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Based on review of the Quality Plan, Quality activities, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate the quality of 12 of 18 patient care services (In Patient, Health Information Management, Emergency, Specialty Clinic - Neurology, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Environmental Services, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, and Plant Operations) and 4 of 4 contracted patient care services (Anesthesia, Nuclear Medicine, Stereotactic Breast Biopsy, and Speech Therapy). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

The CAH administrative staff identified the CAH staff provided care to patients for 12 months for FY 2019 as follows:

- In Patient - 429 admissions
- Emergency - 6906 patient visits
- Specialty Clinic - Neurology
- Rehabilitation Services - (Physical Therapy - 5660 patient visits, Occupational Therapy - 896 patient visits)
- Cardiac Rehabilitation - 12 current patients
- Respiratory Therapy - 1772 procedures

Contracted patient care services:
- Anesthesia - 592 patients
- Nuclear Medicine - 239 studies
- Stereotactic Breast Biopsy - 13 studies
- Speech Therapy - 162 patient treatments

Findings include:

1. Review of the "Quality Assurance Performance Improvement Plan," dated FY2021, revealed in part, "The purpose of the Quality Assurance Performance Improvement (QAPI) Plan is to ensure that Washington County Hospital and Clinics (WCHC) has a systematic approach to enable reflection on past and existing practices, assessment of current state, and driving of active effort toward improvement of processes and systems. Following the QAPI Plan will ensure that WCHC provides quality services to the patients entrusted into our care, supporting our mission, vision and values ... Documentation of activities shall include at least the following: Findings, conclusions, recommendations, actions taken, and results are reported according to established reporting mechanisms. The results will be recorded in departmental or committee minutes and shall include summation of data analysis and results of problem resolution and effectiveness of improvement activities...The Patient & Resident Care Review Committee (PRCRC) serves as the oversight committee for quality assurance and performance improvement throughout the organization."

2. Review of Patient & Resident Care Review Committee Meeting Minutes, dated January 21, 2021 through December 16, 2021, revealed the lack of department quality reports for In Patient, Health Information Management, Emergency, Specialty Clinic - Neurology, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Environmental Services, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, and Plant Operations and contracted patient care services Anesthesia, Nuclear Medicine, Stereotactic Breast Biopsy, and Speech Therapy.

3. During an interview on 01/13/2021 at 9:00 AM, the Chief Operating Officer (COO) acknowledged the lack of department quality reports for In Patient, Health Information Management, Emergency, Specialty Clinic - Neurology, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Environmental Services, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, and Plant Operations and contracted patient care services Anesthesia, Nuclear Medicine, Stereotactic Breast Biopsy, and Speech Therapy. The COO confirmed patient care departments report quality information one time per fiscal year - Pharmacy last reported quality December 2019 and would report again May 2021. The COO acknowledged the department quality dashboards lack documentation of recommendations and actions taken to correct any problems identified.

Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 Emergency Medicine physicians and 2 of 2 Radiologists, selected for review received outside entity peer review by the appropriate entity, 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. (Emergency Medicine Physician A, Emergency Medicine Physician F, Radiologist D and Radiologist E).
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The CAH administrative staff identified the identified physicians provided care to patients from 9/1/20 to 11/30/20 as follows:

Emergency Medicine Physician A provided care to 446 emergency room patients.
Emergency Medicine Physician F provided care to 254 emergency room patients.
Radiologist D provided imaging studies for 240 patients.
Radiologist E provided imaging studies for 526 patients.

Findings include:

1. Review of the CAH's network agreement, effective 7/1/08, revealed in part " ... Assist Hospital in identifying and arranging for qualified physicians and other practitioners to consult with Hospital on peer review matters as needed, including but not limited to the establishment of standards and protocols, the provision of peer review ..."

2. Review of the CAH's Physician Services Agreement, effective January 2019, revealed in part "... Client desires the results of a Peer Review for the express purpose of quality improvement; ... Client desires to engage [Network Hospital] to provide such Peer Review as described in this Agreement and [Network Hospital] desires to provide such services to Client ... [Network Hospital] shall perform Services in accordance with the accepted standard of care in the professional specialties ...".

3. Review of a CAH agreement titled "Radiology Information Services Agreement", effective 2/26/07, revealed in part "... This Radiology Information Services Agreement ("Agreement") is between [Radiology Entity A], an Iowa Professional Limited Liability Company and [CAH] ..." and identified radiology services the company would provide both onsite and from a distant site.

4. Review of the CAH Medical Staff Bylaws, dated 4/2019, revealed in part " ... Peer recommendations concerning professional competency are part of the basis for the development of recommendations for continued membership on the Medical Staff for the delineation of individual clinical privileges ... Each recommendation concerning the reappointment shall be based upon such member's professional competency and clinical judgement in the treatment of patients ...".

5. Review of an undated CAH policy "Medical Staff Credentialing and Privileging Policy," revealed in part "... All Medical Staff providers are subject to [CAH] Peer Review policy. Results of Peer Reviews will assist in approval and recommendation process of reappointment requests ...".

6. Review of external peer review for the selected physicians revealed the medical staff approved Emergency Medicine Physician A for reappointment to the Medical Staff on 2/22/19. The Board of Trustees approved Physician A for reappointment to the Medical Staff on 2/28/19. Physician A lacked results of any external peer review conducted by the Network Hospital, prior to Physician A's reappointment to the Medical Staff.

7. Review of external peer review for the selected physicians revealed the medical staff approved Emergency Medicine Physician F for reappointment to the Medical Staff on 2/22/19. The Board of Trustees approved Physician F for reappointment to the Medical Staff on 2/28/19. Physician F lacked results of any external peer review conducted by the Network Hospital, prior to Physician F's reappointment to the Medical Staff.

8. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist D for reappointment to the Medical Staff on 1/27/20. The Board of Trustees approved Radiologist D for reappointment to the Medical Staff on 2/27/20. Radiologist D lacked results of any external peer review conducted by the Network Hospital, prior to Radiologist D's reappointment to the Medical Staff.

9. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist E for reappointment to the Medical Staff on 4/30/20. The Board of Trustees approved Radiologist E for reappointment to the Medical Staff on 5/20/20. Radiologist E lacked results of any external peer review conducted by the Network Hospital, prior to Radiologist E's reappointment to the Medical Staff.

10. During an interview on 1/12/21, beginning at 12:30 PM, the Chief Operating Officer and Quality/Infection Control Nurse reported their Network Hospital conducts the majority of the external peer review completed on their medical staff. They reported a [Hospital A] physician conducts external peer review for the Emergency Medicine physicians and [Radiology Entity A] conducts external peer review on the Radiology physicians. The Chief Operating Officer and Quality/Infection Control Nurse confirmed they did not have any external peer review completed by their Network Hospital for Emergency Medicine Physicians A and F or for Radiologists D and E prior to their reappointment to medical staff.

11. During an interview on 1/13/21, at 8:30 AM, the Chief Operating Officer reported she discovered their Network Hospital had completed external peer review on Emergency Medicine Physicians A and F but the results went to the Radiology Director and confirmed the results failed to go through quality and had not been available for review prior to the physicians reappointment to medical staff.

I. Based on document review, observation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to post a notice conspicuously, in a place likely to be noticed by all individuals entering the dedicated emergency department (DED) that the CAH did not have either a medical doctor (MD) or doctor of osteopathy (DO) present at the hospital 7 days a week, 24 hours a day, and how the the CAH will meet the medical needs of any patient with an emergency medical condition at a time when there is no doctor of medicine or doctor of osteopathy present in the CAH. Failure to post the notice the CAH did not have a physician on-site 24 hours a day, 7 days a week resulted in the patients lacking sufficient information to determine if they wanted to receive emergency care at the CAH, without a physician present at all times. The CAH staff identified approximately 6,906 patients presented to the DED for emergency care in Fiscal year 2019.

Findings include:

1. Review of the Emergency Department (ED) schedule for January 2020 revealed the CAH staff utilized a mixture of physicians, Physician Assistant's (PAs), and Advanced Registered Nurse Practitioners (ARNPs, nurses with advanced training which allows them to diagnose, treat, and prescribe medications to patients) to staff the Emergency Department.

2. Review of the CAH website revealed the ED is staffed with a mixture of physicians, PAs, and ARNPs experienced in emergency medicine.

3. Observations during a tour of the Emergency Department on 1/5/21 at 1:55 PM revealed the Emergency Department staff failed to provide notice to patients the CAH did not have a physician present at the CAH 24 hours per day, 7 days per week.

4. During an interview, at the time of the ED tour, the Director of Emergency and Perioperative Services, the CNO, and the Compliance Officer revealed the CAH had PAs and ARNPs who served as the sole medical provider in the ED on a regularly scheduled basis and they were not aware of the regulation that required patients be notified that there was not an MD/DO in the hospital 24 hours a day, 7 days a week.




II. Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to provide, at the beginning of a planned or unplanned inpatient stay or outpatient visit to all inpatients and outpatients receiving observation services, surgery or another procedure requiring anesthesia, written notice that the CAH did not have either a medical doctor (MD) or doctor of osteopathy (DO) present at the hospital 7 days a week, 24 hours a day. Failure to provide the notice the CAH did not have a physician on-site 24 hours a day, 7 days a week resulted in the patients lacking sufficient information to determine if they wanted to receive their inpatient or outpatient care at the CAH, without a physician present at all times. The CAH staff identified approximately 429 Acute, 411 Observation, and 506 Surgical patients presented to the CAH for care in Fiscal year 2019.

Findings include:

1. Review of 5 of 5 closed surgical patient records (Patient #28, Patient #29, Patient #30, Patient #31, and Patient #32), 4 of 4 open medical records (Patient #19, Patient #20, Patient #21, and Patient #22), 1 of 3 closed medical records (Patient #18) revealed lack of signed acknowledgment of such disclosure by the CAH prior to patient's admission or before applicable outpatient procedure.

2. During an interview, at the time of the ED tour on 1/5/21, the DON and the Compliance Officer revealed they were not aware of the requirement for the ED posting or the written notice and disclosure required at the beginning of a planned or unplanned inpatient stay or outpatient procedures, that the CAH did not have either a MD or DO at the hospital 7 days a week, 24 hours a day.

3. During an interview on 1/12/21 at 1:19 PM, at the time of record reviews, the Compliance Officer acknowledged the medical records lacked a signed acknowledgement by the patient of such disclosure, obtained by the CAH prior to the patient's admission or before applicable outpatient procedures.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 2 of 2 anesthesia carts (Operating Rooms 1 & 2) and 1 of 1 Anesthesia Office supply closet. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after which the manufacturer will no longer guarantee the quality and effectiveness of the product. The CAH administrative staff identified approximately 46 pediatric and 460 adult surgical procedures from 1/1/20 - 12/31/20.

Findings include:

1. Observations on 1/06/21 at 9:20 AM, during a tour of the OR Department, revealed the following expired supplies in 1 of 1 Anesthesia Office and 2 of 2 Anestheisa Carts (OR 1 and OR 2)

A. The Anesthesia Office contained the following expired supplies:
1. 2 of 2 Lactated Ringers IV fluid bags, expired 9/2020
2. 18 of 18 Masimo Set 10 - 50 Kg Pediatric Pulse Oximeter Adhesive Sensors (measures the proportion of oxygenated hemoglobin in the blood), expired 9/2020
3. 1 of 2 4.0 Mallenckrodt ET (endotracheal tubes- a flexible plastic tube placed through the mouth into the windpipe to help a patient breath, expired 8/2020
4. 2 of 2 5.0 Mallenckrodt ET tubes, expired 9/30/20
5. 1 of 2 Shiley 4 DCT Tracheostomy Tube Cuffed with Disposable Inner Cannula, expired 10/1/20
6. 1 of 2 Shiley 4 DCT Tracheostomy Tube Cuffed with Disposable Inner Cannula, expired 2/2020
7. 2 of 2 Shiley 6 DCT Tracheostomy Tube Cuffed with Disposable Inner Cannula, expired 10/2019
8. 1 of 1 Shiley 8 DCT Tracheostomy Tube Cuffed with Disposable Inner Cannula, expired 11/2019

