HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Governing Body failed to provide oversight to ensure documentation showed new hires received the orientation procedure to include education of the CAH's policy and procedures in accordance with the new hire checklist. Failure of the Governing Body to ensure oversight related to the health and safety of patients receiving services at the CAH and ensure new hires receive orientation could potentially result in poor patient outcomes. The administrative staff reported 59 outpatient echocardiogram exams from 1/19/23 through 2/17/23.

Findings include:

1. Review of the CAH's policy titled "Contract, Agency, and Non-Employee Personnel" policy 11923538 with a revision date of 7/2005 and a current approval date of 9/22, included in part, "...PURPOSE...To identify the requirements and expectations of all contract, agency, or non-employee personnel providing direct and non-direct patient care...Non-employee personnel: All personnel who provide direct or non-direct patient care services or any other services...and subsidiaries through contractual agreement with an agency or directly as an independent contractor...All non-employee personnel who are not LIP's (Licensed Independent Practitioners) are credentialed through the Human Resources Department and must meet the following criteria...Provide evidence of education and training consistent with applicable legal and regulatory requirement as outlined in...job description for the position the non-employee personnel is filing...Provide evidence of applicable current license, certification, or registration prior to the first day of assignment, including Mandatory Reporting of Child and Dependent Adult Abuse and (basic life support) BLS (if applicable)...Comply with all...Employee Health requirements, drug screening, health assessment and physical testing...If applicable complete an annual competency assessment or renewal of contract (may include an annual performance evaluation) if applicable...Comply with all applicable policies and procedures relating to contract or agency licenses professionals...Complete necessary New Hire courses, training and other requirements as directed...All documentation pertaining to non-employee personnel is maintained in the Human Resources Department..."

2. Review of the agency contract/agreement titled, "CLIENT SERVICES AGREEMENT Healthcare Division" showed the facility's Human Resource Director signed the agreement on 1/6/23 regarding hiring of an agency echo technician. Closer review of the contract/agreement provided instructions that the hospital/client had entered "...into this non-exclusive Client Services Agreement for the purpose of referring and placing its employees ("Consultants") with Client (the hospital). This Agreement shall govern the overall terms of the relationship, while a separate Assignment Confirmation for each placement will outline specifics as to bill rates, personnel, and assignment lengths...Section 5: On-Site Responsibility...Client (hospital) is responsible for providing all support, facilities, training, direction, and means for the Consultant to complete the assignment...Client (hospital) warrants that its facilities and operations will comply at all times with all federal, state and local safety and health laws, regulations and standards, including OSHA standard, and that Client will be responsible for providing all safety training and equipment, and for each Consultant's compliance with health and safety requirements, including those instituted by Client (hospital)..."

3. Review of the document titled in part, "...New Hire Orientation Itinerary & Checklist" included the task to be performed and the department/staff responsible for the task completion. Closer review showed several task to include, "Prior to Start Date" (to be conducted by HR (Human Resource department)..."First day (Usually Tuesday)" to be conducted by HR, Administrative Assistant, and IT, "New Hire Orientation (First Wednesday of the month - Bi-Monthly) 8:30am - 12:00pm" (to be conducted by Several Directors, Managers, and/or Occupational Health staff), and "Employee in Department" (to be conducted by the new hires departmental leader).

4. An interview conducted on 2/24/23 at 1:45 PM with the Human Resource (HR) Director and the hospital CEO/CNO (Chief Executive Officers and Chief Nursing Officer). The HR Director reported the CAH implemented a new hire orientation itinerary and checklist form that was to be completed by assigned facility staff starting August 3, 2022 at the facility's orientation meeting. The HR Director went on to report the CAH did not have a policy addressing new hire orientation and instead developed the new hire checklist. The HR Director and the hospital CEO/CNO acknowledged the CAH lacked documentation to show all new hires had completed the orientation checklist to include, but not limited to, education, review of the CAH'S policies and procedures and completion of educational courses assigned to each new hire located on the HealthStream computer program.

5. During an interview on 2/24/23 at 3:01 PM, the Radiology Manager reported she was aware of the new hire orientation checklist and acknowledged she did not always document the orientation processes she completed with all new hires.