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Based on review of the patient admission packet, review of staff training records, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure compliance with applicable laws and regulations regarding Advance Directives at 489.102, for 3 of 3 days of survey (February 13-15, 2012). Failure to ensure the CAH's policy and procedure included required information regarding potential conscience objections and information regarding filing complaints with the State survey and certification agency (SA), placed patients at risk of receiving undesired treatment. Failure to educate all staff regarding the CAH's policy and procedure on Advance Directives limited the CAH's ability to provide appropriate information and treatment to patients.

Findings include:

Review of the CAH's patient admission packet, on 02/13/12, included the policy and procedure, Advance Directives. This document, revised September 2007, stated, "POLICY: Mountrail County Medical Center [MCHC] will comply with the patient Self Determination Act or Federal law that requires health care providers to educate all patients and community on issues related to advance directives.
PROCEDURE: . . . 5. All patients, family members or responsible person, shall complete 'Advance Directive Acknowledgement.' . . . 9. Yearly in-services will be given staff members, to include:
Making Health Care Decisions . . .
Advance Directive Acknowledgement
Code Level"

The policy and procedure and the Advance Directive Acknowledgement lacked a statement of limitation if the CAH cannot implement the patient's advance directive on the basis of conscience. The policy and procedure also lacked information for patients and responsible persons concerning filing complaints with the SA regarding advance directives.

Reviewed, on 02/15/12 at 10:00 a.m. with a nursing management staff member (#1), the computerized staff education program lacked information regarding the CAH's policy and procedure.

This staff member (#1) provided a policy and procedure, "Advance Directives," identified by the staff member as a "nursing" document. This document, revised March 2006, stated, "PROCEDURE: . . . If MCHC has a conflict with a specific directive, the resident and/or family/legal representative will be notified and assistance provided to transfer the resident to a health care provider who will comply with the directive." The staff member (#1) reported staff does not provide this "nursing" policy and procedure to patients or their responsible persons and this policy is not available to other CAH departments.

Based on policy and procedure manual review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to have 12 of 14 policy and procedure manuals (Cardiac Rehab [Rehabilitation], Infection Control, Laboratory, Radiology, Social Services Swing Bed, Dietary, Clinic, Pharmacy, Nursing, Emergency Room, Medical Records, and Quality Assurance) reviewed annually by the required members of a group of professional personnel in 2011. By not having the required group annually review the policies and procedures, the CAH cannot ensure the policies and procedures model the CAH's current practices and are in compliance with federal regulations.

Findings include:

Review of the policy titled "Quality Assurance Program" occurred on 02/14/12. This policy, revised in 2007, stated,
". . . Annual Review of Policy and Procedure Manuals
The Mountrail County Health Center . . . manuals will be reviewed and/or revised on an annual basis by the department manager, medical staff members, administration, and governing boards. . . ."
The policy did not specifically require a physician assistant, nurse practitioner, or clinical nurse specialist to annually review the CAH's policies.

Review of the policy titled "Critical Access Hospital Periodic Evaluation Policy and Procedure" occurred on February 13-15, 2012. This policy, revised January 2010, stated, ". . . The following policy and procedure manuals will be reviewed annually by the department manager, Medical Staff, administration, and governing board . . .
Cardiac Rehab
Clinic . . .
Dietary
ER . . .
Infection Control
Lab/x-ray
Medical Records
Nursing
Pharmacy . . .
Quality Assurance . . ."
The policy did not specifically require a physician assistant, nurse practitioner, or clinical nurse specialist to annually review the CAH's policies.

Review of the CAH's policy and procedure manuals occurred on all days of the survey. The following manuals lacked evidence of annual review in 2011 by the required members of a group of professional personnel (a physician; a physician assistant, nurse practitioner, or clinical nurse specialist; and a non-staff member): Cardiac Rehab, Nursing, ER, Medical Records, and Quality Assurance. The following manuals lacked evidence of annual review in 2011 by a physician assistant, nurse practitioner, or clinical nurse specialist and a non-staff member: Infection Control, Laboratory, and Radiology. The following manuals lacked evidence of annual review in 2011 by a non-staff member: Social Services Swing Bed, Dietary, and Clinic. The Pharmacy manual lacked evidence of annual review in 2011 by a physician assistant, nurse practitioner, or clinical nurse specialist.

