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The Critical Access Hospital (CAH) reported a census of six swing bed patients Based on personnel record review, policy review and staff interview, the CAH failed to ensure staff of the CAH are licensed in accordance with applicable state and local laws and regulations for one of five licensed personnel reviewed.

Findings include:

- The CAH ' s job description "Licensed Practical Nurse (LPN)" reviewed on 3/6/13 at 5:15pm stated "...Qualifications ...Current license issued by the Kansas State Board of Nursing as a Licensed Practical Nurse in good standing."

- LPN Staff F ' s personnel record reviewed on 3/6/13 at 4:45pm revealed a hire date of 8/8/11. Staff F ' s personnel record contained a nursing license that expired on 2/28/13.

- Human Resources Staff D, interviewed on 3/6/13 at 4:45pm, acknowledged the personnel records of Staff F lacked a current nursing license.

- Human Resources Staff D, interviewed on 3/7/13 at 12:08pm acknowledged Staff F had worked shifts on 3/1/13, 3/3/13, and 3/6/13 without a current nursing license.

- Director of Nursing Staff A acknowledged the CAH failed to identify Staff F ' s LPN expired nursing license and allowed staff F to work without a current nursing license. Staff A indicated the CAH suspended Staff F until they obtained a current LPN nursing license

The Critical Access Hospital (CAH) reported the surgical department performed 83 endoscopic scope procedures in the last 12 months. Based on observation, policy review, manufacturer ' s guidelines reviewed, and staff interview the infection control officer failed to ensure staff followed established standards of practice to clean and reprocess two of two endoscopic scopes. The infection control officer failed to ensure the surgical staff followed established standards of practice to use the blanket/fluid warmer to store and warm irrigation and intravenous fluids.

The cumulative effect of failure to develop and implement an effective Infection Control program, failure to conduct CAH wide surveillance for both patients and personnel working in the hospital placed all patients at risk for healthcare acquired infections.

Findings include:

- The CAH failed to ensure the infection control officer developed an active infection control system to identify report, investigate, monitor, and implement infection control practices of staff that are responsible for cleaning and reprocessing endoscopic equipment and supplies used with procedures... See further evidence at C-278, 42 CFR 485.635(a)(3)(vi).

The Critical Access Hospital (CAH) reported the surgical department performed 83 endoscopic scope procedures in the last 12 months. Based on observation, policy review, manufacturer's guidelines reviewed, and staff interview the infection control officer failed to develop an active infection control system to ensure staff followed established standards of practice to clean and reprocess two of two endoscopic scopes. The infection control officer failed to ensure the surgical staff followed established standards of practice to use the blanket/fluid warmer to store and warm irrigation and intravenous fluids.

Findings include:

- CAH policy titled "Care and Maintenance of Flexible Endoscopes" reviewed on 3/7/13 at 12:30pm directed "...after leak testing the scope, it will be thoroughly cleaned with an enzymatic cleaner " ( a cleaning solution made of chemicals to break down and digest bioburden) per manufacturer ' s instructions.

- The manufacturer's guidelines for Val Sure Alkaline Detergent reviewed on 3/6/13 at 2:00pm directed Val Sure Alkaline Detergent is a liquid detergent. The manufacturer ' s guidelines failed to ensure the detergent is an enzymatic cleaner, and failed to indicate the detergent for use on flexible endoscopes.

- The manufacturer ' s guidelines for Fujinon scope cleaning reviewed on 3/7/13 at 1:55pm directed " ...submerge pressurized scope in enzyme/water solution ...attach proper irrigation kit to scope and thoroughly flush a minimum of 90cc of enzymatic/solution..."

- Observation in the decontamination room on 3/4/13 at 12:30pm revealed a gallon jug of Val Sure Alkaline Detergent used to clean endoscopes.

Central supply technician Staff E, interviewed on 3/7/13 at 12:45pm stated the ASC for the past year used Val Sure Alkaline Detergent to clean the endoscopes.
The failure to clean the endoscopes with enzymatic cleaner as required by the manufacturer placed patients at risk for healthcare acquired infections.

Health information manager Staff B, explained on 3/7/13 at 12:45pm in the past year the ASC performed 83 endoscopic procedures.

- Observation in the decontamination room on 3/4/13 at 12:30 pm revealed an Olympus EndoTherapy cleaning brush (a single use cleaning brush) draped over the top of the water faucet.

