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Based on observation and interview, the facility failed to ensure the proper disposal of trash and failed to maintain policies and procedures for proper storage and disposal of trash, as required per regulations. (photographic evidence obtained)

The findings were:

On 11/14/17 at approximately 1:35 pm, during a tour with the Housekeeping Director, an observation was made of the facility's dumpster area. It was observed to be a fenced in area with a separate attached fenced in area specifically for cardboard boxes. The dumpster had six areas with lids in which the trash could be contained. Of the six lids, one lid was fully open and one lid was partially open. The trash dumpster had a black trash bag, which appeared full, laid on top of the fully open lid. On the ground near the dumpster, there was debris which included a styrofoam cup, gloves, a plastic cup, paper, and a plastic drink bottle. There were also miscellaneous papers strewn throughout the area where the cardboard boxes were held. At that time, an interview was conducted with the Housekeeping Director. He stated that it was the responsibility of the work-study student employee to clean the grounds and he would speak with him about it that day. He further stated the work-study student was not employed by the facility, but paid through a school-work program to work two hours per day.

On November 15, 2017 at approximately 10:16 am, a second observation of the dumpster area was made. Debris of a styrofoam cup, gloves, a plastic cup, paper, and a plastic drink bottle remained on the ground on the right side dumpster. The area for the cardboard boxes continued to have miscellaneous papers strewn throughout the area. Of the six dumpster lids, one lid continued to be fully open and one lid continued to be partially open.

On November 15, 2017 at approximately 1:13 pm, a third observation of the dumpster area was made. The debris on the right side of the dumpster had been removed. In the cardboard box area, miscellaneous papers remained strewn throughout the area. Of the six dumpster lids, one lid continued to be fully open and one lid continued to be partially open.

On November 16, 2017 at approximately 9:02 am, a fourth observation of the dumpster area was made. The cardboard box area continued to have miscellaneous papers strewn throughout. Of the six dumpster lids, one lid continued to be fully open and one lid continued to be partially open.

An interview with the Housekeeping Director was conducted on November 16, 2017 at approximately 9:09 am. He stated that a work-study student came every day from 3:00pm-5:00pm and did rounds. He explained that the work-study student's rounds included cleaning the grounds around the hospital, picking up trash on the grounds, and cleaning the dumpster and cardboard box area. He stated that he does not know why the student did not clean the area for the past two afternoons and that staff should not be throwing paper in the area for cardboard boxes. He further stated that he would clean the area immediately.

A follow-up interview was conducted with the Housekeeping Director on November 16, 2017 at approximately 9:33 am. He stated the facility did not have any written policies and procedures for garbage disposal, only biohazardous waste.

Based on interview and facility record review, the facility failed to ensure the annual review of the utilization of CAH (Critical Access Hospital) services included the number of patients served and the volume of services provided.

The findings include:

On 11/15/2017 at approximately 2:30pm interviews were conducted with the two registered nurse case managers who performed utilization review for appropriateness of admission. The case managers indicated they reviewed every admission, and worked with the hospitalist if there was ever a change in a patient's condition. Both were unaware of any utilization review committees within the hospital.

The governing board meeting minutes for 09/25/2017 indicated, "Utilization Review - Case management. Reporting on swing beds. An increased focus on ensuring swing bed activities requirements are met. Group tracks swing bed admission. In October started collecting info on interventions, readmissions."

A review of the facility's "Utilization Review" policy indicated "the purpose of this policy is to ensure standardized utilization review processes are conducted in accordance with regulatory requirements, accreditation standards and payer contracts for patients admitted to inpatient or observation status."