Reviewed February 13-15, 2012, the 2011 meeting minutes from medical staff, governing board, and quality assurance lacked evidence of the above mentioned reviews.

During interview on 02/14/12 at 4:15 p.m., two administrative staff members (#1 and #3) confirmed the required members had not reviewed the above mentioned policy manuals in 2011.

Based on policy review, schedule review, contracted services list review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate 20 of 25 contracted services in 2011 (consulting dietitian, consulting pharmacist, laboratory/pathology, radiology, anesthesia, diagnostic imaging, speech pathology, consulting dentist, home health, mammography, occupational therapy, blood products, radiographic maintenance, EKG [electrocardiogram] professional services, eye tissue donation, tissue service procurement, organ recovery, nursing monitoring equipment, social services consultant, and activities consultant). Failure to evaluate contracted services limited the CAH's ability to ensure the services provided enabled the CAH to comply with all applicable conditions of participation and the services met the standards.

Findings include:

Review of the policy titled "Quality Assurance Program" occurred on 02/14/12. This policy, revised in 2007, stated, ". . . Goal: . . . That the quality and appropriateness of patient/resident care are constantly being monitored within all clinical/ancillary departments and services of our institutions. . . . Scope: The Quality Assurance Program shall be facility wide, apply to all departments, services and practitioners whose activities within the facility have direct influence on the quality of patient/resident care. . . ."

Review of the "Mountrail County Health Center Schedule of Monitoring Activities Quality Improvement Reports" occurred on 02/14/12. This schedule, undated, required quarterly reports for the following contracted services: Anesthesia, Dietary, Lab (laboratory) Tech (technologist) Consultant, Pathology, Pharmacy, and Social Services.

Review of the CAH's undated list of contracted services occurred on 02/14/12. Upon request the CAH staff provided no evidence the CAH evaluated the following contracted services in 2011: consulting dietitian, consulting pharmacist, laboratory/pathology, radiology, anesthesia, diagnostic imaging, speech pathology, consulting dentist, home health, mammography, occupational therapy, blood products, radiographic maintenance, EKG professional services, eye tissue donation, tissue service procurement, organ recovery, nursing monitoring equipment, social services consultant, and activities consultant.

During interview on 02/15/12 at 10:30 a.m., an administrative staff member (#3) confirmed the CAH failed to evaluate the above mentioned contracted services in 2011.

Based on observation, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to consider side rails as a potential entrapment and safety hazard for 10 of 10 patient beds located in the acute patient rooms (Rooms #1-#5). Failure to consider side rails as a potential entrapment and safety hazard may place patients at risk of entrapment or injury if staff utilize side rails.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings," dated April 2003, stated, ". . . CMS [Centers for Medicare and Medicaid Services] . . . issued guidance in June 2000 . . . 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . ."

The United States Department of Health and Human Services, Food and Drug Administration (FDA), and Center for Devices and Radiological Health (CDRH) publication titled, "Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/12/06, stated, ". . . FDA is recommending dimensional limits for zones 1 through 4 . . . because . . . the majority of the entrapments . . . have occurred in these zones. . . . Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. . . . FDA is recommending a measure of less than . . . 4 3/4 inches as the dimensional limit for any open space within the perimeter of a rail. Zone 2 . . . This space is the gap under the rail between a mattress . . . Preventing the head from entering under the rail would most likely prevent neck entrapment in this space. FDA recommends that this space be small enough to prevent head entrapment, less than . . . 4 3/4 inches. . . . Zone 3 . . . This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment . . . FDA is recommending a dimensional limit of less than . . . 4 3/4 inches for the area between the inside surface of the rail and the compressed mattress. Zone 4 . . . This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of a rail. . . . The space poses a risk for entrapment of a patient's neck. . . . to prevent neck entrapment. . . . FDA recommends that the dimensional limit for this space . . . be less than . . . 2 3/8 inches. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts," revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . ."

