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Based on document review, policy and procedure review, and staff interview, the facility failed to conduct a periodic evaluation for it's total program in 2017.

Findings include:

Review of a one (1) page facility summary document revealed the only statistics on this page was the volume of services by department. There was no documented evidence the facility conducted an annual evaluation of its total program for October 2016 - September 2017.

Policy review revealed no documented evidence the facility reviewed their policy and procedures in the last year. Their swing bed policies were reviewed on May 28, 2015.

Review of the facility's Quality Assessment (QA) Program minutes revealed no documented evidence of data showing an effective QA Program. The minutes from 04-23-17 to 11-28-17 contain no Quality Assessment data that is measurable or Performance Improvement plans or data.

Review of facility documents revealed no documented evidence of:
1. Policy and Procedures for QA;
2. No QA program set up;
3. No corrective actions in place for problem prone data gathered;
4. Both active and closed clinical records reviewed annually to show best utilization of services.

During an interview on 02/01/18 at 12:45 p.m. the Hospital Administrator confirmed there had been no review of hospital policies and procedures in the last year.

On 02/01/18 at 1:25 p.m. the facility's Periodic Evaluation Plan and Policy, Policy and Procedure review policy, Quality Assurance policy and procedures, and Remedial Action in Quality Assurance process were requested. At 2:05 p.m. the Administrator stated, "We do not have these plans or policies. I called (name of company). They manage us, and they said they don't have them."


In an interview on 02/01/18 at 1:45 p.m. the Director of Nursing, who is in charge of Quality, confirmed the facility had no available program provided to utilize the data. She stated, "I've gathered the data. I inherited this job and I do what was already being done. I don't do anything after I gather it. I wasn't sure what to do."


In an exit conference on 02/01/18 at 2:53 p.m. these findings were revealed. No further documentation was provided.

Based on document review, policy and procedure review, and staff interview, the facility failed to carry out or arrange for a periodic evaluation of its total program at least once a year.

Findings include:

Cross Refer to C330 for the facility's failure to carry out or arrange for a periodic evaluation of its total program at least once a year.

Based on document review, policy and procedure review, and staff interview, the facility failed to review at least once a year the utilization of CAH services, including at least the number of patients served and the volume of services.


Findings include:


Cross Refer to C330 for the facility's failure to review at least once a year the utilization of their services, including at least the number of patients served and the volume of services.

Based on document review, policy and procedure review, and staff interview, the facility failed to evaluate and review at least once a year a representative sample of both active and closed clinical records.

Findings include:

Cross Refer to C330 for the facility's failure to evaluate and review at least once a year a representative sample of both active and closed clinical records.

Based on document review, policy and procedure review, and staff interview, the facility failed to evaluate and review at least once a year the CAH's health care policies.


Findings include:

Cross Refer to C330 for the facility's failure to evaluate and review at least once a year their health care policies.

Based on document review, policy and procedure review, and staff interview, the facility failed to ensure an effective Quality Assurance (QA) Program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.


Findings include:


Cross Refer to C330 for the facility's failure to ensure an effective QA Program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

Based on document review, policy and procedure review, and staff interview, the facility failed to
have an effective Quality Assurance (QA) Program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes of all patient care services and other services affecting patient health and safety.

Findings include:


Cross Refer to C330 for the facility's failure to have an effective QA Program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes of all patient care services and other services affecting patient health and safety.

Based on document review, policy and procedure review, and staff interview, the facility failed to
take appropriate remedial action to address deficiencies found through the Quality Assurance (QA) Program.


Findings include:


Cross Refer to C330 for the facility's failure to take appropriate remedial action to address deficiencies found through the QA Program.

Based on document review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the Critical Access Hospital (CAH), for two (2) of 12 months of 2017. One (1) patient in January and 1 patient in October.

Findings Include:

Review of the facility's "2017 Tissue Donation Report" from the OPO for the year 2017 revealed: One (1) patient death was referred to the OPO more than one hour after Cardiac Time of Death (CTOD) in January of 2017 and 1 patient death was referred to the OPO more than one hour after CTOD in October of 2017.

During an interview on 2/1/18 at 10:05 a.m. the Director of Nurses (DON) confirmed the facility had been late in calling in 1 death to the OPO in January of 2017 and 1 in October of 2017.

Review of the facility's "Organ and Tissue Donation" Policy and Procedure revealed: " ...Donor referral procedure: Upon determination of cardiac death or the potential brain death, the nurse caring for the patient (or other designated person or group) will be responsible for notifying MORA ...2. The nurse shall make the referral, ideally within one hour of cardiac death ..."

No other Policy and Procedures related to notifying MORA were submitted.

Based on document review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the CAH, for two (2) of 12 months of 2017. (January and October)

Findings Include:

Cross Refer to C344 for the facility's failure to notify the OPO in a timely manner of individuals whose death was imminent or who had died in the CAH for one (1) patient in January of 2017 and one (1) patient in October of 2017.