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Based on the Life Safety Code (LSC) survey component. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiencies cited at: K341, K361, K372, and K712.

Based on interview and document review, the Critical Access Hospital (CAH) failed to assure a comprehensive list of all services furnished under arrangement or agreements had been maintained. This had the potential to affect all patients receiving services at the CAH.

Findings include:

The CAH's undated, untitled list of services provided by the facility on 9/26/17, had 58 agreements/contracted services. The list index provided the name of the agreement/contract, however lacked documentation of the scope of service provided and the contracted services responsibilities.

On 9/27/17, at 10:00 a.m. the executive assistant (EA) and administrative assistant (AA) confirmed the aforementioned list of agreed/contracted services were not maintained by the CAH, was not an accurate list and did not include the scope of services provided and the contracted services responsibilities. AA confirmed the list was maintained by St. Cloud hospital and she did not have individual access to the list of services.

On 9/27/17, at 11:40 a.m. an untitled, undated list of services provided by the facility, had 41 agreements/contracted services which listed the contract name, responsible type, and services provided. The list included services provided through arrangement/agreement such as Little Falls Orthopedics, Lifesource, Telehealth, American Red Cross, Ultane (general anesthesia,) White Sell (emergency physician weekend coverage,) Ambulance and Saint Cloud Hospital Psychology Department.

On 9/27/17, at 11:45 a.m. the AA confirmed the updated list provided was accurate and had been provided to her by St. Cloud hospital. The administrator indicated the original list of services St. Cloud hospital had maintained for the CAH was accurate and the aforementioned list was accurate and the AA would be maintaining the list.

Based on interview and document review the critical access hospital (CAH) failed to develop ongoing hospital wide Quality Assurance Performance Improvement program (QAPI) monitors that included: clinical records. This had the potential to affect all patients at the CAH.

Findings include:

During an interview on 9/26/17, at 2:00 p.m. the health information manager (HIM) indicated the health information department indicated the current Quality Assurance Performance Improvement (QAPI) program had been working on the same projects for the last five years. HIM manager indicated she had been looking at medical records for completion of history and physicals, discharge summaries and operative/procedure case completion. HIM indicated the projects they were working on were at 100% compliance with auditing. She further indicated she was currently looking for new projects to work on.