HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements of 42 CFR 482.1 as evidenced by failing to be primarily engaged in providing inpatient services. The regulation at 42 CFR 482.1 implements the statutory requirement at Section 1861(e) of the Social Security Act (Act). The regulation requires that: (i) Hospitals participating in Medicare must meet certain specified requirements and (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals.

The Act defines hospital as: an institution that ". . . is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons..."

Findings:

Average Daily Census

The hospital's ADC, as provided by S1DQRM was 1.1 for 2017 and 1.5 for 2018 (January through May).

On the start of the survey, 6/4/18 at 9:45 a.m., there were no current inpatients in the hospital to directly observe the actual provision of care and services to patients, and the effects of that care.

Review of a hospital Utilization Report , provided by S2DQRM, revealed the hospital admitted 180 patients from January 2017 through December 2017. Further review revealed the following.

Month and Year Inpatient Admission
January 2017 12
February 2017 14
March 2017 14
April 2017 14
May 2017 9
June 2017 21
July 2017 16
August 2017 15
September 2017 16
October 2017 15
November 2017 20
December 2017 14
January 2018 10
February 2018 14
March 2018 22
April 2018 23
May 2018 28


Month and Year Average LOS(days)
January 2017 2.5
February 2017 1.6
March 2017 2.1
April 2017 2.1
May 2017 2.7
June 2017 2
July 2017 1.9
August 2017 2.7
September 2017 1.9
October 2017 3.9
November 2017 1.8
December 2017 2.1
January 2018 2.4
February 2018 2.4
March 2018 2
April 2018 2
May 2018 1.8


Month and Year Average Daily Census
January 2017 1
February 2017 0.8
March 2017 1
April 2017 1
May 2017 0.8
June 2017 1.4
July 2017 1
August 2017 1.3
September 2017 1
October 2017 1.9
November 2017 1.2
December 2017 1
January 2018 0.8
February 2018 1.2
March 2018 1.4
April 2018 1
May 2018 1.6


Review of the admission and discharge patterns by day of the week from December 2017 through May 2018 (6 months) revealed the following:
Sunday: 0 admissions and 7 discharges
Monday: 43 admissions and 5 discharges
Tuesday: 10 admissions and 26 discharges
Wednesday: 22 admissions and 13 discharges
Thursday: 3 admissions and 18 discharges
Friday: 23 admissions and 16 discharges
Saturday: 0 admissions and 16 discharges

No admissions on Christmas eve, Christmas, New Years eve, New Years day, or Memorial day.

The length of stay is not consistent as to whether they are overnight stays (sometimes a 1 day stay was admitted and discharged the same day, while others were admitted on one day and discharged on the next). The surveyor asked for a ADC by day, but that was not provided. All that was provided was an ADC by month.

The census on June 4, 2018 at 9:45 a.m. was 0 (Inpatients) upon entrance to the survey.

Type of patients admitted as inpatients and Criteria for Hospital Admission:

A request for criteria for admission to the hospital as an inpatient was made. Documentation of the criteria or definitions of admission status (such as inpatient, outpatient, and outpatient observation) was requested. No documentation with this information was provided.


Staffing Patterns:

Review of staffing schedules revealed a minimum of 2 nurses were scheduled at all times in the hospital on the Medical/Surgical unit. Further review revealed staff for surgical services (OR, Pre/Post Operative areas, Anesthesia, Radiology were routinely scheduled Monday through Friday during the day shift. Further review revealed staff for the surgical services (as above) were scheduled on-call for the night, weekends, and holidays during 2017 and 2018.

In an interview on 6/4/18 at 9:45 a.m. S1DQRM verified at least 2 nurses were assigned on each 12 hour shift every day, whether or not the hospital had current inpatients. S1DQRM further reported all services were available 24 hours a day, 7 days a week whether or not the hospital had current patients admitted. These included, in part, Pharmacy, Dietary Services, Radiology, and Laboratory. S1DQRM verified a hospitalist was on call 365 days, during night hours, weekends, and holidays should there be any inpatient needs.


Surgical Services:

Review of the 2017 and 2018 Utilization Stats provided by S1DQRM revealed the hospital had the following outpatient and inpatient procedures:

-2017: 3,796 outpatient procedures performed ; 180 inpatient procedures performed; and

-2018 to date of survey: 1,760 outpatient procedures performed, 97 inpatient procedures performed.


Review hospital policy #30.12, titled "Scope of Services" revealed the following inpatient and outpatient surgical services, as well as related care in these specialties: General Surgery, Internal Medicine, Ophthalmology, Podiatry, Pain Management, Plastic and Reconstructive Surgery, Orthopedics, Otolaryngology, and Neurosurgery.


Provider-based off campus departments: The provider does not have off campus departments.


Number of Inpatient beds:

The provider has 10 licensed beds. In an interview 6/4/18 at 9:45 a.m., S1DQRM verified the hospital had 10 licensed beds.


In an interview 6/4/18 at 9:45 a.m. S1DQRM reported that the current census was 0. She reported the hospital has not had an inpatient since last Friday, 6/01/18. S1DQRM verified the average length of stay and average daily census were as reported on the 2017 and 2018 Utilization Stat Report provided. S1DQRM reported that a patient was admitted as an inpatient if their physician thought they needed to stay longer, but there was no written criteria. S1DQRM verified the services offered were elective surgical services and post-operative surgical care.


How the facility advertises itself to the community:

The hospital advertised itself to the community as a surgical hospital.