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Based on review of policies, meeting minutes, and staff interviews, the CAH (Critical Access Hospital) failed to ensure one or more physicians attended 7 of 7 months of scheduled CAH Committee Meetings to review all hospital patient care policies. (2/18/15, 4/1/15, 5/1/15, 6/30/15, 8/25/15, 10/27/15, and 1/16/16)

Failure to ensure one or more physicians attended 7 of 7 months of CAH Committee Meetings scheduled to annually review the CAH patient care policies could potentially result in failure to address and develop policies for changing patient care needs and/or opportunities to update the policies as needed.

Findings include:

1. Review of CAH policy/procedure titled "Policy Procedure Review and Revision", dated 10/21/15, revealed in part, ". . . All policies/procedures will be reviewed/revised/approved annually by the Responsible Person, Affected Department, Administrative Council Representative, Critical Access Hospital (CAH) Committee and the Board of Trustees. . . The CAH committee is comprised of the Chief Executive Officer, Chief Nursing Officer, Chief Patient Experience Officer, two Leadership team members, a mid-level practitioner, and a physician. . . Annual policy review will be completed once per year. . . ."

2. Review of 7 of 7 CAH Committee Meeting minutes lacked documented evidence one or more physicians annually reviewed the CAH patient care policies. (February 18, 2015, April 1, 2015, May 1, 2015, June 30, 2015, August 25, 2015, October 27, 2015, and January 16, 2016.)

3. During an interview on 2/11/16 at 10:35 AM, Staff I, Patient Experience Officer, and Staff J, Quality Improvement and Community Resource Manager, acknowledged one or more physicians did not attend 7 of 7 CAH Committee Meetings to annually review the CAH patient care polices.