B. Operating Room 1 Anesthesia Cart contained the following expired supplies:
1. 3 of 4 Masimo SET Pediatric Pulse Oxymeter Adhesive Sensors, expired 7/1/20
2. 1 of 1 BD Insyte 14G 1.75 " IV needle, expired 4/30/20
3. 1 of 3 BD Insyte Autoguard 22 G 1 " IV Needle, expired 5/3/20
4. 2 of 2 8 Fr Slick Stylet Disposable Endotracheal Stylet, expired 9/2020
5. 2 of 2 6 Fr Slick Stylet Disposable Endotracheal Stylet, expired 3/2020
6. 2 of 2 Povidone-Iodine Antiseptic swab sticks, expired 7/2019
7. 1 of 2 BD Whitacre Needle 25 G 3.5" (type of spinal needle used in spinal anesthesia), expired 2/2020

C. Operating Room 2 Anesthesia Cart contained 1 of 1 8 Fr Slick Sylet Disposable Endotracheal Stylet, expired 8/2020

2. During an interview, at the time of the tour on 1/02/20, Director of Emergency and Perioperative Services reported the OR staff did not check for outdated supplies in the anesthesia closet or the anesthesia carts, as they did for all other OR department supplies. The Director of Emergency and Perioperative Services verbalized she thought that the Anesthesia Group was monitoring their supplies for outdates.

Based on review of the Quality Plan, Quality activities, Board of Trustees Bylaws and Meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the governing body evaluated the quality of 18 of 18 patient care services (In Patient, Diabetes Education, Specialty Clinic - Neurology, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, Food & Nutrition, Health Information Management, Emergency, Perioperative Services, Imaging, Laboratory, Environmental Services, Infection Control, and Plant Operations) and 4 of 4 contracted patient care services (Anesthesia, Nuclear Medicine, Stereotactic Breast Biopsy, and Speech Therapy). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

The CAH administrative staff identified the CAH staff provided care to patients for 12 months for FY 2019 as follows:

- In Patient - 429 admissions
- Emergency - 6,906 patient visits
- Specialty Clinic - Neurology
- Rehabilitation Services - (Physical Therapy - 5,660 patient visits, Occupational Therapy - 896 patient visits)
- Cardiac Rehabilitation - 12 current patients
- Respiratory Therapy - 1,772 procedures

Contracted patient care services:
- Anesthesia - 592 patients
- Nuclear Medicine - 239 studies
- Stereotactic Breast Biopsy - 13 studies
- Speech Therapy - 162 patient treatments

Findings include:

1. Review of the "Quality Assurance Performance Improvement Plan," dated FY2021, revealed in part, "... The Board of Trustees is ultimately responsible for ensuring that high quality care is consistently and effectively delivered to patients ... Documentation of activities shall include at least the following: Findings, conclusions, recommendations, actions taken, and results are reported according to established reporting mechanisms. The results will be recorded in departmental or committee minutes and shall include summation of data analysis and results of problem resolution and effectiveness of improvement activities ... The Patient & Resident Care Review Committee (PRCRC) serves as the oversight committee for quality assurance and performance improvement throughout the organization."

2. Review of Board of Trustees Meeting Minutes, dated 1/31/20 through 10/29/20, revealed the lack of department quality reports for In Patient, Diabetes Education, Specialty Clinic - Neurology, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Respiratory Therapy, Wound, and OTIC - Out Patient Infusion Center and 4 of 4 contracted patient care services - Anesthesia, Nuclear Medicine, Stereotactic Breast Biopsy, and Speech Therapy. The Board of Trustees Meeting Minutes included dashboard reports from departments Food & Nutrition, Health Information Management, Emergency, Perioperative Services, Imaging, Laboratory, Environmental Services, Infection Control, and Plant Operations. The department dashboards included data only and failed to include recommendations and actions taken to correct identified problems.

3. During an interview on 01/13/21 at 9:00 AM, the Chief Operating Officer (COO) acknowledged the lack of department quality reports for In Patient, Health Information Management, Emergency, Specialty Clinic - Neurology, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Environmental Services, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, and Plant Operations and contracted patient care services Anesthesia, Nuclear Medicine, Stereotactic Breast Biopsy, and Speech Therapy. The COO confirmed patient care departments report quality information once per fiscal year - Pharmacy last reported quality 12/2019 and would report again 5/2021. The COO acknowledged the department quality dashboards lack documentation of recommendations and actions taken to correct any problems identified.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician periodically reviewed the care provided for CAH patients, in conjunction with the mid-level provider, for 4 of 4 mid-level providers selected for review (Advanced Registered Nurse Practitioner (ARNP) B, ARNP C, Physician Assistant (PA) G and ARNP H). Failure to ensure a physician periodically reviewed mid-level provider's patient medical records, in conjunction with the mid-level provider, could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

The hospital staff identified the mid-level providers provided care to patients from 9/1/20 to 11/30/20 as follows:

- ARNP B : 63 inpatient admissions
- ARNP C: 77 inpatient admissions
- PA G: 1 emergency room patient
- ARNP H: 45 inpatient admissions and 111 wound clinic patients

Findings include:

1. Review of an undated CAH policy titled "Provisional Status and Advanced Practice Providers Chart Review", revealed in part " ... The Executive Committee and other Medical Staff members will conduct chart reviews on Advanced Practice Providers ... The monitoring and review process assesses and validates an individual's ability to perform competency within the boundaries of which they are privileged ... Advanced Practice Providers at the [CAH] shall undergo monthly medical record reviews by the Executive Committee or designee utilizing quality indicators to ensure care is rendered according to accepted standards ... " The policy failed to define a process, whereby patient chart review, by the physician would be conducted in conjunction with the mid-level provider.

