HospitalInspections.org
Bringing transparency to federal inspections
RAINY LAKE MEDICAL CENTER
PATIENT CARE POLICIES
Tag No.: C1008
Based on interview and document review, the critical access hospital (CAH) failed to ensure health organizational wide policies of the CAH were reviewed biannually as directed by CAH regulations.
Findings include:
On 3/28/24 at 11:52 a.m. the director of quality (QD)-A confirmed hospital organizational policies were to be reviewed and approved biennially. QD-A confirmed multiple polices up to as many as 161, were still needing to be reviewed by the hospital's chief nursing officer (CNO); however, they had been sitting in her mailbox and had not been addressed since 8/2023.
On 3/28/24 at 12:29 p.m. the chief executive officer (CEO) stated corporate policies were reviewed and approved every two years corporate wide. The CEO stated he had been aware of multiple polices still needing to be approved by the CNO as far back as 8/2023; however, he was not aware of the magnitude of the number of polices still requiring approval from the CNO. The CEO stated it was important for all CAH polices to be reviewed biennially to ensure the CAH was in compliance with all required regulations.
The CNO was unavailable for interview.