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Based on observation, record review and staff interview, the hospital failed to provide housekeeping and preventive maintenance in the radiology and surgical areas to ensure the facilities, supplies and equipment were maintained for safety and quality.

Findings:

During observations in the radiology department, the following practices were noted:
1. The radiology manager could not verify that the CT power injector was safe for patient use. She could not tell surveyors when the report was specified for as there was no documented date on the report. The radiology manger did tell surveyors that the CT power injector was recently serviced.
2. The radiology manager provided a report for the CT power injector that documented, "...I attempted to clean off sensors and checked the board seating but resulting in replacing the head since I had limited parts for this unit..."
3. These findings were verified with the Chief of Hospital Administration.

During observations of the surgical department, the following practices were noted:

4. A free-standing fluid/blanket warmer was located next to the hand washing sink right outside of the surgical procedure room. The operating room (OR) manager stated there were problems with the fluid/blanket warmer temperature. She told surveyors they put an oven thermometer in the different compartments to measure the correct temperature so the fluids/blankets don't get too hot. The OR manager told surveyors that the equipment had not been serviced and the OR department continues using the equipment.

5. Sterile surgical instruments were stored in a corridor enclosed by a door. This area was not ventilated and did not maintain temperature and humidity as required for the storage of sterile supplies. The area did not allow for adequate air circulation and was over-crowded with supplies and equipment.

6. Sterile supplies were stored in plastic tubs. The tubs were dirty, dusty and had multiple areas where old adhesive tape had been applied.

7. Endoscopy equipment was cleaned in a small area originally designed as a janitor's closet. The room was not large enough to process this equipment without multiple opportunities for contamination and breeches in infection control.

Based on observation, document review, and staff interview, the hospital failed to store and secure drugs and biological appropriately.

Findings:
1. Surveyors toured the hospital on the morning of 05/07/14, where the follow observations were made:

a. An emergency medication box was in the medical office building (MOB)/radiology department. Surveyors opened the medication box and observed multiple medications outdated and expired. Medications that were outdated and expired are listed below:

Epinephrine injection 1:1000
Epinephrine injection 1:10,000
Atropine Sulfate 1mg/mL
Adenosine injection 6mg/2 mL
Normal Saline 0.9% injections 10 mL 10 pre-filled syringes
Nitroglycerin injection two bottles 250 mLs

b. A removable tray with emergency medicine was in the emergency department (ED). Surveyors opened the removable tray and observed medications outdated and expired. Medications were outdated and expired which are listed below:

Epinephrine injection 1:1000
Epinephrine injection 1:10,000
Atropine Sulfate 1mg/mL
Nitroglycerin injection two bottles 250 mLs
Normal Saline 0.9% injections 10 mL 5 pre-filled syringes

c. There were also multiple bags of Dopamine injection solution 400 mg that were outdated and expired in the ED trauma room.

d. Throughout the facility, plastic bottles with clear solution was placed inside recessed fire extinguisher cabinets. There were also a small bottle of chemicals inside a clear zip lock bag that was labeled chemical spill kit.

2. The director of nursing (DON) took surveyors on a tour of the facility.

A. The radiology manager accompanied surveyors on the MOB/radiology department tour. The radiology manager was not able to tell surveyors what medications or supplies were kept in the emergency medicine box.

The radiology manager, drug room supervisor, and DON verified multiple medications expired that were in the emergency medicine drug box that is stored in the MOB.

B. The DON accompanied surveyors on a tour of the ED. The DON, ED staff, and drug room supervisor verified that the removal tray with emergency medicines were outdated and expired.

C. The DON, ED staff, and drug room supervisor verified that multiple dopamine injection solution 400 mg bags were outdated and expired in the ED trauma room.

D. The DON told surveyors, "The plastic bottles contain our eyewash solution in them and we have always stored them in with the fire extinguishers." The DON also informed surveyors that the chemical spill kits have also been stored in with the fire extinguishers.

E. The recessed fire extinguisher cabinets are not locked or secured. The DON and maintenance manager verified that the recessed fire extinguisher cabinets have never been locked.

F. The DON could not verify that the clear plastic bottles containing "eye wash solution" had not been tampered with. The DON could not verify what was actually in the "eye wash solution bottles" throughout the hospital.