2. During an interview on 1/12/21, beginning at 12:30 PM, the Chief Operating Officer and Quality/Infection Control Nurse reported 10% of mid-level charts are selected monthly for physician review, to evaluate the quality and appropriateness of care. The process included sending selected charts to a physician for review and the physician completed a chart evaluation form. The form is then sent to the mid-level provider for review, the mid-level provider signs the evaluation form, and the form is returned to the Quality Nurse. The Chief Operating Officer and Quality Nurse confirmed the current process fails to ensure the physician conducts chart review in conjunction with the mid-level provider.

Based on document review, policy review and staff interview the CAH administrative staff failed to ensure a physician periodically reviewed and signed all midlevel provider inpatient records and a sample of midlevel outpatient records for 4 of 4 mid-level providers selected for review (Advanced Registered Nurse Practitioner (ARNP) B, ARNP C, Physician Assistant G and ARNP H). Failure to review mid-level practitioners medical records could potentially result in misdiagnosing a patient and/or providing inappropriate or substandard patient care.

The hospital staff identified the mid-level providers provided care to patients from 9/1/20 to 11/30/20 as follows:

- ARNP B : 63 inpatient admissions
- ARNP C: 77 inpatient admissions
- PA G: 1 emergency room patient
- ARNP H: 45 inpatient admissions

Findings include:

1. Review of a the "[CAH] Medical Staff Bylaws and Rules and Regulations", dated 4/2019, revealed in part " ... ARNP's will perform the duties of a hospitalist in the Hospital under the direction and supervision of the physician members ... which may include admission, history and physical examination, diagnosis and treatments orders ... Each Physician Assistant will have at least one supervising physician responsible for their overall clinical performance ... Supervising physician must periodically co-sign all medical records, signed by the Physician Assistant, confirming their review of the completeness and accuracy of such information and records of inpatients seen by a Physician Assistant ...". The document failed to identify a similar process to ensure a representative sample of PA outpatients charts were reviewed and signed or all inpatient medical records of an ARNP were reviewed and signed.

2. Review of an undated CAH policy titled "Mid-level Practitioner Supervision Policy", revealed in part "To ensure Mid-level Practitioners are practicing within scope of practice and to provide quality patient care ... The supervising physician will review all patient medical records on a regularly defined basis for quality assurance ..." The policy failed to identify the process and frequency with which the physician signs all inpatient medical records and a sample of PA outpatient records.

3. During an interview on 1/12/21 at 3:40 PM, the Chief Operating Officer reported mid-level providers are highly involved in managing the care of inpatients and some outpatients and their care for patients is supervised by a physician, but does not believe there is a defined process to ensure all inpatient records and a sample of outpatient records are reviewed and signed by a physician.

4. During an interview on 1/13/21 at 11:30 AM, the Chief Nursing Officer and Chief Operating Officer reported a physician supervises and is involved in the mid-level providers provision of care to patients but confirmed the CAH failed to define a process to ensure 100% of all inpatient charts and a sample of PA outpatient charts are reviewed and signed by a physician.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a mid-level provider participated in a periodic review of the care provided to CAH patients, in conjunction with a physician, for 4 of 4 mid-level providers selected for review (Advanced Registered Nurse Practitioner (ARNP) B, Advanced Registered Nurse Practitioner C, Physician Assistant (PA) G and Advanced Registered Nurse Practitioner H). Failure to ensure a mid-level provider participated with a physician in a periodic review of the mid-level provider's patient medical records could potentially result in the mid-level misdiagnosing patient and/or providing inappropriate or substandard patient care.

The hospital staff identified the mid-level providers provided care to patients from 9/1/20 to 11/30/20 as follows:

- ARNP B : 63 inpatient admissions
- ARNP C: 77 inpatient admissions
- PA G: 1 emergency room patient
- ARNP H: 45 inpatient admissions and 111 wound clinic patients

Findings include:

1. Review of an undated CAH policy titled "Provisional Status and Advanced Practice Providers Chart Review", revealed in part "The Executive Committee and other Medical Staff members will conduct chart reviews on Advanced Practice Providers ... The monitoring and review process assesses and validates an individual's ability to perform competency within the boundaries of which they are privileged ... Advanced Practice Providers at the [CAH] shall undergo monthly medical record reviews by the Executive Committee or designee utilizing quality indicators to ensure care is rendered according to accepted standards ... " The policy failed to define a process, whereby patient chart review, by the physician would be conducted in conjunction with the mid-level provider.

2. During an interview on 1/12/21, beginning at 12:30 PM, the Chief Operating Officer and Quality/Infection Control Nurse reported 10% of mid-level charts are selected monthly for physician review to evaluate the quality and appropriateness of care. They reported the process included sending selected charts to a physician for review and the physician completes a chart evaluation form. The form is then sent to the mid-level provider for review, the mid-level provider signs the evaluation form and it's returned to the Quality Nurse. The Chief Operating Officer and Quality Nurse confirmed the current process fails to ensure the physician conducts chart review in conjunction with the mid-level provider.

Based on document review and staff interview, the Critical Access Hospital (CAH) staff failed to ensure 2 of 2 sampled Advanced Registered Nurse Practitioners (ARNP C and ARNP K), notified a physician when they admitted a patient to the CAH for inpatient care, for 4 of 4 open medical records reviewed (Patient # 19, Patient #20, Patient #21, and Patient #22) and 1 of 1 closed medical records reviewed (Patient #18). Failure of ARNPs C and K to notify a physician of the admission could potentially result in ARNPs C and K's patients receiving inadequate or substandard care because ARNPs C and K did not discuss the patient's plan of care and medical needs with a physician. The CAH's administrative staff identified a current inpatient census of 10 patients at the beginning of the survey.

Findings include:

1. Review of Patient #19's medical record revealed that ARNP K admitted Patient #19 to the CAH on 1/08/21 for treatment of pain. The medical record lacked documentation that ARNP K notified a physician that ARNP K admitted Patient #19 to the CAH for inpatient medical care.

