HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell NKB021.
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Based on interview and document review, the Critical Access Hospital's Governing Body failed to periodically review their bylaws as directed in their bylaws.

Failure to periodically review bylaws risks inappropriate oversight and outdated practice.

Findings included:

1. Document review of the hospital's document titled, "Public Hospital District No. 1, Okanogan and Douglas Counties, Washington, d/b/a Three Rivers Hospital, Board of Commissioners Bylaws," dated 02/27/18, showed that the bylaws shall be periodically reviewed, at least once every two years and revised as appropriate.

2. On 02/05/25 at 3:30 PM, Surveyor #4 reviewed the hospital's Board of Commissioners (governing body) Bylaws and meeting minutes from 2024 and 2025 to date. The surveyor noted that the bylaws had not been updated since 02/27/18. Surveyor #4 interviewed the Chief Operating Officer (Staff #401) about the bylaws and whether there were any updated versions. Staff #401 confirmed that the 2018 dated bylaws were the most current reviewed version.
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Item #1 - Nephrostomy tube care policy

Based on record review and interview, the hospital failed to develop and implement policies and procedures to define standards of care for nephrostomy tube patients.

Failure to develop and implement policies and procedures risks inappropriate and/or ineffective patient care and poor patient outcomes.

Reference: Agency for Clinical Innovation, Management of patients with nephrostomy tubes Nursing toolkit, (2022). Management principles in the acute care setting; all nephrostomy tubes must be checked for patency and abnormal signs or symptoms (e.g. pain, leakage, bleeding, tubing placement) at least once per 8-10-hour shift; at every bedside handover, or as required in the acute care setting.

Findings included:

1. On 02/06/25 between 9:15 AM and 12:30 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 2 inpatients and 4 Swingbed patients admitted to the medical/surgical unit. The review showed Patient #217 was a 64-year-old female admitted as a Swingbed patient to the medical/surgical unit on 09/27/24 with a diagnosis of strengthening (PT/OT) post pyelonephritis and a history of uterine cancer with a left sided nephrostomy tube. Surveyor #2 found no evidence of documented care for Patient #217's nephrostomy tube.

2. On 02/06/25 at 10:15 AM, Surveyor #2 interviewed Staff #201 what the policy is for routine nephrostomy tube care. Staff #201 stated the facility does not have a policy for nephrostomy tube care, however the facility refers to Lippincott's Nursing Procedures for care. Staff #201 reviewed Lippincott's Nursing Procedures for nephrostomy tube care and could not find specific information pertaining to timeframes for nephrostomy tube care.

3. At the time of the review, Staff #201 verified there was no documentation in the medical record for nephrostomy tube care.

Item #2 - Surgical time out

Based on observation, interview, and document review, the Critical Access Hospital failed to implement its policy and procedure for completing a surgical time out for 1 surgical time out observed (Patient #203).

Failure to systematically perform a time out risks medical errors and patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Fire Safety in the Operating Room," Policy Stat ID 15421622, last approved 07/24, showed the patient's fire risk needs to be communicated during the timeout procedure.

2. On 02/04/25 between 1:30 PM and 2:50 PM, Surveyor #2, the Chief Nursing Officer (Staff #201) and Surgical Services Manager (Staff #202) inspected the Operative Area. Surveyor #2 observed a surgical procedure of an inguinal hernia repair. Surveyor #2 observed that the surgical time out did not include a fire risk assessment or discussion.

3. After the observation, Staff #201 confirmed that there was not a fire risk assessment and discussion completed as part of the surgical time out process for the case observed as per policy.

Item #3 - Chemical restraint orders

Based on record review, interview, and document review of hospital policy and procedures, the hospital failed to ensure providers orders for restraint contained the appropriate order of restraints to be utilized for 2 of 2 patients placed in restraints reviewed (Patient #222 and #223).

