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At the time of revist on January 21, 2015 this deficiency was not corrected.

Based on review of infection control surveillance activities, infection control policies and procedures, Quality Assurance Performance Improvement (QAPI) meeting minutes, and interview, the Critical Access Hospital (CAH) failed to:

a. have an active infection control surveillance program that included measures to identity, report, and investigate infections and communicable diseases.

b. have a mechanism in place to evaluate the effectiveness of the infection control program and provide corrective action when needed.

c. use nationally recognized systems of infection control guidelines.

Findings:

1. On the morning of January 21, 2015, administrative staff told surveyors that the CAH had a new Infection Control Practitioner. Administrative staff told surveyors that staff G was the Infection Control Practitioner who had worked at the CAH since November 2014.

2. There was no documentation that staff G had been designated as the Infection Control Practitioner (ICP)

3. On the morning of January 21, 2015, surveyors reviewed the infection control plan and infection control policies and procedures. There was no documentation that the infection control plan and policies and procedures were based on a nationally recognized system of infection control guidelines.

4. On the morning of January 21, 2015, surveyors requested all infection control surveillance and monitoring activities. None was provided.

5. On the afternoon of January 21, 2015, surveyors reviewed QAPI meeting minutes. The QAPI meeting minutes contained an infection control "score card' for every month. The "score card" contained numbers and percentage values for handwashing observations, handwashing compliance, isolation compliance, cultures reviewed, percentage of antibiotic prescribed that were appropriate, hospital acquired infections (HAI) and surgical site infections (SSI).

6. The infection control "score card" documented "...action plan required...more than 20% away from target..." The "score card" documented, a 100% target for handwashing compliance. In June 2014 the handwashing compliance target was 68%, In August 2014 the handwashing compliance target was 64% and in September 2014 the handwashing compliance target was 64%. There was no documentation of any follow up action taken.

7. The infection control "score card" documented, a 100% target compliance for isolation compliance. In the months of July 2014 and September 2014 the isolation compliance was 50%. There was no documentation of any follow up actions taken.

8. On the afternoon of January 21, 2015, surveyors requested all documentation of departmental rounds. None was provided. Administrative staff told surveyors that the ICP did make departmental rounds monthly but they did not know where the documentation was kept.

9. On the afternoon of January 21, 2015, administrative staff told surveyors the chemicals and disinfectants used at the CAH had not been reviewed and approved. Administrative staff told surveyors that the ICP had started to review and approve all chemicals and disinfectants. There was no documentation of reviewal and approval of all the chemicals and disinfectants used at the CAH.

10. On the afternoon of January 21, 2015, administrative staff told surveyors that the previous ICP had evaluated the contracted linen service. Surveyors requested documentation of the evaluation. None was provided. A roster sheet was provided from the contracted linen service that documented the ICP had "signed in" at the linen company in Oct, 2014.

11. Staff G, the ICP was unavailable during the survey for interview.

At the time of revisit on January 21, 2015, this deficiency was not corrected.

Based on hospital document review and staff interview, the hospital failed to ensure that a list of all services provided through arrangements, contracts, and or agreements were maintained describing the nature and scope of the services provided.

Findings:
1. On the morning of 01/21/2015, surveyors requested a list of contracted services. A list that was not complete was provided by the CEO.

2. The CEO verified that the list of contracted services was not complete. The list was missing several contractors (current linen service, current contractor dietician, current contractor radiology supervisor, current contractor CDM, etc.)

3. The CEO verified that the list of contracted services did not contain nature and scope of services provided.

At the time of revisit on January 21, 2015, this deficiency was not corrected.

Based on document review, observation, and staff interviews, the CAH (critical access hospital) failed to ensure nurses in the emergency department were adequately trained and qualified to furnish all services offered in a safe manner in accordance with acceptable standards of practice.

Findings:
1. On the morning of 01/21/2015, surveyors reviewed the ED (emergency department) log. The triage log documented 86% of all patients presenting to the ED were triaged incorrectly.

2. 12 (# 12-15, 17-22, and 25-28) of 14 medical records reviewed had documented incorrect triage levels for patients presenting to the ED. The facility used a five level triage system. Level 1-resuscitation, 2-emergent, 3-urgent, 4-less urgent, 5-nonurgent.

3. Staff C verified that 12 (# 12-15, 17-22, and 25-28) of 14 patient's were triaged incorrectly.

4. On the afternoon of 01/21/2015, surveyors reviewed Staff J and Staff K's personnel files. The ED nursing personnel files did not include skills specialized for working in the ED.

Staff training and education files were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency room:

-Triage Assessment using the emergency severity index (ESI);

-Intravenous (IV) insertion, accessing/de-accessing implanted central venous devices, venous blood draw sampling, and blood glucose monitoring;

-Respiratory treatments, assessing, performing, and documenting;

-Accessing, assembling, and delivering oxygen cylinders with regulators for patient use;

-Neurological assessment using Glasgow coma scale;

-IV conscious sedation, rapid sequence intubations (RSI), and airway management based on American Society of Anesthesiologists guidelines;

-Restraint training (crisis intervention protection);

-Restraint application, use, monitoring, and documenting;

-Abuse training.

None of the records had documentation of verification of skills competencies related to specialized tasks in the ED.

5. Findings were verified during review and at exit conference the afternoon of 01/21/2015.

At the time of revisit on January 21, 2015, this deficiency was not corrected.

Based on hospital document review and staff interviews, the CAH (critical access hospital) failed to ensure that a periodic evaluation of its total program was conducted at least once a year and included a review of the following: a representative sample of both active and closed medical records an evaluation of all services provided, and if policies were followed and what changes if any were needed.

Findings:
1. On the morning of 01/21/2015, surveyors requested the CAH's program evaluation. The CEO provided the program evaluation that was incomplete and did not include all CMS required components.

2. On the afternoon of 01/21/2015, surveyors reviewed medical staff and governing body meeting minutes for 2014 through current. There was no documented evidence that a sample of active and closed medical records were reviewed. There was no documented evidence that an evaluation was done of all services provided. There was no documented evidence that all policies were followed and what changes if any were needed.

3. On the afternoon of 01/21/2015, the CEO verified that the program evaluation was not complete.