2. Review of Patient #20's medical record revealed that ARNP K admitted Patient #20 to the CAH on 1/10/21 for treatment of Patient #20. The medical record lacked documentation that ARNP K notified a physician that ARNP K admitted Patient #20 to the CAH for inpatient medical care.

3. Review of Patient #21's medical record revealed that ARNP K admitted Patient #21 to the CAH on 1/9/21 for treatment of Covid-19. The medical record lacked documentation that ARNP K notified a physician that ARNP K admitted Patient #21 to the CAH for inpatient medical care.

4. Review of Patient #22's medical record revealed that ARNP K admitted Patient #22 to the CAH on 1/10/21 for treatment of Patient #22. The medical record lacked documentation that ARNP K notified a physician that ARNP K admitted Patient #22 to the CAH for inpatient medical care.

5. Review of Patient #18's medical record revealed that ARNP C admitted Patient #18 to the CAH on 2/21/20 for treatment of Patient #18's Pneumonia. The medical record lacked documentation that ARNP C notified a physician that ARNP C admitted Patient #18 to the CAH for inpatient medical care.

6. Review of the CAH's policies revealed the CAH lacked a policy requiring an ARNP to notify a physician when the ARNP admitted a patient to the CAH for inpatient medical care.

7. Review of the CAH's "Medical Staff Rules and Regulations," revised 4/2019, revealed the rules and regulations lacked a requirement for the ARNP to notify a physician when the ARNP or PA admitted a patient to the CAH for inpatient medical care.

8. During an interview on 1/13/21 at 11:30 AM, the Chief Nursing Officer verified the medical records lacked documentation that ARNP C and ARNP K notified a physician when they admitted the patients to the CAH for inpatient medical care. The Chief Nursing Officer also verified the CAH lacked a requirement for an ARNP to notify a physician when an ARNP admitted a patient to the CAH for inpatient medical care.

Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 Emergency Medicine physicians and 2 of 2 Radiologists, selected for review received outside entity peer review by the appropriate entity, 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. (Emergency Medicine Physician A, Emergency Medicine Physician F, Radiologist D, and Radiologist E).

The CAH administrative staff identified the identified physicians provided care to patients from 9/1/20 to 11/30/20 as follows:

Emergency Medicine Physician A provided care to 446 emergency room patients.
Emergency Medicine Physician F provided care to 254 emergency room patients.
Radiologist D provided imaging studies for 240 patients.
Radiologist E provided imaging studies for 526 patients.

Findings include:

1. Review of the CAH's network agreement, effective 7/1/08, revealed in part "Assist Hospital in identifying and arranging for qualified physicians and other practitioners to consult with Hospital on peer review matters as needed, including but not limited to the establishment of standards and protocols, the provision of peer review..."

2. Review of the CAH's Physician Services Agreement, effective 01/2019, revealed in part "Client desires the results of a Peer Review for the express purpose of quality improvement; ... Client desires to engage [Network Hospital] to provide such Peer Review as described in this Agreement and [Network Hospital] desires to provide such services to Client ... [Network Hospital] shall perform Services in accordance with the accepted standard of care in the professional specialties ...".

3. Review of a CAH agreement titled "Radiology Information Services Agreement", effective 2/26/07, revealed in part "This Radiology Information Services Agreement ("Agreement") is between [Radiology Entity A], an Iowa Professional Limited Liability Company and [CAH] ..." and identified radiology services the company would provide both onsite and from a distant site.

4. Review of the CAH Medical Staff Bylaws, dated 4/2019, revealed in part "Peer recommendations concerning professional competency are part of the basis for the development of recommendations for continued membership on the Medical Staff for the delineation of individual clinical privileges ... Each recommendation concerning the reappointment shall be based upon such member's professional competency and clinical judgement in the treatment of patients ..."

5. Review of an undated CAH policy "Medical Staff Credentialing and Privileging Policy," revealed in part "All Medical Staff providers are subject to [CAH] Peer Review policy. Results of Peer Reviews will assist in approval and recommendation process of reappointment requests ..."

6. Review of external peer review for the selected physicians revealed the medical staff approved Emergency Medicine Physician A for reappointment to the Medical Staff on 2/22/19. The Board of Trustees approved Physician A for reappointment to the Medical Staff on 2/28/19. Physician A lacked results of any external peer review conducted by the Network Hospital, prior to Physician A's reappointment to the Medical Staff.

7. Review of external peer review for the selected physicians revealed the medical staff approved Emergency Medicine Physician F for reappointment to the Medical Staff on 2/22/19. The Board of Trustees approved Physician F for reappointment to the Medical Staff on 2/28/19. Physician F lacked results of any external peer review conducted by the Network Hospital, prior to Physician F's reappointment to the Medical Staff.

8. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist D for reappointment to the Medical Staff on 1/27/20. The Board of Trustees approved Radiologist D for reappointment to the Medical Staff on 2/27/20. Radiologist D lacked results of any external peer review conducted by the Network Hospital, prior to Radiologist D's reappointment to the Medical Staff.

9. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist E for reappointment to the Medical Staff on 4/30/20. The Board of Trustees approved Radiologist E for reappointment to the Medical Staff on 5/20/20. Radiologist E lacked results of any external peer review conducted by the Network Hospital, prior to Radiologist E's reappointment to the Medical Staff.

10. During an interview on 1/12/21, beginning at 12:30 PM, the Chief Operating Officer and Quality/Infection Control Nurse reported their Network Hospital conducts the majority of the external peer review completed on their medical staff. They reported a [Hospital A] physician conducts external peer review for the Emergency Medicine physicians and [Radiology Entity A] conducts external peer review on the Radiology physicians. The Chief Operating Officer and Quality/Infection Control Nurse confirmed they did not have any external peer review completed by their Network Hospital for Emergency Medicine Physician A, Emergency Medicine Physician F, Radiologist D, and Radiologist E prior to their reappointment to medical staff.

11. During an interview on 1/13/21, at 8:30 AM, the Chief Operating Officer reported she discovered their Network Hospital had completed external peer review on Emergency Medicine Physician A and Emergency Medicine Physician F but the results went to the Radiology Director and confirmed the results failed to go through quality and had not been available for review prior to the physicians reappointment to medical staff.