Observation of the beds utilized in the acute patient rooms on the nursing unit occurred on February 13-14, 2012. The beds appeared to be the same make and model and had four half rails (two half rails on each side) attached to the beds. Measurements of the bed, located in "Acute #2," identified a 7 inch open space within the top half rail and a 7 1/4 inch open space within the bottom half rail.

During an interview on 02/14/12 at 9:35 a.m., an administrative nurse (#1) stated all of the patient rooms on the nursing unit, except the special care room, contained the same type of bed. The nurse (#1) stated patients used elevated side rails for positioning/bed controls and stated nursing staff performed and documented an assessment for risk factors or safety for utilization of side rails, but failed to realize the potential for entrapment or injury due to the large spaces within the side rails.

Based on record review, review of policy and procedure, review of Medical and Dental Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff completed medical records accurately and promptly for 14 of 18 emergency room (ER) records (Patient #3, #18, #20, #21, #22, #23, #24, #25, #26, #27, #30, #31, #32, and #33); 3 of 3 closed swing bed records (Patient #4, #5, and #6); 3 of 3 closed observation records (Patient #7, #8, and #9); 4 of 5 closed acute inpatient records (Patient #10, #11, #13, and #14); and 3 of 3 closed outpatient surgical records (Patient #15, #16, and #17). Failure to ensure accurate and prompt completion of medical records, limited the CAH staff's ability to access information necessary to provide patient care during the episode of care and for follow-up care.

Findings include:

Review of the CAH's Medical and Dental Staff Rules and Regulations occurred on February 13-15, 2012. This document, approved on 04/01/99, stated,
". . . 7. All orders for treatment shall be in writing. . . .
9. A complete history and physical examination shall in all cases be completed within eight hours after admission of the patient. A complete history and physical examination shall be completed prior to any surgery.
10. The attending physician shall be held responsible for the preparation of a complete medical record for each patient. . . . No medical record shall be filed until it is complete . . . All medical records shall be completed within 15 days after the patient is discharged.
11. When a history and physical examination and preopertive [sic] diagnosis is not recorded before the time stated for surgery, the operation shall be postponed unless the attending surgeon states in writing that such delay would constitute a hazard to the patient. . . .
13. All operations performed shall be dictated or handwritten and fully described by the operating surgeon immediately following surgery. . . ."

Review of the policy "Completion of Records" occurred on February 14-15, 2012. This policy, revised 10/01/03, stated, ". . . Medical records are to be completed within fifteen (15) days from discharge date. . . ."