3. On the morning of 05/08/14, surveyors observed operating room (OR) staff K carry in a 20 milliliter (mL) syringe filled with white liquid substance, set it on the top of a cart and wrote "propofol 1000."

4. Surveyors asked staff K what was in the syringe and she told surveyors propofol. Staff K was unable to tell the surveyor how many milligrams per mL was in the syringe. Staff K told surveyors they draw up medications and label the syringe with the name of medications and the time the medication was drawn up.

5. The OR staff told surveyors, "If the medication is placed on the cart, we know that area is clean. We clean up after a patient procedure while setting up for the next patient."

Based on hospital document review, and staff interview, the hospital failed to:

a. ensure the pharmacist is responsible for developing, supervising, and coordinating all the activities of the CAH (Critical Access Hospital) pharmaceutical service. See Tag C-0276;

b. develop and maintain an active on-going infection control program. See Tag C-0278;

c. ensure radiology services were supervised and performed according to accepted national standards. See Tag C-0283.

Based on observation and staff interview, the hospital failed to ensure the pharmacist is responsible for developing, supervising, and coordinating all the activities of the CAH (Critical Access Hospital) pharmaceutical service. All drugs and biologicals were not kept in a locked storage area and outdated/unusable drugs and biologicals were not unavailable for patient use and there was no evidence licensed hospital personnel were trained, had a job description and had been oriented to drug room principles by the pharmacist.

Findings:

1. Staff G's and Staff S's ,who work in the drug room, personnel files did not have evidence of job descriptions, orientation or competency evaluations for the drug room.

2. Surveyors toured the hospital on the morning of 05/07/14, where the following observations were made:

a. An emergency medication box was in the medical office building (MOB)/radiology department. Surveyors opened the medication box and observed multiple medications outdated and expired. Medication that's were outdated and expired are listed below:

Epinephrine injection 1:1000
Epinephrine injection 1:10,000
Atropine Sulfate 1mg/ml (milligram/milliliter)
Adenosine injection 6mg/2ml
Normal Saline 0.9% injection 10 ml 10pre-filled syringes
Nitroglycerin injection two 250 ml bottles

b. A removable tray with emergency medications was in the emergency department (ED). Surveyors opened the removable tray and observed medications outdated and expired. Medications that were outdated and expired are listed below:

Epinephrine injection 1:1000
Epinephrine injection 1:10,000
Atropine Sulfate 1mg/ml
Nitroglycerin injection two 250 ml bottles
Normal Saline 0.9% injections 10 ml 5 pre-filled syringes

c. There were also multiple bags of Dopamine injection solution 400 mg that were outdated and expired in the ED trauma room.

d. Throughout the facility, plastic bottles containing a clear solution and clear zip lock bags that were labeled chemical spill kit containing a small bottle of chemical were observed inside recessed unlocked fire extinguisher cabinets. During the tour the these bottles were identified as eye wash solution and part of the chemical spill kit by the Director of Nursing (DON). The DON was unable to identify what was contained in the bottles.

These findings were verified with hospital staff during the survey.