I. Based on policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure all CAH departments developed policies/procedures to define the expected practice and performance in the provision of patient care services. The problem was identified for 1 of 1 applicable departments (Diabetes Education Program). The Diabetes Education Coordinator identified the program served approximately 5-8 patients daily.
Failure to ensure policies and procedures are developed and approved by the medical staff and governing body could potentially result in miscommunication of expected practices and performances in the provision of patient care and result in patients receiving less than optimal care or failure to provide the patient with the care and services needed resulting in patient harm.

Findings include:

1. Review of CAH policies and procedures for patient care services revealed a lack of policies and procedures for provision of the Diabetes Education service.

2. During an interview on 1/11/21 at 2:30 PM, the Diabetes Education Coordinator reported the Diabetes Education Program follows the American Diabetes Association (ADA) guidelines in the provision of patient care and the program does not maintain a set of policies and procedures specific to the Diabetes Education CAH service.

3. During an interview on 1/12/21 at 9:10 AM, the Chief Operating Officer confirmed the Diabetes Education Program follows ADA guidelines for patient care and the service does not have policies and procedures specific to the provision of care for CAH patients, approved by the CAH medical staff and governing body,



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II. Based on document review and staff interviews, the Critical Access Hospital failed to follow its own admission policies and procedures when the CAH admitting staff failed to obtain signed consent for treatment forms for 2 of 5 open inpatient records (Patient #19 and Patient #20), 1 of 3 open observation patient records (Patient #21), 4 of 6 ER closed records (Patients #24, Patient #25, Patient #26, and Patient #27), 1 of 5 surgical patient records (Patient #28), and 3 of 5 closed swing bed patient records (Patient #13, Patient #14 and Patient #16). Failure of the CAH staff to complete the consent for treatment process an form may result in a patient receiving care they do not want and the patient or authorized representative may not receive information such as a Patients Rights and Responsibilities, Notice of Privacy Practices, knowledge of billing information, and other information pertinent to the treatment or care provided. The CAH Administrative staff identified a census of 10 on entrance and 840 Inpatients,174 Swingbed patients, 6,906 ER Patients, and 767 surgical patients in Fiscal year 2019.

Findings include:

1. Review of the CAH policy, "Admission Status Procedure Inpatient Unit", undated, revealed in part, "All patients receiving treatment ... required to ... sign Consent for Treatment."

2. Review of the CAH policy, "Admitting an ER patient", undated, revealed in part, "Explain consent form ... have patient or authorized representative sign."

3. Review of CAH policy, "Admitting for OP Services", undated, revealed in part, "Explain consent form ... have patient or authorized representative sign."


4. Review of inpatient medical records on 1/12/21 at approximately 1:30 PM revealed the following:

a. Patient #19, admitted to the CAH inpatient unit on 1/8/2021 for care and treatment, lacked a signed Consent for Treatment form in Patient #19's open medical record.

b. Patient #20, admitted to the CAH inpatient unit on 1/10/2021, for care and treatment lacked, a signed Consent for Treatment form in Patient #20's open record.

c. Patient #21, placed on observation status on the CAH inpatient unit for care and treatment on 1/07/2021, lacked a signed Consent for Treatment form in Patient #21's open medical record.


Review of ER patient medical records on 1/12/2021 at approximately 9:00 revealed the following:

a. Patient #24, admitted to the ER for emergency care and treatment on 1/4/2021, lacked a signed Consent for Treatment form in Patient #24's closed medical record.

b. Patient #25, admitted to the ER for emergency care and treatment on 11/2/2020, lacked a signed Consent for Treatment form in Patient # 25's closed medical record.

c. Patient #26, admitted to the ER for emergency care and treatment on 12/30/2020, lacked a signed Consent for Treatment form in Patient # 26's closed medical record.

d. Patient #27, admitted to the ER for emergency care and treatment on 11/20/2020, lacked a signed Consent for Treatment form in Patient # 27's closed medical


Review of Surgical Records on 1/12/2021 at 11:30 AM revealed Patient #28, admitted to the CAH for a surgical procedure on 9/29/2020, lacked a signed Consent for Treatment form in Patient 28's closed medical record.


Review of Swingbed Patient Records on 1/12/2021 3:30 PM and 1/13/2020 8:30 AM revealed the following:

a. Patient #13, admitted to the inpatient unit for swingbed services on 9/4/2020, lacked a signed Consent for Treatment form in Patient #13's closed medical record.

b. Patient #14, admitted to the inpatient unit for swingbed services on 3/21/2020, lacked a signed Consent for Treatment form in Patient #14's closed medical record.

c. Patient #16, admitted to the inpatient unit for swingbed services on 12/13/2020, lacked a signed Consent for Treatment form in Patient #16's closed medical record.



5. During an interview, on 1/12/2021, at the time of the record review, the Compliance Officer acknowledged the medical records lacked signed Consent for Treatment forms and that the forms should have been completed and a part of the medical record. The Compliance Officer also acknowledged she was not aware of the lack of a signed consent form on every patient.

6. During an interview, on 1/13/2021 at 9:33 AM, CFO acknowledged the above cited medical records lacked signed Consent for Treatment forms and verbalized she was not aware this had been a problem prior to the survey.

Based on review of policies/procedures, meeting minutes, documents, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician, and a midlevel provider reviewed all patient care policies annually for 15 of 18 patient care departments (In Patient, Diabetes Education, Health Information Management, Emergency, Specialty Clinic - Neurology, Perioperative Services, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Environmental Services, Infection Control, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, and Plant Operations). The CAH administrative staff identified a census of 9 patients at the beginning of the survey. Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the policy "WCHC Policy on Policies," approved 6/5/19, revealed in part, "... All patient care policies will be reviewed annually by the Patient and Resident Care Review Committee at which time the committee will have the opportunity to recommend changes to the policies."

