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I. Based on document review and staff interview, the facility failed to ensure the Network Hospital staff annually reviewed the facility's Credentialing Policies and Procedures in accordance with the approved Network Hospital agreement. The facility reported 3 active medical staff members and 70 consulting medical staff members.

Failure to ensure the Network Hospital staff annually reviewed the facility's Credentialing Policies and Procedures, in accordance with the agreement for Credentialing, could potentially result in the facility's Medical Staff and Board of Trustees failure to credential all medical staff members per the facility's policy.

Findings include:

1. Review of the Network Agreement, dated November 1, 2006, revealed in part. ". . .C. Credentialing. . . [Network Hospital] shall annually review and make recommendations regarding the Credentialing Policies and Procedures of HOSPITAL [Pocahontas Community Hospital]. . . ."

-Review of a document titled, "Critical Access Hospital Credentialing Policy/Procedure Review," used by the Network Hospital to document their review and recommendations of specific policies/procedures related to the CAHs Credentialing, showed the Network Hospital staff last reviewed and made recommendations related to the policies on 5/12/2010.

-Further document review revealed the facility failed to ensure the Network Hospital completed an annual review of the facility's Credentialing Policy/Procedures 2011 or thus far in 2012, as required by the Network Agreement.

2. During an interview on 9/26/12 at 7:35 AM, Staff E, Administrative Assistant, acknowledged the last time the Network Hospital reviewed their credentialing policy and procedures was 5/12/2010. Staff E further stated, the Network Hospital representative had stated the review did not need to occur as often as documented in the Network Agreement.

II. Based on document review and staff interview, the facility failed to ensure the Network Hospital staff annually reviewed the facility's quality assurance plan and its implementation in accordance with the approved Network Hospital agreement. The facility reported a current census of 2 inpatients at the beginning of the survey.

Failure to ensure the Network Hospital staff annually reviewed the facility's quality assurance plan, in accordance with the agreement for Quality Assurance, could result in the facility's quality staffs failure to identify and act on patient care related issues and potentially cause adverse patient outcomes.

Findings include:

1. Review of the Network Agreement Amendment, dated January 20, 2011, revealed in part. ". . . A. Quality Assurance . . . [Network Hospital] will review HOSPITAL's [Pocahontas Community Hospital] quality assurance plan and its implementation of such plan on an annual basis and make appropriate recommendations for modification. . . ."

-Review of Rural PI (Performance Improvement) Leaders Quarterly Meeting Minutes, dated from April 20, 2011 to June 14, 2012, where Network Hospital staff attended, lacked documentation that showed the Network Hospital staff completed the annual review of the facility's quality assurance plan and its implementation in accordance with the approved Network Hospital agreement.

2. During an interview on 9/26/12 at 9:30 AM, Staff F, Director of Patient Quality, acknowledged the lack of evidence that the Network Hospital staff completed the annual review the facility's quality assurance plan and its implementation in accordance with the approved Network Hospital agreement. Staff F further stated the review last occurred in the fall of 2011 but lacked any documented evidence that the review had occurred.

I. Based on document review and staff interview the facility administrative staff failed to establish a system to identify and prevent transmission of infections and communicable diseases for the facility volunteers. Administrative staff reported an average census of 3 patients and identified 18 volunteers.

Failure to identify infections and communicable diseases among volunteers could potentially result in transmission to patients, increasing inpatient stays or death.

Findings include:

1. Review of the personnel file for Staff C, Volunteer, revealed a document titled "Employee/Volunteer Health Assessment," dated 6/22/11, signed by Staff C, but lacked a signature in the area designated for the employee health nurse. In addition, the file lacked documentation of a tuberculosis test (TB).

-Review of the personnel file for Staff D, Volunteer, revealed a document titled "Employee/Volunteer Health Assessment," dated 6/22/11, signed by Staff D, but lacked a signature in the area designated for the employee health nurse. In addition, the file lacked documentation of a TB test.

-Review of the personnel file for Staff G, Volunteer, revealed a document titled "Employee/Volunteer Health Assessment", dated 6/22/11, signed by Staff G, but lacked a signature in the area designated for the employee health nurse. In addition, the file lacked documentation of a TB test.

2. Review of a facility policy title "Pocahontas Community Hospital Program", last revised in 3/12, revealed in part ". . . 2. Health screenings/immunizations: These are not needed for volunteers. . . "

3. During an interview on 9/25/12 at 3:30 PM, Staff A, Human Resources, reported she was unsure of the policy on TB testing for the volunteers and called Staff B, Volunteer Coordinator, who reported TB testing of volunteers was no longer conducted, and addressed in the current volunteer policy.

-During an interview on 9/26/12 at 9:00 AM, Staff B reported TB testing of volunteers was discontinued at some point in 2009, but could not be sure of the specific date the change in policy occurred. She reported the employee health nurse attended an infection control conference in 2009 and received information that indicated the health assessment and TB testing was no longer required for volunteers, so the facility policy was changed. Staff B reported the facility had previously completed TB tests on all volunteers and verified this through documentation completed previous to 2/2009. Staff B confirmed the Employee/Volunteer Health Assessment is completed by all volunteers but is not reviewed by anyone.


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