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Based on record review and interviews with hospital staff, the governing body does not ensure that policies governing the CAHs total operation are implemented and staff providing patient care are oriented, trained, and evaluated to ensure quality health care is provided in a safe envirornment.

Findings:

1. On 04/20/11 surveyors reviewed registered nursing personnel files. Two (G,J) of four (B,C,G,J) registered nurse personnel files reviewed for licensure verification did not contain licensure verification. Staff G was providing care 4/19/2011.

2. On 4/20/2011 surveyors reviewed magnetic resonance imaging (MRI) personnel files. Three (P,S, U) of six (P,Q,R,S,T,U) MRI technicians did not have current licenses. Six of Six technicians did not have orientation, training, and evaluation for the hospital.

3. Staff A told surveyors on 4/19/2011 Staff Z was the consultant dietitian. Surveyors were provided consultant dietitian report which were written by Staff M. The reports provided by Staff M were dated from December 2010 through the March 2011. Later in the afternoon Staff A told surveyors Staff M was new. Staff M did not have a personnel file. Later in the afternoon Staff A brought surveyors Staff M's current dietitian license. The hospital failed to provide a job description, orientation, evaluation and training to the facility. Surveyors reviewed Staff Z's personnel records. Staff Z did not have evidence of orientation, training and evaluation to the facility. The above finidings were reviewed with administration at the exit survey.

4. On 4/20/2011 surveyors reviewed the contract social worker's personnel file. There was no documentation the social worker had been oriented, trained, or the license verified.

5. On 4/20/2011 surveyors reviewed the physical therapy contract and were told Staff O provided physical therapy. There was no documentation the physical therapist had been oriented, trained, or evaluated. These findings were reveiwed with administration at the exit conference. No further documentation was provided.

Based on record review and interviews with hospital staff, the governing body does not ensure that policies governing the CAH"s total operation are implemented and medical staff providing patient care are evaluated and appointed by the governing body and ensure quality health care is provided in a safe envirornment.

Findings:

1. One ( Y ) of two physicians ( W & Y ) providing patient care did not have evidence in his credential file or in meeting minutes of appointment to the medical staff by the governing body.

2. The governing body failed to ensure orientation, training, and oversight of the radiology services personnel is provided and there is documentation showing all the contract personnel operating the radiology equipment are qualified and trained. Refer to Tag 0283.

3. The governing body failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer/nurse (ICO). Refer to Tag 0278.

4. The governing body does not assure nursing staff are adequately trained to meet the needs of the patients. Nine of fourteen nursing (B,C,D,E,F,G,J,K,L,M,N,O,P,Q) personnel did not have departmental orientation, competency, and evaluation for the specialized areas where they worked. Refer to Tag 294.

Based on review of the infection control documents, hospital meeting minutes, policies, procedures and personnel files, and interviews with staff, the hospital failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer/nurse (ICO).

Findings:

1. The administrator told the surveyors on 04/19/2011 that Staff C and D were sharing responsibility for infection control coordinator.

2. Review infection control policy and procedures, committee meetings where infection control was discussed, and Staff C and D's personnel files did not demonstrate either or both had been designated as the infection control officer/preventionist.

3. Staff C's personnel file did not contain evidence of ongoing training in infection control on setting up an infection control program with active surveillance and analysis of data. The only training contained in Staff C's personnel file was an Occupational Safety and Health Administration inservice in 2000.

4. Staff D's personnel file did not contain evidence of any infection control training on setting up an infection control program with active surveillance and analysis of data.

5. These findings were reviewed and verified with Staff A on the afternoon of 04/20/2011.

Based on document reviews and interviews, the hospital failed to assure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

Findings:

1. The hospital uses the services of a consultant dietitian. Staff A told surveyors on 4/19/2011 Staff Z was the consultant dietitian. Surveyors were provided consultant dietitian report which were written by Staff M. The reports provided by Staff M were dated from December 2010 through the March 2011. Later in the afternoon Staff A told surveyors Staff M was new. Staff M did not have a personnel file. Later in the afternoon Staff A brought surveyors Staff M's current dietitian license. The hospital failed to provide a job description, orientation, evaluation and training to the facility.

2. Surveyors reviewed Staff Z's personnel records. Staff Z did not have evidence of orientation, training and evaluation to the facility. The above finidings were reviewed with administration at the exit survey.

Based on policy and procedure manual review, review of hospital documents, and interviews with the radiology department manager and administration, the hospital failed to provide orientation, training, and oversight of the radiology services personnel. The hospital also failed to have documentation showing all the contract personnel operating the radiology equipment are qualified and trained.

Findings:

1. On 4/19/2011 surveyors were given radiology personnel files including contract magnetic resonance imaging (MRI). Seven of seven (Staff P,Q,R,S,T,U,V) contract MRI personnel files did not contain orientation, training, competency or evaluation. On the afternoon of 4/19/2011 surveyors spoke with Staff E. Staff E told surveyors the hospital did not have any orientation, training, competencies or evaluations for MRI, contracted ultrasound, or mammography.

2. On the morning of 4/19/2011 surveyors were provided radiology policy and procedure. Three of three (D,E,K) radiology personnel providing services at the facility did not have documentation indicating the Medical Staff or radiologist had deemed them competent to provide radiology services. This finding was reviewed with Staff E. No further documentation was provided.

3. On the morning of 4/19/2011 Staff E told surveyors Staff D was the Director of Radiology. There was no information in Staff D's personnel record indicating Staff D had education, training, or experience in Radiology. The above findings were reviewed with administration and no further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure the quality assurance program evaluates the quality and appropriateness of diagnosis and treatment furnished in the CAH. Review of quality assurance, medical staff and governing body meeting minutes for 2010 and 2011 did not have evidence that the CAH reviews and evaluates the quality and appropriateness of treatment provided by contracted services. This was verified with hospital staff on 04/20/11 in the afternoon.