2. Review of the "Patient and Resident Care Review Committee Meeting" minutes, dated from 1/21/20 through 12/16/20, lacked annual approval for all policies for In Patient, Diabetes Education, Health Information Management, Emergency, Specialty Clinic - Neurology, Perioperative Services, Pharmacy, Rehabilitation Services, Cardiac Rehabilitation, Environmental Services, Infection Control, Respiratory Therapy, Wound, OTIC - Out Patient Infusion Center, and Plant Operations.

3. During an interview on 01/13/2021 at 8:45 AM, the Chief Operating Officer (COO) stated all policies were reviewed by the departments and then go to the Patient and Resident Care Review Committee (PRCRC) where a physician and a mid-level provider attend. The PRCRC only looks at new or revised policies. The COO acknowledged not all patient care policies were reviewed annually by the required group of professionals.

Based on policy/procedure, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure timely physician notification for the occurrence of a medication error for 11 of 15 medication errors reviewed. (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, and Patient #11). The CAH administrative staff reported a census of 9 patients at the beginning of the survey. Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction.

Findings include:

1. Review of the policy "Occurrence Reporting," dated 7/18/18, revealed in part, "The purpose of the Occurrence Reporting Policy is to provide a system for promptly reporting and investigating occurrences which include defects, errors, medical incidents, near misses, significant procedure variances, or other risks to safety that could result in patient or employee injury, hazardous condition or risk in the environment of care ... Each occurrence involving a patient will be documented in the medical record at the time it occurred or was discovered. Documentation will include ... date/time of provider notification."

2. Review of medication errors from 1/19/20 to 11/22/20 revealed the following:

a. The nursing staff made a medication error (incorrect route administered) on 11/22/20 at 9:23 AM which involved Patient #1. Patient #1's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #1's medical care of the medication error.

b. The nursing staff made a medication error (wrong medication administered) on 09/13/20 at 8:50 AM which involved Patient #2. Patient #2's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #2's medical care of the medication error.

c. The nursing staff made a medication error (wrong medication administered) on 04/26/20 at 6:25 PM which involved Patient #3. Patient #3's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #3's medical care of the medication error.

d. The nursing staff made a medication error (medication ordered not given) on 11/28/20 at 9:00 PM which involved Patient #4. Patient #4's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #4's medical care of the medication error.

e. The nursing staff made a medication error (medication ordered not given) on 11/07/20 at 7:10 PM which involved Patient #5. Patient #5's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #5's medical care of the medication error.

f. The nursing staff made a medication error (wrong dose) on 10/19/20 at 4:30 AM which involved Patient #6. Patient #6's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #6's medical care of the medication error.

g. The nursing staff made a medication error (wrong medication) on 09/04/20 at 8:56 PM which involved Patient #7. Patient #7's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #7's medical care of the medication error.

h. The nursing staff made a medication error (medication ordered not given) on 08/16/20 at 3:00 AM which involved Patient #8. Patient #8's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #8's medical care of the medication error.

i. The nursing staff made a medication error (wrong time) on 08/07/20 at 1:00 AM which involved Patient #9. Patient #9's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #9's medical care of the medication error.

j. The nursing staff made a medication error (medication ordered not given) on 03/18/20 at 12:00 AM which involved Patient #10. Patient #10's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #10's medical care of the medication error.

k. The nursing staff made a medication error (wrong dose) on 01/28/20 at 6:47 PM which involved Patient #11. Patient #11's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #11's medical care of the medication error.


3. During an interview on 01/11/2021 at 4:15 PM and 01/12/21 at 9:00 AM, the Chief Nursing Officer (CNO) acknowledged the medication error paperwork for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, and Patient #11 lacked documentation that the nursing staff notified the patient's provider of the medication error.

Based on observation, document review, and staff interviews, Critical Access Hospital (CAH) administration failed to ensure the CAH staff tested the laboratory staff members for color blindness so laboratory staff could correctly read results for occult blood (blood in the stool) in 2 of 2 laboratory staff (Staff I and Staff J). The CAH identified laboratory staff performed 165 occult blood tests from January 1, 2020 to December 31, 2020. Failure to test laboratory staff for color blindness before performing this test may result in providers misreading the results of the Hemoccult slide which could potentially adversely affect the diagnosis and treatment plan for patients.

Findings include:

1. Observation on 1/6/21 at 10:10 AM, during a tour of the Laboratory with the Laboratory Director, revealed the laboratory staff utilized Beckman Coulter Hemoccult Slides for testing of occult blood (blood in the stool).

2. During an interview on 1/6/2021 at 10:25 AM, the Laboratory Director reported the laboratory staff had not been color blind tested but were tested today after found out the staff had not been tested. The Laboratory Director acknowledged the laboratory staff read and interpreted the results of fecal occult blood tests.

3. Review of documentation revealed the CAH staff did not perform color blindness testing on Laboratory Staff I and Laboratory Staff J until after the tour of the Laboratory with the Laboratory Director at 1/6/21 at 10:10 AM.

4. Review of the manufacturer's directions for the Beckman Coulter Hemoccult Slides, dated January 2014, revealed in part, "The Hemoccult test is a rapid and qualitative method for detecting fecal occult blood (blood in the stool) ... Because this test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness)."

Based on document review and staff interviews, the Critical Access Hospital (CAH) Administrative Staff failed to create and implement written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reason for the clinical restriction or limitation. Failure to create and implement written policies and procedures regarding visitation rights of patients may result in a violation of patients rights and lack of the health and safety benefits visitation may provides the patient. The CAH's administrative staff identified a census of 10 patients on entrance, and 6906 ER patients, 1,014 inpatients and 53,937 outpatient visits in Fiscal year 2019.

Findings include:

1. Review of the CAH policy index revealed the CAH lacked a policy related to the visitation rights of patients.

2. During an interview on 1/13/2021 at 11:30 AM, the Chief Nursing Officer ackowledged the CAH lacked a policy on the visitation rights of patients.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to inform each patient of their visitation rights, including any clinical restriction or limitation on such rights, and the reasons for the clinical restriction or limitation for the inpatient unit, outpatient services, and emergency department. Failure to inform each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The CAH's administrative staff identified a census of 10 patients on entrance, and 6,906 ER patients, 1,014 inpatients and 53,937 outpatient visits in Fiscal year 2019.