Failure to place complete provider orders increases the risk of incorrect restraint application and risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Use of Patient Restraints," Policy Stat ID 17075325, last revised 11/24, showed the following:

a. A restraint is defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely. Use of measures to involuntarily restrain movement of the whole or a portion of a patient's body; as a means of modifying a patient's behavior, in a patient who does not require medical immobilization; adaptive support or those patients not requesting voluntary immobilization.

b. A physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove, that restricts freedom of movement or normal access to one's body.

c. A chemical restraint is a drug used as a restraint is a medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition.

d. Restraints will only be used when less restrictive methods are not sufficient to protect the patient or others from injury. The decision to restrain requires adequate and appropriate clinical justification. Restraint is to be applied for no longer than it is clearly needed and any doubts about the need for restraint should be resolved in favor of an alternative to restraint.

e. Provider order should be obtained and documented, unless a licensed nurse authorizes its emergent use because the patient poses an immediate danger to self, staff, or others.

f. Documentation entries in the patient's record is relative to each episode of restraint use must be documented on the Restraint E-form, and must include the type of restraint authorized and duration of use.

2. On 02/06/25 between 2:10 PM and 3:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201), reviewed the medical records of 2 restraint patients. The review showed the following:

a. Patient #222 was a 31-year-old female brought to the Emergency Department (ED) on 10/12/23 at 1:00 PM by her mother stating she is having a psychotic episode. Patient #222 had nursing documentation at 2:30 PM of increased agitation, pacing the room, pulling at clothing, going through drawers in the hospital room, throwing things on the floor, and throwing drawers on the floor. Patient #222 had nursing documentation at 2:45 PM of being at the triage desk, not making sense, provider attempted to talk to patient, and patient throwing items in the hallway. Patient #222 had a provider order to receive Haldol (an antipsychotic medication used to treat mental health conditions) 5 milligrams intramuscularly (IM) and Benadryl (a medication used in combination with antipsychotic medications to treat medical health conditions) at 5:20 PM. Surveyor #2 found no evidence of an order for chemical restraints. Patient #222 had nursing documentation at 4:40 AM that she eloped but had returned to the hospital and police assistance was requested to get her back in the hospital. Patient #222 had a provider order on 10/13/23 and was administered Benadryl 50 milligrams IM at 5:04 AM, Ativan (a medication used to treat anxiety) 2 milligrams IM at 5:05 AM, and Haldol 5 milligrams IM at 5:06 AM. Surveyor #2 found no evidence of an order for chemical restraints.

b. Patient #223 was a 38-year-old male brought the ED on 02/24/24 at 8:34 PM by Sheriff for a domestic violence call and being severely agitated. Patient #223 had a provider order on 02/04/24 and was administered Ativan 2 milligrams IM at 8:54 PM, Benadryl 50 milligrams IM and Haldol 5 milligrams IM at 8:55 PM. Surveyor #2 found no evidence of an order for chemical restraints.

3. At the time of the review, Staff #201 verified the missing orders for chemical restraints.

Item #4 - Restraint renewal orders

Based on record review, interview, and document review of hospital policy and procedures, the hospital failed to ensure providers orders for restraint contained the appropriate order of restraints to be utilized for 1of 2 patients placed in restraints reviewed (Patient #222).

Failure to place complete provider orders increases the risk of incorrect restraint application and risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Use of Patient Restraints," Policy Stat ID 17075325, last revised 11/24, showed the following:

a. A restraint is defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely. Use of measures to involuntarily restrain movement of the whole or a portion of a patient's body; as a means of modifying a patient's behavior, in a patient who does not require medical immobilization; adaptive support or those patients not requesting voluntary immobilization.

b. A physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove, that restricts freedom of movement or normal access to one's body.

c. Restraint will only be used when less restrictive methods are not sufficient to protect the patient or others from injury. The decision to restraint requires adequate and appropriate clinical justification. Restraint is to be applied for nor longer than it is clearly needed and any doubts about the need for restraint should be resolved in favor of an alternative to restraint.

d. Orders for restraint are defined by specific time limits and the continued need for restraint will be reassessed within the time limit.

e. The frequency for which a new order is required for behavioral restraints is 4 hours for adults over the age of 17.