Based on review of hospital documents, infection control policies and procedures, infection control meeting minutes, personnel file review, staff interview, and observation the hospital failed to:
a. Have a system in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.
b. Provide a safe sanitary environment consistent with nationally recognized infection control precautions.
c. Designate in writing an individual who is qualified through education, training, experience and certification or licensure, as an infection control officer.
d. Identify and approve for use all disinfectant agents used in the hospital.
e. Evaluate staff practices for cleaning the OR between surgical cases, terminal cleaning at the end of the day, and the performance of deep cleaning at regular intervals to maintain the clean/sterile environment required of the surgery department.
f. Ensure surgical staff utilized the appropriate personal protective equipment for tasks performed in the decontamination room.
Findings:
1. On the morning of 05/07/2014, surveyors requested infection control policies and procedures, infection control meeting minutes, and the name of the infection control practitioner.
2. Administrative staff told surveyors that staff A was the infection control practitioner. On the afternoon of 05/07/2014, surveyors reviewed the personnel file of staff A. The personnel file of staff A contained no evidence of infection control training.
3. On the afternoon of 05/07/2014, staff A was asked what infection control training she had. Staff A told surveyors she had not had any training.
4. On the morning of 05/07/2014, surveyors requested documentation that hospital used disinfectants had been reviewed and approved by the infection control practitioner, and the medical staff. Staff A told surveyors that the disinfectants had not been reviewed and approved since she had been the infection control practitioner which had been 2 years.
5. Review of infection control meeting minutes and infection control documents contained no evidence of environmental rounds to include all departments in the hospital. On the morning 05/07/2014, staff A told surveyors that she had done hand washing surveillance throughout the hospital but had not made infection control rounds in all areas of the hospital.
6. On the morning of 05/07/2014, Staff A told surveyors that the hospital wide linen service was a contracted service. Staff A told surveyors that she had not done quality checks on the linen service provider.
7. On the morning of 05/07/2013, review of infection control meeting minutes contained no evidence that all departments reported regular ongoing infection control activities and surveillance to the infection control committee.
8. There was no documentation in the infection control documents of ongoing tracking of employee illnesses or surgical site infections.
9. Twenty six of twenty six personnel files reviewed contained no documentation of ongoing infection control training.