Findings include:

1. Observation during a tour of the inpatient unit on 1/04/21 at 3:40 PM revealed the CAH staff displayed the "Patient Rights and Responsibilities" brochure at the nurses' station.

2. Observations during a tour of the outpatient and inpatient registration area on 1/04/21 at 3:30 PM revealed the CAH staff displayed the "Patients Rights and Responsibilities" brochure on the registration counter.

3. Observations during a tour of the ER on 1/05/21 at 1:15 PM revealed the CAH staff displayed the "Patient Rights and Responsibilities" brochure at the nurses' station.

4. Review of the brochure "Patient Rights and Responsibilities," revealed the brochure lacked information to inform patients and/or their support person of the reasons the CAH staff could place clinical restrictions or limitations on the patient's right to receive visitors.

5. Review of inpatient and outpatient medical records revealed the records lacked documentation that the required notice of the patient's visitation rights was provided to the patient or, if appropriate, the patient's support person.

6. During an interview on 1/12/2021, at the time of record review, the Compliance Officer acknowledged all patient medical records lacked documentation that the required visitation rights notice was provided to the patient or the patient's support person.

7. During an interview on 1/13/21 at 11:30 AM, the Chief Nursing Officer confirmed the CAH staff provide the brochure "Patient Rights and Responsibilities" to all patients at registration or admission. The Chief Nursing Officer acknowledged the CAH staff failed to document in the patient's medical record the the required visitation rights notice was provided to the patient or the patient's support person.

Based on policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the abuse policy addressed all allegations that involved abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with the regulations. The CAH administrative staff identified 174 swing bed patient admissions from July 2018 to June 2019. Failure to include the required statutory language in the abuse policy could potentially result in CAH staff failing to notify the State Agency of the abuse allegation and failing to ensure that CAH staff investigated all allegations of abuse in a timely manner.

Findings include:

1. Review of the policy "Abuse Prevention," dated 10/13/2014, failed to include the requirement that all allegations which involved abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with the regulations.

2. During an interview on 01/12/2021 at 9:50 AM, The Chief Nursing Officer acknowledged the CAH's Abuse Prevention Policy did not include the statutory language per the regulations.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 1 of 1 open swing bed patients (Patient #1), and 4 of 5 closed swing bed patients (Patient #13, Patient #14, Patient #16, and Patient #17). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition. The CAH administrative staff identified 174 swing bed patient admissions in fiscal year 2019 and a census of 1 swing bed patient on entrance.

Findings included:

1. Review of Patient #12's open medical record revealed the CAH staff admitted Patient #12 for swing bed level care on 1/7/2021, diagnosed with weakness secondary to condition. Advanced Registered Nurse Practitioner B (ARNP, a nurse with advanced training who may write prescriptions) wrote an order on 1/7/21 at 5:03 PM for the Physical Therapist to evaluate and treat Patient #12 and for the Occupational Therapist to evaluate and treat Patient #12.

2. Review of Patient #13's closed medical record revealed the CAH staff admitted Patient #13 for swing bed level care on 09/04/2020, diagnosed with acute osteomyelitis, right ankle and foot (an infection of the bones in the foot and ankle). The CAH staff discharged Patient #13 on 10/11/20. ARNP C wrote an order on 9/4/20 at 9:45 AM for the Physical Therapist to evaluate and treat Patient #13 for weakness secondary to their condition and ARNP H wrote an order on 10/01/2020 at 1:56 PM for the Physical Therapist to evaluate and treat Patient #13 due to decreased mobility.

3. Review of Patient #14's closed medical record revealed the CAH staff admitted Patient #14 for swing bed level care on 03/21/2020, diagnosed with acute respiratory failure. The CAH staff discharged Patient #14 on 3/26/20. ARNP K wrote an order on 3/26/20 at 9:29 AM for the Physical Therapist and the Occupational Therapist to evaluate and treat Patient #14. The Physical Therapy Evaluation was completed on 3/21/20 at 2:50 PM and the Occupational Therapist attempted to evaluate Patient # 14 twice on 3/23/20.

4. Review of Patient #16's closed medical record revealed the CAH staff admitted Patient #16 for swing bed level care on 12/13/20, diagnosed with lobar pneumonia. The CAH staff discharged Patient #16 on 12/15/20. ARNP K wrote an order on 12/13/20 at 10:54 AM for the Physical Therapist to evaluate and treat Patient #16 and for the Occupational Therapist to consult Patient #16 for therapeutic activities.

5. Review of Patient #17's closed medical record revealed the CAH staff admitted Patient #17 for swing bed level care on 08/06/2020, diagnosed with cellulitis of right lower limb (a skin infection of the right leg). The CAH staff discharged Patient #17 on 8/11/20. ARNP H wrote an order on 8/6/20 at 10:31 AM for the Physical Therapist to evaluate and treat Patient #17. ARNP K wrote an order on 8/10/20 at 2:51 PM for the Occupational Therapist to evaluate and treat Patient #17.

7. During an interview on 1/12/21, at the time of the record review, the Compliance Officer acknowledged that ARNP B, ARNP H, ARNP J, and ARNP K wrote the therapy orders for Patient #12, Patient #13, Patient #14, Patient #16, and Patient #17 when the patients received swing bed services. The Compliance Officer acknowledged a physician did not write the therapy orders for Patient #12, Patient #13, Patient #14, Patient #16, and Patient #17.

8. During an interview on 1/13/2021 at 11:00 AM, the Chief Nursing Officer (CNO) was not aware of the requirement of physicians, either MD or DO, to order specialized rehabilitation therapies for swingbed patients and acknowledged that the facilities ARNP hospitalists order the specialized therapies for the CAH swingbed patients. The CNO verbalized the CAH does not have a policy identifying which providers may order specialized rehabilitation services for swing bed patients.