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Based on policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure all CAH departments developed policies/procedures to define the expected practice and performance in the provision of patient care services. The problem was identified for 3 of 3 applicable departments (Environmental Services (EVS), Nutritional Services, and Facilities).
Failure to ensure policies and procedures are developed and approved by the medical staff and governing body could potentially result in miscommunication of expected practices and performances in the provision of patient care and result in patients receiving less than optimal care or failure to provide the patient with the care and services needed resulting in patient harm. The CAH administrative staff identified an inpatient census of 9 patients upon entrance.

Findings include:

1. Review of CAH policies and procedures for patient care services revealed a lack of policies and procedures for provision of the Environmental Services, Facilities, and Nutritional Services Areas.

2. During an interview on 7/11/23, at 1:00 PM, with the EVS and Facilities Director revealed that he was an employee of Aramark and is contracted through the CAH to oversee the EVS and, Facilities Departments. The Nutritional Service Area is also managed by Aramark. EVS, Facilities, and Nutritional Services have been following in part Aramark's policies and procedures. The EVS, Facilities, and Nutritional Services areas follow Aramark's policies and procedures for the provision of patient care and the CAH does not have access to Aramark's policies or procedures specific to those CAH service areas.

3. During an interview on 7/13/23, at 10:30 AM, with the Chief Nursing Officer (CNO) revealed the CAH administrative staff was unaware the staff did not have access to Aramark's policies and procedures. The CNO acknowledged these policies were not approved by the CAH medical staff and governing body.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure that the individuals responsible for the Antibiotic Stewardship and Infection Preventionist had a cohesive systems in place and operational for tracking of all infection surveillance, prevention and control, and antibiotic use activities, in or to demonstrate any implementation was able to be sustained and successful. Failure to have systems in place with continued surveillance of both programs could potentially risk patient safety, causing harm or death. The CAH administrative staff identified an inpatient census of 9 patients upon entrance.

Findings include:

1. Review of the CAH's, "Quality Assurance Performance Improvement Plan," effective fiscal year 2023, revealed in part ... "Final authority to ensure that patient safety and quality services are provided rests with the Board of Trustees ... The Board Quality Assurance Committee will be responsible for periodic review of PI summary reports, which demonstrate that the purpose of the plan is met."

2. Review of the CAH's, "Infection Prevention 2022 Infection Prevention Plan," last reviewed 7/2022, revealed in part ... "the Infection Prevention Nurse ...concurrent review of all hospital and clinic areas, including Family Medicine, for signs of infection, risk factors, special studies, and healthcare acquired infections ...Order cultures as indicated on hospitalized patients ...Review all infection reports submitted by and presenting data to the committee on surveillance, healthcare-acquired rates, clusters of infections, and special studies ...Assist Employee Health nurse with review and revision of employee health policies ...Provide input on the purchase of equipment and supplies for sterilization, disinfection, and decontamination, or prevention of blood-borne pathogen exposures, as requested."

3. During an interview on 7/13/23 with the Director of Quality revealed the Infection Preventionist only provides audits for hand hygiene, leads the Infection Prevention meeting, but states her main duty is Cardiac Rehab. The Infection Preventionist Nurse relies on other departments to gather the information and report their findings during the Infection Prevention meeting. The Director of Quality stated she correlates the information for the Infection Prevention program and discusses the findings with the Quality Assurance Performance Improvement Committee meeting but does not report this information to The Board of Trustees. The Antibiotic Stewardship information is provided at the Medical Staff meeting but is not shared with The Board of Trustees as well.

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 4 of 38 patient care services. (PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound). The CAH administrative staff reported a census of 9 inpatients at the beginning of the survey. Failure to evaluate all patient care services could potentially result in the CAH staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved patient care services.

Findings include:

1. Review of CAHs, "Quality Assurance Performance Improvement Plan", fiscal year 2023, revealed, in part. "...The purpose ...is to provide a strategy for the performance of activities to ensure departments provide appropriate, high-quality, effective and efficient services in accordance with the Greene County Medical Center mission, while improving patient safety and reducing risks to patients and residents through an environment ...".