Review of closed medical records occurred on February 13-15, 2012 and identified the following:
- ER RECORDS:
*Patient #22 presented on 07/15/11: ER report dictated on 08/03/11 (19 days after ER visit), transcribed on 09/11/11 (39 days after dictation), and signed on 11/02/11. Completion of the record occurred in 110 days. Patient #22 presented to the ER again on 08/28/11: ER report dictated on 09/01/11 (4 days after ER visit), transcribed on 09/12/11 (11 days after dictation), and signed on 11/02/11. Completion of the record occurred in 66 days.
*Patient #24 presented on 10/04/11: ER report dictated on the day of ER visit, transcribed on 12/23/11 (80 days after dictation), and signed on 01/18/12. Completion of the record occurred in 106 days.
*Patient #21 presented on 08/10/11: ER report dictated on 08/24/11 (14 days after ER visit), transcribed on 10/15/11 (52 days after dictation), and signed on 11/02/11. Completion of the record occurred in 84 days.
*Patient #3 presented on 08/14/11: ER report transcribed on 10/04/11 (51 days after ER visit), and signed on 10/31/11. Completion of the record occurred in 78 days.
*Patient #20 presented on 07/16/11: ER report dictated on 09/15/11 (61 days after ER visit) and transcribed on 09/26/11 (11 days after dictation). Completion of the record occurred in 76 days.
*Patient #30 presented on 12/04/11: ER report dictated, transcribed, and signed on 02/13/12. Completion of the record occurred in 71 days.
*Patient #31 presented on 10/04/11: ER report dictated on 10/05/11, transcribed on 11/20/11 (46 days after dictation), and signed on 11/23/11. Completion of the record occurred in 50 days.
*Patient #32 presented on 11/18/11: ER report dictated on the day of ER visit, transcribed on 11/30/11 (12 days after dictation), and signed on 01/06/12. Completion of the record occurred in 49 days.
*Patient #33 presented on 07/13/11: ER report dictated on 07/28/11 (15 days after ER visit), transcribed on 08/17/11 (20 days after dictation), and signed on 08/26/11. Completion of the record occurred in 44 days.
*Patient #18 presented on 04/02/11: ER report dictated on 04/22/11 (20 days after ER visit) and transcribed on 05/07/11 (15 days after dictation). Completion of the record occurred in 35 days.
*Patient #26 presented on 11/10/11: ER report dictated on the day of ER visit, transcribed on 11/28/11 (18 days after dictation), and signed on 12/01/11. Completion of the record occurred in 21 days.
*Patient #23 presented on 09/30/11: ER report dictated on 12/05/11 (66 days after ER visit), transcribed on 12/27/11 (22 days after dictation), and lacked a signature. The record lacked completion.
*Patient #25 presented on 10/31/11: ER report dictated on 12/02/11 (32 days after ER visit), transcribed on 01/23/12 (52 days after dictation), and lacked a signature. The record lacked completion.
*Patient #27 presented on 12/18/11: ER report dictated on the day of admission, transcribed on 02/09/12 (53 days after dictation), and lacked a signature. The record lacked completion.

- SWING BED RECORDS:
*Patient #4 admitted on 10/11/11 and discharged on 10/22/11: Discharge (D/C) summary dictated on 10/25/11 (3 days after discharge), transcribed on 10/28/11 (3 days after dictation), and signed on 11/14/11. Completion of the record occurred in 23 days.
*Patient #5 admitted on 11/15/11 and discharged on 01/13/12: Dictation of Progress Notes (PN), dated 12/04/11 and 12/14/11, occurred on 01/13/12 (30-40 days later).
*Patient #6 admitted on 08/11/11 and discharged on 08/22/11: PN for length of stay dictated on 08/22/11 and signed on 10/21/11 (60 days after dictation). D/C summary signed on 11/08/11. Completion of the record occurred 78 days after discharge.

- OBSERVATION PATIENT RECORDS:
*Patient #7 admitted on 09/26/11 and discharged on 09/26/11: H&P signed on 10/27/11 (31 days after admission) and D/C summary signed on 11/01/11. Completion of the record occurred 36 days after discharge.
*Patient #8 admitted on 11/15/11 and discharged on 11/16/11: History and Physical (H&P) signed on 01/12/12 (58 days after admission). D/C summary dictated on 01/14/12 (59 days after discharge), and signed on 01/24/12. Completion of the record occurred 69 days after discharge.
*Patient #9 admitted on 11/30/11 and discharged on 12/02/11: H&P dictated on 12/01/11 and signed on 12/21/11 (20 days after dictation). PN dated 12/01/11 and signed on 01/18/12 (48 days after completion). D/C summary dictated on 12/21/12 (19 days after discharge), transcribed on 01/08/12 (18 days after dictation), and signed on 01/18/12. Completion of the record occurred 47 days after discharge.