The medical staff (MS) bylaws were reviewed and indicated the MS shall conduct utilization review studies designed to evaluate the appropriateness of admissions to the hospital, lengths of stay, discharge practices, use of medical and hospital services, all related factors which may contribute to the effective utilization of hospital services, and over utilization of each of the hospital's services affecting the quality of patient care provided at the hospital. Utilization review studies shall study patterns of care and obtain criteria relating to average or normal lengths of stay by specific disease categories and shall evaluate systems of utilization review employing such criteria. It shall also work towards the assurance of proper continuity of care upon discharge through the accumulation of appropriate data on services outside the hospital. The committee shall communicate the results of its studies and other pertinent data to the entire medical staff and shall make recommendations for the optimum utilization of hospital resources and facilities commensurate with quality of patient care and safety.

On 11/16/2017 at 09:25am an interview was conducted with the Chief Executive Officer (CEO). The CEO was asked about the facility's peer review and utilizattion review process. He stated, " I would say we don't have what we need to have." He indicated that this was brought up in the Quality Assurance and Performance Improvement review and that the process needed to be restructed. He confirmed there was no current utilization review process.

Based on interviews and facility record review, the facility failed to ensure an annual review of the utilization of CAH (Critical Access Hospital) services, including the evaluation of active and closed clinical records.

The findings include:

On 11/15/2017 at approximately 2:30pm interviews were conducted with the two registered nurse case managers who performed utilization review for appropriateness of admission. The case managers indicated they reviewed every admission, and worked with the hospitalist if there was ever a change in a patient's condition. Both were unaware of any utilization review committees within the hospital.

The governing board meeting minutes for 09/25/2017 indicated, "utilization review - case management reporting on swing beds. An increased focus on ensuring swing bed activities requirements are met. Group tracks swing bed admissions, in October started collecting information on interventions, readmissions."

A review of the facility's "utilization review" policy indicated "the purpose of this policy is to ensure standardized utilization review processes are conducted in accordance with regulatory requirements, accreditation standards and payer contracts for patients admitted to inpatient or observation status."

The medical staff (MS) bylaws were reviewed and indicated the MS shall conduct utilization review studies designed to evaluate the appropriateness of admissions to the hospital, lengths of stay, discharge practices, use of medical and hospital services, all related factors which may contribute to the effective utilization of hospital services, and over utilization of each of the hospital's services affecting the quality of patient care provided at the hospital. Utilization review studies shall study patterns of care and obtain criteria relating to average or normal lengths of stay by specific disease categories and shall evaluate systems of utilization review employing such criteria. It shall also work towards the assurance of proper continuity of care upon discharge through the accumulation of appropriate data on services outside the hospital. The committee shall communicate the results of its studies and other pertinent data to the entire medical staff and shall make recommendations for the optimum utilization of hospital resources and facilities commensurate with quality of patient care and safety.

On 11/16/2017 at 09:25am an interview was conducted with the Chief Executive Officer (CEO). The CEO was asked about the facility's peer review and utilizattion review process. He stated, " I would say we don't have what we need to have." He indicated that this was brought up in the Quality Assurance and Performance Improvement review and that the process needed to be restructed. He confirmed there was no current utilization review process.

Based on interviews, medical staff record reviews and review of the facility's medical staff and governing body bylaws, the facility failed to ensure that medical staff were appointed/reappointed for membership to the medical staff and that the process for requesting and granting of clinical privileges was in accordance with the facility's bylaws for 7 of 8 medical staff records reviewed. (Medical Staff Members Z, Y, W, X, S, U & T)

The findings include:
On 11/13/2017 at approximately 4:30pm, medical staff file reviews were conducted with the assistance of the Director of Health Information Management (HIM). The Director stated that approximately 60 days before the staff member's privileges expired, they were sent a "Request for Privileges for Staff Appointment / Reappointment." She stated that when the request was returned to her, it would go to be signed by the board, and then go for verification which was done by an outside company. The CEO then approached and sat down and asked if the director needed any help. The CEO was asked about what information he received, as a member of the board, to determine the reappointment of staff members. He stated the director got all the information together for them and they reviewed it and signed off on it. I asked if there was documentation of this reflected in the governing body meeting minutes, and he stated, "probably not." I questioned whether the information received included data captured from the outside verification company, and he stated, "yes."