2. On 02/06/25 between 2:10 PM and 3:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201), reviewed the medical records of 2 restraint patients. The review showed Patient #222 was a 31-year-old female brought to the Emergency Department (ED) on 10/12/23 at 1:00 PM by her mother stating she is having a psychotic episode. Patient #222 had nursing documentation at 4:40 AM that she eloped but had returned to the hospital and police where assistance was requested to get her back in the hospital. Patient #222 had a provider order for 4-point leather restraints to all 4 extremities on 10/13/23 at 4:45 AM and was placed in 4-point leather restraints at 4:55 AM. The 4-point leather restraints were discontinued at 12:35 PM. Surveyor #2 found no evidence of an order to renew restraints after the initial order at 4:45 AM (missing a period of approximately 3 ½ hours).

3. At the time of the review, Staff #201 verified the missing order to renew the restraints after the first hours.

Item #5 - Face-to-Face Evaluation

Based on record review, interview, and document review of hospital policies and procedures, the hospital failed to ensure that staff performed a face-to-face evaluation for patients with restraint orders for 2 of 2 patients reviewed (Patient #222 and #223).

Failure to perform the required face-to-face evaluation to determine whether the patient meets the specific criteria for physical or chemical restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Use of Patient Restraints," Policy Stat ID 17075325, last revised 11/24, showed when behavioral restraints are used a provider must assess the patient face-to-face within one hour.

2. On 02/06/25 between 2:10 PM and 3:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201), reviewed the medical records of 2 restraint patients. The review showed the following:

a. Patient #222 was a 31-year-old female brought to the Emergency Department (ED) on 10/12/23 at 1:00 PM by her mother stating she is having a psychotic episode. Patient #222 had a provider order for 4-point leather restraints to all 4 extremities on 10/13/23 at 4:45 AM. Surveyor #2 found no evidence of a face-to-face assessment by a provider within one hour in the medical record.

b. Patient #223 was a 38-year-old male brought the ED on 02/24/24 at 8:34 PM by Sheriff for a domestic violence call and being severely agitated. Patient #223 had a provider order for 4-point restraints on 02/24/24 at 8:30 PM. Surveyor #2 found no evidence of a face-to-face assessment by a provider within one hour in the medical record.

3. At the time of the review, Staff #201 verified the missing face-to-face assessments by the provider.
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Based on interview, document review, and review of the hospital's quality and performance improvement program, the Critical Access Hospital failed to ensure that performance measures for patient care services furnished under arrangement or agreements (contracted services) were developed and evaluated through the hospital's quality program as directed by 2 of 3 contracts reviewed.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Contract Management," Policy Stat ID 14134073, last approved 10/24, showed the following:

a. Contract owners will complete an annual review of their contracts either with a physical Contract/Agreement Review Checklist form or in Intelligent Contract. If completing a physical form, the completed review should be uploaded for storage in Intelligent Contract.

b. All contracts will be evaluated by the Compliance Officer on a rolling month-to-month basis as they become due, on or before the date of execution, using the "Contract Quality Review Checklist".

c. Reviewed contracts will be routed to the Chief Executive Officer (CEO) for final review.

d. Upon review by the Compliance Committee and CEO, the contract/agreement and checklist will be routed to the Administrative Assistant for scanning, filing, and logging.

2. On 02/05/25 between 1:00 PM and 1:30 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed 3 contracts. The review showed the following:

a. The facility had a contract with AMN Healthcare for nurse staffing (previously the facility used a company called Medefis) dated 04/23. Surveyor #2 found no evidence of an annual review of the contracted service for AMN Healthcare or Mediefis.

b. The facility had a contract for tele-pharmacy services provided by Medication Review that was updated on 02/20. Surveyor #2 found no evidence of an annual review of contracted service.

3. At the time of the review, Staff #201 verified that there was not annual review of the contracted services.
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Item #1 -Surgical informed consent

Based on interview, record review, and review of policy and procedures, the Critical Access Hospital failed to properly obtain surgical informed consent as directed by the hospital's policy and procedure for 5 of 5 patient consent's reviewed (Patient #206, #207, #208, #209, and #210).