2. Review of the CAH's quality documents revealed the lack of documentation the CAH staff evaluated all patient care services, including PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound.

3. During an interview on 7/13/23, at 8:00 AM, with the Director of Quality reported all CAH departments are required to report quality measures and data to the Quality Committee quarterly. Each department is assigned to a reporting schedule. Imaging was scheduled to report November's 2022 first quarter results for 2023 and the third quarter's results. The Director of Imaging confirmed she had not been reporting quality measures for PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound.

Based on review of documentation, governing board meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed ensure The Board of Trustees has sufficient information regarding the CAH's quality improvement activities to ensure the CAH's Board of Trustees could exercise oversight of the quality for all patient care services, including contracted services, offered at the CAH for 35 of 38 departments (Anesthesia, Surgery, Emergency Room, Pharmacy, Lab, IT, Respiratory Therapy, Occupational Therapy, Physical Therapy, Public Health, Radiology, NucMed, PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Cat Scan, Ultrasound, MRI, Materials Management, Dietary, Dietician, Nursing, Diabetic Education, Employee Health, Pulmonary Rehab, Cardiac Rehab, Sleep Lab, Facilities, HIM, Clinic, Infusion clinic, Quality, and Environmental Services). The CAH administrative staff identified a census of 9 inpatients at the time of the survey. Failure of the CAH Board of Trustees to review and evaluate Quality Improvement information could potentially result in the Board of Trustees inability to provide effective oversight to the Quality Improvement committee and result in the CAH staff delaying actions to correct any identified deficiencies in the quality of care provided to patients at the CAH.

Findings include:

1. Review of the Board of Trustee Bylaws, December 2022, revealed in part, " Duties...the board of trustees shall ...engage in all activities necessary to manage, control, and govern the medical center ...exercise all the rights and duties of medical center ...including but not limited to authorizing the delivery of healthcare service, or other ancillary service."

2. Review of CAHs, "Quality Assurance Performance Improvement Plan", fiscal year 2023, revealed, in part, " ...The Quality Assurance Performance Improvement plan shall be evaluated annually and revised as necessary to: Provide the ... Board of Trustees with a planned and systematic evaluative mechanism designed to safeguard the resources of the organization and to oversee the safe, efficient, and effective delivery of service and patient safety."

3. Review of the Board of Trustee meeting minutes, from 6/23/2022-5/25/2023, revealed the CAH's quality staff provided the Board of Trustees with a quality presentation in September 2022 for the fiscal year 2023 Quality Assurance Performance Plan Priorities that addressed topics including handwashing compliance, infection prevention practices for Covid, stroke ready certification for the Emergency Department (ED), develop policies/procedures for standardize care, Urology, Pain clinic, Merit based incentive payment system for colorectal screenings/high blood pressure/pneumococcal vaccine, extended swing bed service, and safety/work place violence. The meeting minutes lacked information on the CAH's Quality Improvement activities for Anesthesia, Surgery, Emergency Room, Pharmacy, Lab, IT, Respiratory Therapy, Occupational Therapy, Physical Therapy, Public Health, Radiology, NucMed, PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Cat Scan, Ultrasound, MRI, Materials Management, Dietary, Dietician, Nursing, Diabetic Education, Employee Health, Pulmonary Rehab, Cardiac Rehab, Sleep Lab, Facilities, HIM, Clinic, Infusion clinic, Quality, and Environmental Services.