Central supply technician staff E on 3/4/13 at 12:30pm reported staff draped the single use scope cleaning brush over the faucet for future cleaning of scopes. Central supply technician E explained they used the brush to clean the inside of multiple endoscopes and replace the brush only when it begins to show wear.

- The manufacturer ' s packaging instructions for use for Olympus EndoTherapy cleaning brush reviewed on 3/4/13 stated the cleaning brush was intended for "...single use only...Single Use Combination Cleaning Brush."

The CAH failed to ensure staff followed their established policies and the manufacturer's guidelines for cleaning and disinfecting of the endoscopes creating a potential for cross contamination and the spread of healthcare associated infections.

- The guidelines provided by the CAH and reviewed on 3/4/13 at 2:00pm for use and storage of irrigation and intravenous solutions directed "solutions in...may be warmed not to exceed 40 degrees centigrade (104 degrees Fahrenheit)...for a period no longer than two weeks (14 days), the manufacturer recommends the use of a controlled temperature warming cabinet that is monitored by a calibrated temperature measurement device. "

- Observation of the blanket/fluid warming cabinet in the surgical procedure room observed on 3/4/13 at 12:45pm revealed the warming cabinet lacked a thermometer to monitor the temperature of the warming cabinet to insure fluids did not exceed the 40-degree temperature. The warming cabinet contained 5-1,000cc bottles of sterile water for irrigation, 4-500cc bottles of sterile water for irrigation, 6-500cc bottles of 0.9% sodium chloride for irrigation. The irrigation bottles lacked the date staff placed the containers in the warming cabinet. The warming cabinet contained 2-1,000cc bags of 0.9% sodium chloride used for intravenous (IV) therapy, and 1-1,000cc bag of Lactated Ringers solution used for IV therapy. The intravenous bottles lacked the date staff placed the bottles in the warming cabinet.

Staff A, Director of Nursing, interviewed on 3/4/13 at 2:00pm acknowledged the CAH failed to follow manufactures guidelines when placing fluids in the warming cabinet.

The Critical Access Hospital (CAH) reported a census of six swing bed patients. The CAH reported on the Medicare Data Base worksheet 25 staffed beds, one operating room, two procedure rooms, emergency services, laboratory, radiology, swing beds and therapy services. Based on document review and staff interview the CAH failed to completed an annual program evaluation of patient services and quality assurance review for the past 9 years. The CAH failed to identify who was responsible for conducting the evaluation, and ensure the evaluation included; the volume of services provided and the number of patients served, an evaluation of both open and closed medical records, failed to ensure the program evaluation included a review of patient care policies and failed to include a utilization review of the services provided to determine staff followed established policies and the need to revise patient care policies.

The failure to meet the Condition of Participation for an annual evaluation of patient services for the past 9 years to determine if the CAH's actual practice reflected their policies and procedures, as well as the law, regulation or standard of practice placed patients at risk to receive inadequate health care services.

Findings include:

- The CAH failed to complete an annual periodic evaluation of the hospital services, see evidence at C0331, 42 CFR 485.641.

- The CAH failed to ensure the Periodic Evaluation Review included the utilization of CAH services, and at least the number of patients served and the volume of services provided, see evidence at C0332, 42 CFR 485.641.

- The CAH failed to ensure the Periodic Evaluation Review included a representative sample of both active and closed clinical records, see evidence at C0333, 42 CFR 485.641.

- The CAH failed to ensure the Periodic Evaluation Review included an evaluation of their health care policies, see evidence at C0334, 42 CFR 485.61.

- The CAH failed to ensure the Periodic Evaluation Review included an evaluation to determine whether the utilization of services was appropriate, determine if staff followed established policies, and the need to change any patient care policies, see evidence at C0335, 42 CFR 485.61.

The Critical Access Hospital (CAH) reported a census of six swing bed patients. The CAH reported on the Medicare Data Base worksheet 25 staffed beds, one operating room, two procedure rooms, emergency services, laboratory, radiology, swing beds and therapy services. Based on document review and staff interview the CAH failed to completed an annual program evaluation of patient services and quality assurance review for the past 9 years. The CAH failed to ensure the annual program evaluation which included a representative sample of both active and closed clinical records to evaluate patient care and determine if the CAH's actual practice reflected their policies and procedures, as well as the law, regulation or standard of practice placed patients at risk to receive inadequate health care services.