Failure to properly obtain consent for treatment risks patients receiving care that may not be to the patient's desires.

Findings included:

1. Document review of the hospital policy titled "Informed Consent for Treatment" Policy Stat ID #11476877, last approved 11/22, showed informed consent for treatment must consist of a discussion between the patient and provider of:

a. All the material facts that a reasonably prudent patient under similar circumstances would need to make an informed choice as to whether to receive the proposed treatment.

b. The recognized serious possible risks, complications, and anticipated benefits involved in treatment administered and recognized possible alternative forms of treatment, including non-treatment.

c. Alternatives to the proposed treatment include the reasonably possible risks, drawbacks, complications and expected benefits or effects of the proposed treatment.

d. The nature and character of the proposed treatment.

e. Potential complications or problems related to the treatment and recuperation from the treatment.

f. The likelihood of achieving the treatment goals or anticipated outcomes.

g. Verification that the patient understands the information and has had an opportunity to ask questions and have those questions answered to their satisfaction.

h. The informed consent form is prepared by the attending physician or operating physician and is discussed with the patient by the physician.

i. Documentation must clearly indicate that the patient has had the opportunity to ask any and all questions they may have about the proposed procedure.

j. The nurse witnessing the signature of the patient signs, dates and times in the appropriate location.


2. On 02/05/25 between 9:55 AM and 11:00 AM, Surveyor #2, the Surgical Services Manager (Staff #202) and Chief Nursing Officer (Staff #201) reviewed the medical records of 5 patients receiving care in the Surgical Department. The review showed the following:

a. Patient #206 had a right total knee arthroplasty surgery on 01/02/25. Surveyor #2 found no evidence the full disclosure and witness section on the informed consent form was signed by the patient.

b. Patient #207 had a laparoscopic cholecystectomy (a surgical procedure to remove the gallbladder) on 01/21/25. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient.

c. Patient #208 had an open reduction and internal fixation (ORIF) of the right 5th metacarpal neck (a surgical procedure to fix a right-hand fracture) on 01/23/25. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient.

d. Patient #209 had an esophagogastroduodenoscopy (a procedure that allows a healthcare professional to examine the lining of the esophagus, stomach, and part of the small intestine) on 09/18/24. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient.

e. Patient #210 had a colonoscopy (a procedure that allows a healthcare professional to examine the inside of the colon and rectum) on 11/06/24. Surveyor #2 found no evidence the witness section on the informed consent form was signed by the patient.

3. At the time of the observation Staff #202 verified the missing witness signatures on the informed consent form.

Item #2 - Consent to treat

Based on interview, record review, and document review of hospital policy and procedures, the Critical Access Hospital failed to ensure that hospital staff properly obtained consent to treat for 6 of 16 patients reviewed (Patient #201, #204, #205, #214, #215, and #216).

Failure to properly obtain consent for treatment risks patients receiving care that may not be to the patients' desires.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Admission Forms, Advance Directives or POLST, Bill of Rights, Consent for Treatment Medicare Message," Policy Stat ID 10813526, last approved 12/21, showed the following:

a. All patients admitted to Three Rivers Hospital (inpatient or outpatient) will be given disclosure information and appropriate forms of consent pertaining to their care.

b. If the patient has questions regarding the consent forms, these questions will be answered before obtaining signatures.

c. Consent will be obtained before care/treatment is given except in an emergency situation.

d. It is the Patient Registration Representative or Admitting Clerk responsibilities to provide the patient with proper consent forms and applicable disclosure statements at the time of admission.

e. During hours when the Registration Department or Admitting staff is not present, nursing staff will provide these services.

1. On 02/04/25 between 3:10 PM and 4:15 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of patients receiving care in the hospital's Emergency Department (ED) and transferred to a higher level of care. The review showed the following:

a. Patient #204 was an 85-year-old seen in the ED and transferred to a higher level of care for a nosebleed on 01/16/25. Surveyor #2 found no evidence of a consent to treat form for this ED visit.

b. Patient #205 was a 49-year-old seen in the ED and transferred to a higher level of care for saddle pulmonary embolism (a large blood clot in the artery of the lung) on 09/11/24. Surveyor #2 found no evidence of a consent to treat form for this ED visit.