Review of medical staff files revealed the following:
Medical Staff Member Z - completed a request for privileges for staff appointment/reappointment on 01/19/2016. The chief of staff, administrator and governing body signed off on this on 02/19/2016. The file contained a letter, without a date, that indicated "re-appointed to the active medical staff of Calhoun Liberty Hospital for a period of two (2) years beginning January 1, 2016. The medical staff member was granted reappointment before his application had been received or reviewed.

Medical Staff Member Y - completed a request for privileges for staff appointment/reappointment on 04/04/2016. The chief of staff, and administrator signed off on this on 04/13/2016. The file contained a letter, without a date, that indicated "re-appointed to the active medical staff of Calhoun Liberty Hospital for a period of two (2) years beginning April 11, 2016. The medical staff member was granted reappointment before his application had been reviewed.

Medical Staff Member W - completed a request for privileges for staff appointment/reappointment on 07/06/2016. There was no documentation of peer review by the chief of staff, administrator, or governing body. An undated letter indicated "you are hereby appointed to the active medical staff of Calhoun Liberty Hospital for a period of two (2) years beginning July 1, 2016." The medical staff member was granted reappointment before his application had been received or reviewed.

Medical Staff Member X - completed a request for privileges for staff appointment/reappointment on 05/02/2016. There was no documentation of peer review by the chief of staff, administrator, or governing body. An undated letter indicated "you are hereby appointed to the active medical staff of Calhoun Liberty Hospital for a period of two (2) years beginning May 2, 2016." The medical staff member was granted reappointment before his application had been received or reviewed.

Medical Staff Member S - completed a request for privileges for staff appointment/reappointment; however, there was no name on the document to indicate who completed the application, nor was there a signature to confirm the accuracy of the information documented. There was an attached reappointment request questionnaire with the first question being: "do you wish re-appointment to the professional staff of Calhoun-Liberty Hospital?" This question was marked "no." An undated letter indicated "you are hereby re-appointed to the active medical staff of Calhoun-Liberty Hospital for a period of two (2) years beginning October 8, 2016." There was a verification report for re-credentialing dated 10/02/2017, but there was no documentation to support reverification of credentialed information at the time the staff member applied for reappointment in 2016. There was no documented peer review.

Medical Staff Member U - record review failed to locate a delineation of privileges or an application for re-appointment. There was an undated letter that indicated "the credentialing committee of Calhoun Liberty Hospital in Blountstown, Florida reviewed your application for medical staff re-appointment and clinical privileges. It is our pleasure to inform you that you are granted privileges in each of those areas requested.You are hereby re-appointed to the active medical staff of Calhoun Liberty Hospital for a period of 2 years beginning July 19, 2016." There was no documented peer review.

Medical Staff Member T - completed a request for privileges for staff appointment/reappointment with a signature and date that was not legible. The chief of staff's recommendations identified a signature date of 2/11/2016, and recommendation by the governing body was signed on 01/07/2016. There was a recredentialing verification report emailed on 01/11/2016. There was an undated letter indicating "the credentialling committee of Calhoun Liberty Hospital in Blountstown, Florida received and reviewed your application for emergency department staff appointment and clinical privileges. It is our pleasure to inform you that you are granted privileges in each of the areas requested. You are hereby appointed to the active emergency department staff of Calhoun Liberty Hospital as an ARNP for a period of 2 years beginning 12/01/2015." There was no evidence of peer review, and the practitioner was granted privileges before her reappointment application had been completed and reviewed by the chief of staff and governing body.

On 11/16/2017 at 09:25am an interview was conducted with the Director of Health Information Management (HIM) and the Chief Executive Officer (CEO). The Director of HIM, the person responsible for ensuring physician credentialing, was asked about the facility's peer review process. The director had no idea what peer review was. The CEO was asked about the facility's peer review and utilizattion review process, and stated, " I would say, we don't have what we need to have." He confirmed there was no current peer review or rtilization review process.