- ACUTE INPATIENT RECORDS:
*Patient #10 admitted on 11/02/11 and discharged on 11/06/11: H&P signed on 11/22/11 (16 days after discharge). PN dated 11/07/11 signed on 12/13/11 (36 days after completion). D/C summary dictated on 11/07/11 and signed on 12/13/11. Completion of the record occurred 37 days after discharge.
*Patient #11 admitted on 08/22/11 and discharged on 08/25/11: H&P signed on 10/31/11 (70 days after admission). PN dated 08/25/11 signed on 11/01/11 (68 days after completion). D/C summary dictated on 08/25/11 and signed on 11/01/11. Completion of the record occurred 68 days after discharge.
*Patient #13 admitted on 10/21/11 and discharged on 10/25/11: H&P signed on 12/13/11 (53 days after admission). PN dated 10/24/11 and 10/25/11 dictated on 11/08/11 (13-14 days after completion). PN and D/C summary signed on 12/21/11. Completion of the record occurred 57 days after discharge.
*Patient #14 admitted on 01/20/12 and discharged on 01/21/12: H&P unsigned. Admission orders undated. Physician orders, dated 01/20/12 and 01/21/12, unsigned. D/C summary dictated on 01/22/12, transcribed on 02/13/12 (22 days after dictation), and unsigned. The record lacked completion.

- OUTPATIENT SURGICAL RECORDS:
*Patient #15 admitted on 08/26/11 for a colonoscopy: H&P lacked examination information (The record lacked information a delay of the procedure would have been a hazard to the patient). Physician order for the procedure unsigned. Operative report, dated 09/12/11 (this date conflicts with the date Patient #15 admitted for the colonoscopy as it is 17 days after the admission date), obtained by the CAH on 10/28/11. Completion of the record occurred 63 days after the procedure took place at the CAH.
*Patient #16 admitted on 11/08/11 for a colonoscopy: H&P and Physician Orders lacked a date. Operative report dated 11/15/11 (this date conflicts with the date Patient #16 admitted for the colonoscopy as it is 7 days after the admission date). The record lacked completion.
*Patient #17 admitted on 10/27/11 for a podiatric procedure: Operative report, dated 11/04/11 (this date conflicts with the date Patient #17 admitted for the podiatric procedure as it is 8 days after the admission date), obtained by the CAH on 01/19/12. Completion of the record occurred 80 days after the procedure took place at the CAH.

During an interview, on 02/14/12 at 9:30 a.m., a medical records management staff member (#2) and a nursing administrative staff member (#1) agreed the H&P, PN, and D/C summaries identified did not meet the CAH's policy for completion of medical records within 15 days. These staff members reported the CAH staff is aware of difficulty obtaining operative reports in a timely manner and reported the CAH has not implemented corrective action. These staff members also reported staff should have completed the pre-operative H&Ps, and the H&Ps may have been accessible in the CAH's computer system. The CAH staff did not provide additional information.

During an interview, on 02/14/12 at 4:00 p.m., a medical records management staff member (#2) reported the CAH's transcription services have been limited and recently have become fully staffed. The limitation in services delayed the transcription of reports. This staff member reported the CAH is aware of delayed completion of medical records by providers; the staff have monitored the delays; and, staff have provided information to CAH administration. This staff member (#2) reported the CAH has not included this information in quality improvement monitoring or reporting.