Observations:
1. On the morning of 05/07/2014, surveyors toured the facility.
2. Surveyors toured the medical office building. The medical office building contained a room labeled as "clean utility room". The clean utility room contained patient used equipment such as wheelchairs, a patient lift, and a patient walker. The patient walker contained a mop head over the top of it. The equipment did not appear clean. Staff A was asked how staff would know the equipment was clean. Staff A stated that she did not know.
On the morning of 05/07/2014, surveyors toured the operating room and endoscopy suite.
3. Surveyors observed staff entering the semi-restricted and restricted areas with shoe covers that had been worn in the main hallways of the hospital. A hospital policy, titled, " Attire in the Operating room," Documented,"...when shoe covers are worn, they are to be changed whenever torn, soiled or wet. Shoe covers are to be removed whenever leaving the surgical suite..."
4. Surveyors observed multiple times during the survey the operating room staff wearing their surgical scrubs into the main areas of the hospital without covering their scrubs with a gown. A hospital policy, titled, "Attire in the Operating Room," documented, "...a cover gown is to be worn whenever leaving the surgical suite..."
5. On the morning of 05/07/2014, surveyors were taken to the staff changing room. The staff changing room was located in a one stall bathroom. The operating room scrubs were stored in a cabinet in the bathroom. The "scrub cabinet" was noted to be open during both days when the operating room was toured. A hospital policy titled, "Attire in the Operating Room," documented..."OR attire shall be stored in an enclosed cupboard..."
6. Surveyors toured the OR accompanied by Staff H, the OR manager. Staff H was noted to have a bracelet on her wrist. A hospital policy titled, "Attire in the Operating Room", documented ..."personal jewelry worn in the surgical suites shall be limited to the following: bracelets - none ..."
7. Surveyors toured the main OR, staff H had on a surgical mask but did not have her nose covered. A hospital policy titled, "Attire in the Operating Room", documented, "...Masks shall cover the nose and mouth..."
8. Surveyors observed an ante-room to the operating room. In the ante-room there was a room that was labeled as decontamination. The decontamination room stored housekeeping supplies, such as brooms, dust pans, mops and a mop bucket. Staff H told surveyors this decontamination room is where the scrub techs brought surgical instruments for cleaning.
9. The main OR contained paper signs on the walls, paper signs cannot be terminally cleaned.
10. The main OR contained equipment already opened and ready for the next case. The hospital did not have surgical cases scheduled during the three days of the survey. There was a sequential compression device machine in the OR with the connecting tubing on the OR floor. The connecting tubing was dirty. Staff H told surveyors the OR was terminally cleaned and ready for a case.
11. The main OR contained extension oxygen tubing already connected for the next case. Staff H was asked why the tubing was already connected. Staff H told surveyors that it is left that way and is used on all patients.
On the morning of 05/07/2014, surveyors toured the endoscopy suite
12. Surveyors observed an ante-room of the endoscopy suite. The ante-room contained storage racks on each side of the room. Liquids were stored above clean and sterile items. Surveyors observed corrugated boxes on the storage racks.
13. Surveyors observed two connecting rooms to the ante-room. One connecting room was labeled as the decontamination room. The decontamination room contained housekeeping equipment such as mops, brooms, dust pans, and a mop bucket. Staff H told surveyors this room was used for endoscope processing.
14. Surveyors observed another room connected to the ante-room in the endoscopy suite. This room contained endoscopes stored on the wall and not secured in a cabinet. A hospital policy, titled, "High - Level Disinfection of Endoscopes, " documented, "...store endoscopes in a manner which will protect the endoscopes..."
15. Surveyors observed the endoscopy suite. Surveyors observed an endoscope draped over metal hooks on the wall, Staff H told surveyors the endoscope was there for an endoscopic procedure for the next day. Surveyors observed oxygen connecting tubing already connected to the oxygen.
Staff H told surveyors the tubing is ready for the endoscopic procedures the next day. Staff H told surveyors the tubing is used for multiple patients.
On the afternoon of 05/07/2014 surveyors toured the remainder of the hospital.
1. Surveyors observed a clean utility room on the medical surgical area of the hospital. Linens were stored on a metal rack. The rack was not covered.
2. Surveyors observed a storage room in the hospital. The room was unmarked. This room contained several different types of patient equipment such as wheel chairs and bedside commodes. Staff A was asked how staff would know that this equipment was clean. Staff H stated they use a cleaning log. The equipment was not marked in any way to log what equipment had been cleaned and what equipment had not been cleaned.
On the morning of 05/08/2014, surveyors asked to go to the endoscopy room to observe the reprocessing of endoscopes and the cleaning of the endoscopy suite.
1. On the morning of 05/08/2014, surveyors observed Staff I reprocess an endoscope. Staff I carried the endoscope in her gloved hands across the floor of the endoscopy ante room to the decontamination room and placed it in the sink. Staff I took her gloves off and removed the disposable gown she had on. Staff I put on new gloves without washing her hands in between changing her gloves.
Staff I put on a non-disposable apron that did not provide adequate protection. Staff I walked through the ante room with the non-disposable apron on. Staff I was asked when the apron is washed. Staff I stated that she thought it is sent out with the laundry every 2 weeks. Staff I was asked if the apron only got washed every 2 weeks, Staff I stated that it gets bleached at the end of the day but not in between scope cleaning.
2. Surveyors observed a cabinet above the sink that is used to clean the endoscopes. The cabinet contained clean items such as wash cloths and packaged syringes. Surveyors observed Staff I cleaning an endoscope with the cabinet open allowing for splashing into the cabinet. Staff I was observed many times to reach into the cabinet to obtain items without changing her gloves.
3. The endoscope decontamination room contained a medivator (an automated endoscope cleaning machine) Staff I touched the medivator and the inside of the medivator with dirty gloves on.
4. After the endoscope was cleaned in the sink by Staff I, Staff I placed the endoscope in the medivator with dirty gloves on.
5. Staff I was asked if the sink in the decontamination room was cleaned in between scopes. Staff I stated that the sink does not get bleached until the end of the day. Staff I stated that she wipes the sink out with an enzymatic cleaner in between scopes.
6. After staff I placed the scope into the medivator, surveyors observed her walk through the ante room with the dirty apron on to wash her hands.
7. Surveyors observed Staff J bring a 2nd endoscope into the decontamination room. Staff J brought the scope to the decontamination room on a cart covered with a towel. Staff J removed her gloves and donned another set of gloves without washing her hands.
8. Staff I placed the 2nd scope into the decontamination sink and placed a non-disposable long pair of gloves on that covered her fore arms. Staff I was asked why she didn ' t use these same gloves when she cleaned the first scope. She told surveyors it was because she could not find them.
9. Staff I placed the dirty apron on a hook on the wall. She did not clean the apron. A 2nd apron was hanging on the wall. The 2nd apron had dirty splash spots on it.
10. Staff J prepared mop water in a mop bucket while in the decontamination room. Staff I wiped out the sink with enzymatic cleaner while Staff J prepared the mop water.
11. Staff J pulled the chemical dilution hose out of the hopper (a toilet used to dispose of all bodily fluids) and placed the hose into the mop bucket. Staff J prepared a cleaning solution that was used to clean the endoscopy room.
12. Staff J and Staff I were both observed wearing the same gloves while cleaning the endoscopy suite and walking through the ante room and scope storage room and gathered equipment for the next endoscopy case.
13. Staff I placed a clean washcloth into the mop water and washed a table in the endoscopy suite with the same water. Staff I told surveyors that the washcloth and mop heads are never placed back into the mop bucket. Staff I and Staff J placed dirty mop heads and dirty wash cloths into the ringer of the mop bucket that sits above the mop water and the items remained in the ringer while Staff I and Staff J continued to use the mop water.
14. Staff J removed a suction container from the endoscopy suite and placed a new clean suction container back in the endoscopy suite wearing the same gloves.
15. Staff J placed a new patient gown in the endoscopy suite with dirty gloves on while she continued to clean in the endoscopy suite.
16. Staff I opened new suction tubing and new oxygen tubing and placed it in the endoscopy suite with dirty gloves on. Staff I stated she was getting the tubing ready for the next case. The endoscopy suite had not been terminally cleaned yet. Staff I and Staff J simultaneously cleaned the endoscopy suite and placed new patient equipment in the room.
17. Surveyors observed Staff J remove her dirty shoe covers and did not wash her hands. Staff J placed new shoe covers on and touched her face and did not wash her hands.