A review of the hospital's medical staff bylaws indicated an application form for initial appointment and reappointment shall be developed by adminsitration in conjunction with the executive committee, and approved by the governing board. The form shall require detailed information which shall include the applicant's qualifications, peer references familiar with the applicant's medical competence and ethical character, a request for membership categories and clinical privileges, past or pending medical disciplinary actions, physical and mental health status, final judgments or settlements, and medical liability coverage. It further stated that the appointment/reappointment application should be filed at least 120 days prior to expiration date of current staff appointment. If application for reappointment is not received 45 days prior to expiration date, written notice shall be promptly sent to applicant. If the application is not received 30 days prior the expiration date, then the staff member shall be deemed to have resigned his or her staff privileges. The completed application shall be submitted to the credentialling committee for renewal of appointment to the staff for the coming two years subject to the governing board actions.

A review of the facility governing body bylaws indicated the board delegated the responsibility and authority to investigate and evaluate all matters relating to medical staff membership status, clinical privileges and corrective action, and shall require that the staff adopt and forward to the board and quality of care committee, specific written recommendations with appropriate supporting documentation that would allow the board to take informed action. The procedure for this process stated application for membership on the medical staff shall be presented to the CEO (Chief Executive Officer), who collects or verifies the information or evidence submitted. When collection and verification is accomplished, the Chief Executive Officer shall transmit the application to the medical staff credentialing committee who shall review the application as prescribed in the Medical Staff by-laws and recommend to the entire medical staff that the application be accepted, defined, or rejected.

A review of the facility's governing board meeting minutes for the last four quarters failed to include staff appointments/reappointsments and/or credentialling information.

Based on observation, interview and record review, the facility failed to establish or implement quality improvement projects to address concerns identified by the Quality Assurance Performance Improvement (QAPI) committee for 3 of 3 identified concerns.

The findings include:

On 11/14/2017 a review of the QAPI committee meeting minutes for September and October 2017 revealed the committee had identified three areas of concern to include hand hygiene, policies not being updated, and patients leaving against medical advice (AMA), elopements and leaving without being seen (LWBS) in the emergency department. Further review of the committee meeting minutes revealed the committee discussed the 80% hand hygiene compliance rate and the identification that the grievance reports for the AMA, elopements and LWBS were actually complaints and that the policy should be updated to change the category.

On 11/15/2017 at approximately 10:00 AM an interview was conducted with the risk manager who stated that she was aware of the areas of concern discussed during the QAPI meetings and stated that the policy update for changing the AMA, Elopements and LWBS from grievances to complaints was changed, but she was not sure how this would impact the events. She stated that the facility had identified that the high rate of AMAs, elopements and LWBS were the result of the population they serve and not any wrong doing on the part of the facility. She also stated that she was aware that hand hygiene was a concern as well, but that she had not instituted the recommended performance improvement plan to improve compliance. She also stated that the policies for the hospital were under review, but that many, including the policies utilized by the nursing staff, had not been updated or reviewed in several years.

An interview was conducted with the Chief Nursing Officer (CNO) on 11/15/2017 at approximately 1:45 PM in which she stated she was aware that the facility policies had not been updated in a while. She reported she was new to the position as CNO and had interviewed the nursing staff regarding how they followed policy and was told they utilized "Lippincott," a nursing guide which was several years old. She stated that other than the Lippincott guide, the nursing staff were not aware the facility had policies that directed the care they provided. She stated that this issue was a priority for her, and would be one of the first changes she made in her new role.

A review of the facility Hospital Wide Policy and Procedure Manual found the manual had not been reviewed by administration, the governing board, or the QAPI Committee since 2014, as evidenced by a dated signature sheet. Upon further review of the manual, three blank signature sheets were noted on top of the 2014 sheet; however, these sheets were blank with the exception of the top sheet which had written in pencil "November 30, 2017" in the upper left hand corner.