2. Surveyor #2 interviewed Staff #201 regarding the process of obtaining consent to treat from patients. Staff #201 stated if the Registration Staff is not here, the Nursing Staff obtains signatures and later the forms get scanned into the patient's medical record. At the time of the review, Staff #201 verified the missing consent to treat forms in the medical record.

3. On 02/05/25 between 1:30 PM and 4:00 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 6 patients seen in ED. The review showed Patient #202 was a 7-year-old male seen in the ED on 02/02/25 with a chief complaint listed as nausea, vomiting, and chills. Surveyor #2 found no evidence of a consent to treat form for this ED visit.

4. At the time of the review, Staff #201 verified the missing consent to treat form in the medical record.

5. On 02/05/25 between 4:05 PM and 4:40 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 3 patients who expired at the facility. The review showed the following:

a. Patient #214 was a 72-year-old female seen in the ED on 12/29/24 for nausea, vomiting, and abdominal pain and expired on 12/30/24. Surveyor #2 found no evidence of a consent to treat form in the medical record for this visit.

b. Patient #215 was an 84-year-old male admitted to the hospital on 10/02/24 for chronic non-healing extremity ulcer and expired on 10/07/24. Surveyor #2 found no evidence of a consent to treat form in the medical record for this visit.

6. At the time of the review, Staff #201 verified the missing consent to treat form in the medical record.

7. On 02/06/25 between 1:35 PM and 2:10 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of three patients receiving blood transfusions. The review showed Patient #216 was seen in the ED on 01/16/25 and had an order to transfuse two units of packed red blood cells for anemia. Surveyor #2 found no evidence of a consent to treat form in the medical record for this visit.

8. At the time of the review, Staff #201 verified the missing consent to treat form in the medical record.

Item #3 - Blood transfusion consent

Based on interview, record review, and document review of the hospital's policy and procedure, the Critical Access Hospital staff failed to follow its policy and procedure for blood product transfusions for 1 of 3 patients (Patient #211).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Blood and Blood Components, Administration of," Policy Stat ID 15750348, last approved 06/24, showed a consent form will be signed prior to blood transfusion, anyone refusing to accept blood must sign a "Refusal of Blood or Blood Products" form.

2. On 02/06/25 between 1:35 PM and 2:10 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 3 patients receiving blood. The review showed Patient #211 had a provider order to receive three units of packed red blood cells on 11/26/24. Surveyor #2 found no evidence of a blood consent form in the medical record.

3. At the time of the review, Staff #201 verified the missing blood consent form.
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Based on observation, interview, and document review of the hospital's policy, the Critical Access Hospital failed to implement its policy for surgical attire in the restricted areas of the surgical environment.

Failure to ensure that staff members follow hospital policy for surgical attire places patients at risk for developing infections.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Surgery Department: Standards of Practice for Surgical Attire," Policy Stat ID 14320700, last approved 10/23, showed that a beard is to be covered when entering the restricted areas and while preparing and packaging items in the clean assembly section of the sterile processing department.

2. On 02/04/25 between 1:30 PM and 2:50 PM, Surveyor #2, the Chief Nursing Officer (Staff #201) and Surgical Services Manager (Staff #202) inspected the Operative Area. Surveyor #2 observed a surgical procedure of an inguinal hernia repair. Surveyor #2 observed the Surgeon (Staff #203), two surgical technicians (Staff #204 and #205), and a certified registered nurse anesthetist (CRNA) (Staff #206) with exposed facial hair not completely covered by the facial mask.

3. At the time of the observations, Staff #201 verified the observation and stated that beards should be covered.
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Based on observation, interview and document review, the Critical Access Hospital failed to maintain surfaces in a condition that is cleanable and sanitary.

Failure to maintain cleanable surfaces in patient care areas puts patients at increased risk of infection.