Based on record review, policy and procedure review, and staff interview, the hospital failed to ensure radiology services:

1. were supervised and performed according to accepted national standards.
2. provided orientation, training, and oversight of radiology services personnel.
3. have documentation showing all personnel operating radiology equipment were qualified and trained.
4. written policies that were developed and approved by the medical staff.
5. documented which studies required interpretation by a radiologist.

Findings:
1a. Contracted staff personnel files (GG and II) reviewed contained expired certifications and licensures with documented dates of 2008.

1b. Contracted staff personnel files (GG and II) reviewed did not contain documented evidence that they were designated and qualified to use radiological equipment and administer procedures involving nuclear medicine studies.

1c. On the afternoon of 05/07/14, emergency department staff told surveyors that they are not notified when nuclear studies are administered.

1d. Contracted Staff (GG and II) personnel file did not have evidence of being qualified and designated to perform nuclear medicine studies in the medical office building (MOB) due so while Staff DD is seeing patients.

1e. An emergency medication box was observed where multiple medications were expired (Epinephrine injection 1:1000; Epinephrine injection 1:10,000; Atropine Sulfate 1mg/1mL; Adenosine injection 6mg/2 mL; Normal Saline 0.9% injections 10 mL 10 pre-filled syringes; Nitroglycerin injection two bottles 250 mLs).

1f. There was missing equipment for the ambu-bag (used for providing oxygenation to a patient).

1g. Radiology manager told surveyors that there is emergency equipment in the MOB in case there is a nuclear medicine reaction.

1h. On the morning of 05/07/14, the radiology manager told surveyors that nuclear medicine studies are performed in the MOB which is where part of the hospital ' s radiology department is located.

2a. On the afternoon of 05/08/14, surveyors spoke with the radiology department manager. She told surveyors the hospital did not have any orientation, training, competencies or evaluations for any contracted employee.

2b. On the afternoon of 05/08/14, surveyors were given all radiology personnel files including contract personnel. Nine (D, O, Q, W, Z, GG, II, KK, and LL) of nine radiology personnel files did not contain orientation, training, competency or evaluation.

2c. On the morning of 05/07/14, surveyors toured the radiology department with the radiology manager. Surveyors observed two cleaning products throughout the radiology department. Surveyors observed a spray bottle with a label, HB 3M Quat, PDI Sani-Cloth AF Germicidal Disposable wipes.

2d. On the afternoon of 05/07/14, surveyors asked the radiology manager what cleaning products were used in the radiology department. The radiology manager told surveyors the radiology department utilized different cleaners in the department and did not know the names of cleaners used; what organisms the products killed; and kill time for the disinfectants. She also told the surveyors the department switched from Cidex to another cleaner for cleaning the trans-vaginal probes which might have been Cidex OPA.