Findings include:

- The CAH ' s annual program evaluation and policies related to the evaluation were requested on 3/6/13 at 10:00am. The CAH failed to provide the requested information by 3/7/13.

Administrative staff B on 3/7/13 at 12:00 noon reported the CAH ' s last program evaluation was conducted in 2004. Administrative staff B verified the CAH failed to collect data to evaluate on the services provided at the CAH.

The Critical Access Hospital (CAH) reported a census of six swing bed patients. The CAH reported on the Medicare Data Base worksheet 25 staffed beds, one operating room, two procedure rooms, emergency services, laboratory, radiology, swing beds and therapy services. Based on document review and staff interview the CAH failed to completed an annual program evaluation of patient services and quality assurance review for the past 9 years. The CAH failed to ensure the annual program evaluation which included a representative sample of both active and closed clinical records to evaluate patient care and determine if the CAH's actual practice reflected their policies and procedures, as well as the law, regulation or standard of practice placed patients at risk to receive inadequate health care services.

Findings include:

- The CAH ' s annual program evaluation and policies related to the evaluation were requested on 3/6/13 at 10:00am. The CAH failed to provide the requested information by 3/7/13.

Administrative staff B on 3/7/13 at 12:00 noon reported the CAH ' s last program evaluation was conducted in 2004. Administrative staff B verified the CAH failed to conduct an annual program evaluation.

The Critical Access Hospital (CAH) reported a census of six swing bed patients. The CAH reported on the Medicare Data Base worksheet 25 staffed beds, one operating room, two procedure rooms, emergency services, laboratory, radiology, swing beds and therapy services. Based on document review and staff interview the CAH failed to completed an annual program evaluation of patient services and quality assurance review for the past 9 years. The CAH failed to ensure the annual program evaluation which included a representative sample of both active and closed clinical records to evaluate patient care and determine if the CAH's actual practice reflected their policies and procedures, as well as the law, regulation or standard of practice placed patients at risk to receive inadequate health care services.



Findings include:

- The CAH ' s annual program evaluation and policies related to the evaluation were requested on 3/6/13 at 10:00am. The CAH failed to provide the requested information by 3/7/13.

Administrative staff B on 3/7/13 at 12:00 noon reported the CAH ' s last program evaluation was conducted in 2004. Administrative staff B verified the CAH failed to conduct an annual program evaluation for the past 9 years which included a review of representative sample of both open and closed clinical records

The Critical Access Hospital (CAH) reported a census of six swing bed patients. The CAH reported on the Medicare Data Base worksheet 25 staffed beds, one operating room, two procedure rooms, emergency services, laboratory, radiology, swing beds and therapy services. Based on document review and staff interview the CAH failed to completed an annual program evaluation of patient services and quality assurance review for the past 9 years. The CAH failed to ensure the annual program evaluation which included a representative sample of both active and closed clinical records to evaluate patient care and determine if the CAH's actual practice reflected their policies and procedures, as well as the law, regulation or standard of practice placed patients at risk to receive inadequate health care services.


Findings include:

- The CAH ' s annual program evaluation and policies related to the evaluation were requested on 3/6/13 at 10:00am. The CAH failed to provide the requested information by 3/7/13.

Administrative staff B on 3/7/13 at 12:00 noon reported the CAH ' s last program evaluation was conducted in 2004. Administrative staff B verified the CAH failed to complete an annual review of patient care policies for the past 9 years.

The Critical Access Hospital (CAH) reported a census of six swing bed patients. The CAH reported on the Medicare Data Base worksheet 25 staffed beds, one operating room, two procedure rooms, emergency services, laboratory, radiology, swing beds and therapy services. Based on document review and staff interview the CAH failed to completed an annual program evaluation of patient services and quality assurance review for the past 9 years. The CAH failed to ensure the annual program evaluation which included a representative sample of both active and closed clinical records to evaluate patient care and determine if the CAH's actual practice reflected their policies and procedures, as well as the law, regulation or standard of practice placed patients at risk to receive inadequate health care services.

Findings include:

- The CAH ' s annual program evaluation and policies related to the evaluation were requested on 3/6/13 at 10:00am. The CAH failed to provide the requested information by 3/7/13.

Administrative staff B on 3/7/13 at 12:00 noon reported the CAH ' s last program evaluation was conducted in 2004. Administrative staff B verified the CAH lacked a program evaluation which included documentation of a utilization review of patient care services for the past 9 years.