4. During an interview on 7/13/23, at 10:30 AM with the Director of Quality revealed she only reported to the Board of Trustees in September 2022 and acknowledged they failed to present the Board of Trustees at least quarterly with information on the CAH staff's quality improvement efforts to prevent problems, create measurable goals, corrective actions taken for identified problems, and outcomes of the corrective actions for Anesthesia, Surgery, Emergency Room, Pharmacy, Lab, IT, Respiratory Therapy, Occupational Therapy, Physical Therapy, Public Health, Radiology, NucMed, PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Cat Scan, Ultrasound, MRI, Materials Management, Dietary, Dietician, Nursing, Diabetic Education, Employee Health, Pulmonary Rehab, Cardiac Rehab, Sleep Lab, Facilities, HIM, Clinic, Infusion clinic, Quality, and Environmental Services. The Chief Nursing Officer (CNO) and the Director of Quality revealed they were unaware that reporting had stopped at the subcommittees such as the Quality Assurance Committee and Medical Staff Committee and was not being reported to the Board of Trustees.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes for all services, including contracted services for 4 of 38 departments (PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound) by failing to provide any indicators or goals at or above threshold in accordance with facility policy. The CAH administrative staff identified a census of 9 patients at the beginning of the survey. Failure to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality Assurance Performance Improvement Plan" fiscal year 2023, revealed in part, "The governing body, administration, medical staff, and all employees of Greene County Medical Center will demonstrate a consistent endeavor to continuous performance improvement of patient/resident/client care and services in a safe, cost-effective and affordable manner." "The Quality Assurance Performance Improvement plan provides a mechanism for implementing the ongoing, systematic monitoring and evaluation of services provided within Greene County Medical Center."

2. Review of the CAH's quality documentation revealed the following:

a. No quality indicators were identified for PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound.

b. Review of the PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound documentation for year 2023 revealed there were no indicators or goals with measures related to improved health outcomes for patients.

3. During an interview on 7/13/23 at 10:30 AM, the Director of Quality verified the CAH staff failed to ensure these departments reported indicators, goals and measures related to improved health outcomes.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) failed to use the quality measures to analyze and track performance for predictive patient outcomes for all services, including contracted services for 4 of 38 departments (PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound). The CAH administrative staff identified a census of 9 patients at the beginning of the survey. Failure to use the quality measures to analyze and track performance for predictive patient outcomes for all services to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH's "Quality Assurance Performance Plan," fiscal year 2023 revealed in part, "...to provide a strategy for the performance of activities to ensure departments provide appropriate, high-quality, effective and efficient services in accordance with Greene Medical Center mission, while improving patient safety and reducing risks to patients and resident through environment."

2. Review of the "Quality Assurance Performance Plan Priorities ," fiscal year 2023 " documentation revealed the following:

a. The facilities focused objective goal to continue handwashing compliance, infection prevention practices for Covid, stroke ready certification for the Emergency Department (ED), develop policies/procedures for standardize care, Urology, Pain clinic, Merit based incentive payment system for colorectal screenings/high blood pressure/pneumococcal vaccine, extended swing bed service, and safety/work place violence. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance for PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound.

3. During an interview on 7/13/23, at 10:30 AM with the Director of Quality, acknowledged the CAH staff failed to ensure each service offered at the CAH identified quality projects that focused on measures to analyze and track the quality program's performance.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) failed to set priorities for performance improvement with consideration of high volume, high -risk services or problem prone areas for predictive patient outcomes for all services, including contracted services for 4 of 38 departments (PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound). The CAH administrative staff identified a census of 9 patients at the beginning of the survey. Failure to set priorities for performance improvement with consideration of high volume, high-risk services or problem prone areas for predictive patient outcomes for all services to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH's "Quality Assurance Performance Improvement Plan," fiscal year 2023 revealed in part, " ...to provide a strategy for the performance of activities to ensure departments provide appropriate, high-quality, effective and efficient services in accordance with Greene Medical Center mission, while improving patient safety and reducing risks to patients and resident through environment...recognition and acknowledgement of risks to patient safety and medical/health care errors ..."

2. Review of the "Quality Assurance Performance Improvement Plan Priorities" fiscal year 2023 documentation revealed the following:

a. The Priorities Quality presentation revealed the facilities lacked evidence that the CAH's quality staff failed to include PET Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, and Ultrasound as areas needing set priorities that potentially could be considered high volume, high-risk services, or problem prone areas.

3. During an interview on 7/13/23, at 10:30 AM with the Director of Quality, acknowledged the CAH staff failed to ensure each service offered at the CAH identified quality projects that focused on measures that considered high volume, high-risk services, or problem prone areas.