2e. The product labels were HB 3M Quat and PDI Sani-Cloth AF Germicidal Disposable Wipe. The HB 3M Quat indicated a required a wet time of ten minutes in order for the product to be effective. The PDI Sani-Cloth AF Germicidal Disposable Wipe indicated a required time of a three minute kill time.

2f. The radiology manager was unable to provide surveyors with Cidex OPA information. The radiology manager told surveyors that the staff member who cleaned the equipment with the Cidex OPA was not at work and did not know where the cleaning product and information was kept.

2g. On the afternoon of 05/07/14, surveyors asked the radiology manager if radiology staff had received training with the cleaning products that the radiology department used.
The radiology manager told surveyors no infection control training had been provided to the radiology staff.

2h. On 05/07/14, surveyors were given Governing Body and Medical Staff Meeting Minutes. Review of minutes did not indicate there was any type of radiology department review.

2i. On 05/08/14 this finding was reviewed with radiology manager, Director of Nursing/Employee Health & Infection Control, and Chief of Hospital Administration and no further documents were provided.

3a. On the morning of 05/08/14, the facility could not provide documentation indicating the Medical Staff or radiologist had deemed radiology personnel were competent to provide radiology services.

3b. On the afternoon of 05/08/14, the radiology manager told surveyors she would have one of the reading radiologists sign a form she will be typing up that delineated what each staff member could do.

3c. On the afternoon of 05/09/14, the radiology manager provided surveyors with a hospital policy titled, " Competency Designation of Staff " that was signed by Staff PP, dated 05/08/14. This document was not approved by the medical staff/governing body.

4a. On 05/07/14, the radiology policies and procedures were reviewed. Surveyors asked to review the Infection Control Policies that are currently used in the Radiology Department.

4b. There was no documented evidence that cleaning products used in the radiology department had been approved by the Infection Control Practitioner and the Medical Staff.

4c. There was no departmental description of all radiology procedures performed by the hospital.

4d. There was no evidence of a written policy that was developed and approved which designates which personnel are qualified to use the radiological equipment, administer procedures, and which studies require interpretation by a radiologist.

4e. The policies had no documentation they were developed based on accepted standards of practice.

5a. The radiology manager was asked for documentation of which studies required interpretation.

5b. The Chief of Hospital Administration verified that there was no Radiologist appointed over radiology services and had no knowledge that there was a document indicating which radiologic studies required interpretation by a radiologist.

Based on observation, hospital document review, policy and procedure review and staff interview, the hospital failed to ensure surgical services were performed in a manner that conformed to national standards of practice as evidenced by failure to:
a. Define the scope of surgical services;
b. Conform to standards of practice for peri-operative care and the high level disinfection of endoscopes; (see tag 0278) and
c. Perform appropriate cleaning between endoscopy procedures. (see tag C0278)
Findings:
1. On the morning of 05/07/2014, administrative staff was asked to provide surgical policies and procedures and a written scope of surgical services.
2. A binder was provided that contained surgical policies and procedures but there was no documentation of a written scope of surgical services currently provided by the hospital.
3. The surgical policies were not current and were dated 2009.
4. The operating room (OR) register did not include ages of the patients.
5. Endoscopes were not stored in a closed cabinet, they were stored on a wall held by metal hooks and Velcro fabric. Endoscopes that were no longer in use were stored next to endoscopes that were used. Staff H was asked why some endoscopes were not used. She stated she did not know.
6. Infection control practices were not followed for terminal cleaning of the OR and for scope reprocessing (see tag C0278).
7. Surveyors reviewed 3 of 3 personnel files (Staff I, Staff J & Staff K) who worked in the OR that
contained no documentation of staff orientation, training and competency for decontamination processes, high level disinfection and sterilization.
8. Critical medical equipment was not regularly inspected for patient safety. A microscope used in the OR for patients who had eye surgery had not been through preventative maintenance since 03/21/2012. Staff H told surveyors that she did not think equipment had to be checked if it was not directly used on the patient. A Phacoemulsification machine (used in cataract eye surgery) had not been through preventative maintenance since 03/01/2013.
9. Patients were recovered in a room not originally designed as a recovery room. The room did not have emergency power from the critical care branch. There was one room designated as a recovery room. The recovery room did not have oxygen and suction outlets. (see K-tag 201) Staff H told surveyors that sometimes endoscopy patients are recovered in the endoscopy suite. The endoscopy suite does not meet standards for a recovery room.
10. Surveyors observed OR staff walking throughout main areas of the hospital in surgical scrubs not covered with a gown and wearing the same shoe covers. (see tag C0278)
11. Surgical scrubs were not stored appropriately. (see tag C0278)
12. Surveyors reviewed four of four medical records for patients who received surgical services that contained no documentation from the nurse of the patient's disposition. There was no note from the nurse what time the patient was discharged or who the patient was discharged with.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital performs a periodic evaluation and quality assurance review as required. The hospital has not conducted an annual periodic evaluation with all the required elements and does not have an effective and ongoing quality assurance program.