Findings included:

1. Document review of the hospital's checklist titled, "Monthly Inspection Requirements," no policy number or approval date, showed the maintenance department checklist for items to inspect during environment of care rounding. The checklist included general life safety items, including checking for wall penetrations, but did not include checking furnishings or surfaces for damages.

2. On 02/05/25 at 11:00 AM Surveyor #4 observed a discharge cleaning of patient room 21 with the Chief Operations Officer (Staff #401). During the observation, the surveyor noticed a large wood wall cabinet near the patient sink. The cabinet had several areas where the wood varnish was worn away.

3. During the observation, Surveyor #4 discussed the worn areas as being a non-cleanable surface with Staff #401. Staff #401 confirmed the damage.

4. On 02/06/25 at 2:30 PM Surveyor #4 toured the physical therapy/rehabilitation gym with Staff #401. During the tour, the surveyor observed a set of wood steps (used for physical therapy) with areas of worn varnish/seal on the hand railing. Staff #401 confirmed the wood was losing its varnish/seal and was no longer a cleanable surface in those areas.
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Based on interview, record review, and review of policies and procedures, the Critical Access Hospital failed to develop and keep current an interdisciplinary comprehensive plan of care that provided measurable objectives and timeframes, included specialized services, and in consultation with the resident and the resident's representative included the goals for admission and desired outcomes, resident's preference and potential for future discharge, and discharge plans for 2 of 4 patients admitted to the hospital's Swingbed program (Patient #220 and #221).

Failure to develop an interdisciplinary comprehensive plan of care can result in the inappropriate, inconsistent, or delayed treatment of patient's needs and may lead to patient harm and lack of appropriate treatment for a medical condition.

Findings included:

1. On 02/06/25 between 9:15 AM and 12:30 PM, Surveyor #2 and the Chief Nursing Officer (Staff #201) reviewed the medical records of 4 Swingbed patients admitted to the medical/surgical unit. The review showed the following.

a. Patient #220 was an 84-year-old male who was admitted as an inpatient to the medical/surgical unit on 01/11/25 for right hip pain and difficulty ambulation, and on 01/15/25 Patient #220 was transferred to a Swingbed patient for strengthening. Patient #220 was discharged from the facility on 01/25/25. Surveyor #2 found no evidence of an interdisciplinary comprehensive care plan in the medical record.

b. Patient #221 was a 79-year-old male who was admitted as a Swingbed patient for strengthening status post hip fracture on 07/29/24 and discharged on 08/15/24. Surveyor #2 found no evidence of an interdisciplinary comprehensive care plan in the medical record.

2. Surveyor #2 interviewed Staff #201 regarding the interdisciplinary comprehensive care plan process. Staff #201 asked the discharge planning nurse (Staff #207) regarding the interdisciplinary care plan process and Staff #207 stated the facility does not have a policy currently regarding interdisciplinary care plans but will work on creating one. Staff #207 stated the facility usually holds an interdisciplinary comprehensive care plan (care conference) with the patient's provider, therapy, and nursing around every six days and documents the meeting in the discharge planning notes.

3. At the time of the review, Staff #201 verified the missing interdisciplinary comprehensive care plans in the medical records.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop a policy for the CAH's role during an 1135 waiver for providing care at an alternate care site.

Failure to develop a policy for providing care at an alternate care site during an 1135 waiver risks the inability of the CAH to provide adequate care should they need to relocate patients during the activation of the emergency preparedness plan.

Findings included:

1. Record review of the CAH's emergency preparedness program and policies, reviewed 02/06/25, showed that no policy specifying the CAH's role for providing care at alternate care sites under an 1135 waiver was present.

2. On 02/06/25 between 11:30 AM and 1:15 PM, Surveyor #4 interviewed the Facilities Director (Staff #402), the Director of Ancillary Services (Staff #403) and the Chief Medical Officer (Staff #404) about the elements of the emergency preparedness program. Staff #403 confirmed the current plan did not include a specific policy for providing care at alternate care sites under an 1135 waiver.
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