Based on policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance (QA) program evaluated all patient care services and other services affecting patient health and safety for 12 of 12 months reviewed (October 2010-September 2011) and failed to ensure the QA committee met 1 of 4 quarters (July, August, September 2011) reviewed. Failure to ensure departments report to the QA Committee as scheduled and establish thresholds of acceptability for QA monitoring and failure to ensure the QA Committee meets quarterly limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the policy titled "Quality Assurance Program" occurred on 02/14/12. This policy, revised in 2007, stated,
"Purpose: To implement a quality assurance program designed to monitor, evaluate, maintain and/or improve the quality and appropriateness of patient/resident care within available resources. . . .
Scope: The Quality Assurance Program shall be facility wide, apply to all departments, services and practitioners whose activities within the facility have direct influence on the quality of patient/resident care. . . . Each department representative will be responsible for reporting to the Quality Assurance Committee on a quarterly basis. . . .
Methodology: Committees, groups or individuals participating in the Quality Assurance Program shall demonstrate these components in their review activities and shall report to the Quality Risk Management [QRM] Director. The six components of quality assurance activities are: . . . Evaluation: 3. Establishment of criteria or acceptable levels of performance by which to measure acceptable quality. These criteria must reflect current knowledge and clinical practice.
. . .
Implementation: The findings of the Quality Assurance activities throughout the facilities shall be reported to the QRM Director on a quarterly basis. . . .
Activities: The Quality Assurance Committee will meet quarterly. . . . All department QA representatives will submit reports to the QRM Director prior to the quarterly QA meeting. The QRM Director will review these reports and identify problems/issues that need to be addressed at the quarterly QA Committee meeting. . . ."

Review of the policy titled "Quality Assurance Committee" occurred on 02/15/12. This policy, revised May 2003, stated,
"Purpose: The Quality Assurance Committee is responsible for the development, implementation, maintenance, monitoring and evaluation of the Quality Assurance Program. . . .
Meetings: The Quality Assurance Committee will meet quarterly.
Functions: 1. To establish priorities of quality assurance activities by identifying problems in the delivery of health care. . . . 2. Review reports from quality assurance activities on problem identification and problem solving. . . . 3. Directs appropriate departments, committees, and/or individuals to investigate problems. 4. Directs appropriate departments, committees, and/or individuals to implement corrective action. . . . 5. Analyze results of corrective action to ensure that the problem has been resolved or reduced to an acceptable level. . . ."

Review of the "Mountrail County Health Center Schedule of Monitoring Activities Quality Improvement Reports" occurred on 02/14/12. This schedule, undated, required quarterly reports for the following: Activities, Central Supply Reprocessing (CSR), Dietary, Infection Control, Laboratory, Medical Records, Nursing, Physical Therapy, Plant Operations/Housekeeping/
Laundry, Radiology, Surgery, Social Services/Swing bed; contracted services of Anesthesia, Dietary, Laboratory (Lab) Technologist (Tech) Consultant, Pathology, Pharmacy, and Social Services; and chart review of ER (Emergency Room) records, medical charts, and Swing bed charts.

Reviewed on February 14-15, 2012, the October 2010-September 2011 QA records indicated the following departments did not submit reports for the specified quarters:
Activities: October 2010-September 2011
Dietary: October-December 2010 and July-September 2011
Nursing: July-September 2011
Social Services/Swing bed: October 2010-September 2011
ER chart review: July-September 2011
Medical chart review: July-September 2011
Swing bed chart review: July-September 2011
Contracted services Dietary: October 2010-September 2011
Contracted services Lab Tech Consultant: October 2010-September 2011
Contracted services Pathology: October 2010-September 2011
Contracted services Pharmacy: October 2010-September 2011
Contracted services Social Services: October 2010-September 2011

The October 2010-September 2011 QA records indicated the following departments did not establish criteria or acceptable levels of performance for their QA monitoring: anesthesia, CSR, dietary, medical records, cardiac rehab, plant operations/housekeeping/laundry, radiology, surgery, ER chart review, medical chart review, and swing bed chart review.

Reviewed on February 14-15, 2012, the October 2010-September 2011 QA Committee meeting minutes lacked evidence of a meeting for the quarter of July-September 2011. Upon request the facility did not provide evidence of a quarterly meeting for July-September 2011 nor evidence the QRM Director reviewed the departments' reports for July-September 2011 to identify problems.

During interview on 02/15/12 at 10:30 a.m., an administrative staff member (#3) confirmed not all departments reported to the QA Committee as scheduled, not all departments had established criteria or acceptable levels of performance for their monitoring activities, and the QA Committee had not met for the July-September 2011 quarter.