1. The hospital does not ensure a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's (critical access hospital's) health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag C 331.

2. The hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted. Refer to Tag C 0332.

3. The hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records. Refer to Tag C 333

4. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. Refer to Tag C 0334.

5. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag C 0335.

6. The hospital does not have an effective quality assurance program that collects relevant data, includes all analyzes the data and implements corrective action. Refer to Tag C 0336.

7. The hospital does not have an effective quality assurance program that is implemented to evaluate the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. Refer to Tag C 0337.

7. The hospital does not have an effective quality assurance program implemented to evaluate nosocomial infections and medication therapy. Refer to Tag C 0338.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's (critical access hospital's) health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 05/09/14 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2013 and 2014 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

3. Staff provided documentation of a periodic evaluation for the year of 2012, but a periodic evaluation had not been done for 2012.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had a yearly program evaluation which included a review of the number of patients served and the volume of services. Hospital staff verified on 05/09/14 in the afternoon the hospital did not have an annual program evaluation which included these statistics.

Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body, Medical Staff and Performance Improvement meeting minutes for 2013 and 2014 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Hospital personnel stated on the afternoon of 05/09/14 in the afternoon that they did not have an annual periodic evaluation that included a representative sample of active and closed medical records.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had an annual program evaluation which included a review of the hospital's health care policies. The hospital did not have an annual program evaluation that had evidence of review of the hospital's policies. This was verified with hospital staff on 05/09/14 in the afternoon.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had an annual program evaluation that determined whether the utilization of services was appropriate, established policies were followed and any changes were needed. The hospital did not have an annual program evaluation that documented whether any changes to hospital services or policies were added or revised because of information from an annual program evaluation. This was verified by hospital staff during the survey.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital has an effective quality assurance program that collects relevant data, includes all analyzes the data and implements corrective action. The quality assurance meeting minutes for 2013 and 2014 provided for review did not have relevant indicators to identify potential problems and opportunities to improve quality of care. There was no analysis of any data that was collected and no evidence of the implementation of any corrective action taken.

Findings:

1. Data examples for indicators for various departments consisted of refrigerator temperatures and from radiology the amount of money made in that department.

2. There were no indicators for the surgery anesthesia and central sterile departments.

3. The hospital did not have an effective infection control program that included indicators to monitor infections in the hospital.

Based on record review and interviews with staff, the hospital failed to ensure an effective quality assurance program had been implemented which had indicators to identify, prevent and analyze problems and that the problems identified had corrective action taken to improve quality on a continuous basis and included all departments and services under contract. The hospital did not have an effective, ongoing quality assurance program which included all departments including services provided by contract.

Findings:

1. Housekeeping and preventive maintenance in the radiology and surgical areas did not have Qualtity Assessment/Performance indicators to ensure the facilities, supplies and equipment were maintained for safety and quality.

2. Surgery and central sterile did not have indicators to monitor infection control practices in these two departments.

3. Radiology services provided by contract were not monitored and evaluated as part or the quality program.

4. Hospital staff verified these services were not monitored through the hospital's quality program.

Based on record review and interviews with hospital staff, the hospital does not ensure nosocomial infections and medication therapy are evaluated as part of a Quality Assurance Performance Improvement (QAPI) program. Review of medical staff , governing body and quality meeting minutes for 2013 and 2014 did not have evidence of evaluation of nosocomial infections or medication therapy. This was verified by hospital staff on 05/09/14.