based on interview and review of quality improvement documentation, the Critical Access Hospital failed to develop and implement an effective quality assurance program that included monitoring the correction of previously cited deficiencies, including a serious Life Safety Code deficiency related to the Essential Electrical System and detailed on the accompanying Life Safety Code Survey.

This impaired the facility's ability to provide quality care in a safe environment.

Findings:

The hospital was cited on 8/18/2011 for failure to separate the life safety and critical branches of the Essential Electrical System. The deficiency remained uncorrected at the time of this survey.
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Cross-reference: C0220, C0231, K0145
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