HospitalInspections.org

Based on Record Review and interview, facility staff failed to review patient care policies biennially by members of the Critical Access Hospital's professional healthcare staff and governing body for 9 of 20 facility policies reviewed.

Findings Include:

Review of Facility Policy titled, "Policy on Policies," approved 05/31/22, revealed, "The purpose of this Policy is to provide a structured and system-wide approach to policy development and management supported by appropriate tools and technology to ensure Policy Documents are developed, drafted, reviewed and approved in a collaborative, consistent and streamlined manner......All Policy Documents must be reviewed biennially, unless otherwise required for more frequent review by federal, state, or local laws and/or accrediting bodies."


Review of Facility Policy #308071219, titled, "Transfer Of Patient to Another Facility External Or Patient Care Unit Internal," last reviewed 12/27/2019.

Review of Facility Policy #678, titled, "Complaint And Grievance Policy,"last reviewed 08/19/2020.

Review of Facility Policy #030041219, titled, "Patient's Rights and Responsibilities,"last reviewed 12/26/2019.

Review of Facility Policy #180610120, titled, "Patient Diversion/Bypass Protocol,"last reviewed 01/15/2020.

Review of Facility Policy #SS-GEN-013, titled, "Family & Visitors," last reviewed 01/12/2020.

Review of Facility Policy #463, titled, "Tube Feeding," last reviewed 08/19/2020.

Review of Facility Policy #290, titled, "Nutrition Risk Evaluation," last reviewed 08/19/2020.

Review of Facility Policy #301131219, titled, "Discharge of Patient," last reviewed 12/16/2019.

Review of Facility Policy # 250380120, titled, "Discharge Planning Scope of Service," last reviewed 01/20/2020.

In an interview on 08/30/2022 at 4:30 PM with Vice President B, VP B stated, "Policy review is now every 2 years with Joint Commission and every 2 years with a Critical Access Hospital. We're changing our platform and transitioning to system policies, not all policies have been updated or uploaded."

In an interview on 08/31/2022 at 8:10 AM with Quality Specialist D, when asked how frequently policies are reviewed, Staff D stated, "Corporate policies are reviewed every 3 years and supercede all policies if it is a (facility name) policy. We follow the system policies, if it is specific to our hospital then it would be called out in the policy or be a separate policy."