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RIVER FALLS AREA HOSPITAL
COMPLIANCE WITH 489.24
Tag No.: C2400
Based on record review and interview facility staff failed to ensure annual assessment of community call plan and that all hospitals involved had staff signing off on plan in 1 of 1 emergency department reviewed.
Findings include:
Facility staff failed to ensure annual assessment of community call plan and that all hospitals involved had staff signing off on plan. See tag A2404.
ON CALL PHYSICIANS
Tag No.: C2404
Based on record review and interview the facility staff failed to ensure there were signatures by staff from each participating hospital in the "Community Call Plan" (the facility plan that provides for general surgeons to be available on-call to evaluate, stabilize and treat patients with emergency medical conditions) and that an annual assessment of the plan was conducted by the participating hospitals in 1 of 1 Emergency Department reviewed.
Findings include:
The facility document "Community Call Plan" was reviewed on 12/8/2020 at 2:00 PM. This document revealed the plan for on-call general surgeons for the facility. The document did not have a policy number, date of review or revisions or signatures indicating approval by the governing board.
When requested documentation of the "Community Call Plan" being approved by the facility, Quality Manager A provided an "Medical Executive Committee" note from 8/7/2017 that revealed "The attached general surgery Community Call Agreement was reviewed and discussed by the committee...The regional model will be evaluated for effectiveness on an ongoing basis."
An interview was conducted with Quality Manager A on 12/15/2020 at 10:00 AM who, when asked if the "Community Call Plan" is being reviewed annually and if it was signed off by staff from each participating hospital, provided documentation of annual evaluation completed in 2018 and September of 2019 but no documented review for 2020. Quality Manager A stated, when asked about 2020 review "Yes the annual review is late." When asked for documentation to show that the "Community Call Plan" was signed off by the other hospitals involved both in origination of the 2017 plan and in the annual review, Quality Manager A stated "I don't have documentation of either."