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Based on interview and document review, the provider failed to ensure:
*A comprehensive facility wide Quality Assurance Performance Improvement (QAPI) program was developed for 13 of 13 reviewed (nursing services, social services, activities, environmental services, dietary services, contracted vendors, emergency department, pharmacy department, rehabilitation department, diagnostic services, laboratory services, outpatient services, and swing bed services) departments and/or services.
*An annual utilization review was completed.
*All peer reviews for mid-level practitioners and physicians were incorporated in the facility's QAPI program.
*The emergency preparedness plan had been incorporated into the facility's QAPI program and implemented and maintained.
*Medication security was maintained for the pharmacy department.
*Activity assessments and an individualized program was implemented and completed on five of five swingbed patients (1, 2, 3, 4, and 5) by social services.
*Care plans and discharge plans were completed and implemented for five of five swing bed patients (1, 2, 3, 4, and 5).
*An authorized staff member assumed responsibility for day-to-day operations and commanded a presence during a federal survey.
Findings include:

1. The hospital failed to ensure a facility wide QAPI program was developed for 13 of 13 reviewed (nursing services, social services, activities, environmental services, dietary services, contracted vendors, emergency department, pharmacy department, rehabilitation department, diagnostic services, laboratory services, outpatient services, and swing bed services) departments and/or services.

Refer to C330.

2. The hospital failed to develop a process to ensure a utilization review of their total program was conducted annually.

Refer to C330.

3. All peer reviews for mid-level practitioners and physicians were incorporated in the facility's QAPI program.

Refer to C330.

4. The emergency preparedness plan had not been incorporated into the facility's QAPI program, implemented, and maintained.

Refer to E0001.

5. The hospital failed to ensure a process was in place for the security of medications upon arrival to the facility.

Refer to C276.

6. The hospital failed to ensure social services completed an individualized program with activities for all swing bed patients (1, 2, 3, 4, and 5).

Refer to C385.

7. The hospital failed to ensure care plans and discharge planning had occurred for all swing bed patients (1, 2, 3, 4, and 5).

Refer to C388.

8. On 7/23/29 at 9:30 a.m., the start of the survey, the following was relayed to the surveyors:
*The administrator/president was not in the facility. He was at the other facility where he was also the administrator.
*The next in command was the nurse manager/director of patient services. But she was on leave and not in the facility.
*The executive assistant stated she would make some phone calls to alert the appropriate people.

After approximately forty-five minutes, the director of nursing (DON) for the regional market and the supervisor for safety and quality from a different provider arrived to take charge of the survey. The DON went to the patient floor and the supervisor assumed control of the survey. No policy or procedure was given to show the supervisor could assume control of the survey with a different provider.

The above individuals names were not listed on the managing officers at LDRH (Lead-Deadwood Regional Hospital) list or the organizational chart provided at the time of survey.

Interview on 7/18/19 at 3:10 p.m. with the president/administrator revealed he:
*Had been the administrator for two years prior to becoming the president for two facilities approximately one and half years ago.
*Was at this campus off and on during the week.
*Had a 'pulse' on all departments and received information regarding the day-to-day operations by text on his phone or by email.
*Was aware of the operating budget and employee concerns for this campus.
*Had been doing this for years, so he had an understanding how everything should work.

Review of the 9/8/18 President Custer LD-DWD (Lead-Deadwood) Markets job description revealed:
*Provided direct supervision 25% to 35% of the time.
*Developed action plans derived from the short-term and long-term strategic planning process.
*Objectives and goals were created specific to the operations department(s), so there was effective organization and department-wide understanding and deployment.

Based on observation, interview, and policy review, the provider failed to ensure medications (med) had been properly monitored and secured on two of two days to prevent unauthorized access to them. Findings include:

1. Observation and interview on 7/17/19 at 5:00 p.m. with registered nurse (RN) A at the nurses' station revealed:
*Three hard plastic totes on the back west counter.
*They had green plastic zip ties holding them shut.
*The pharmacy technician had gone home.
*RN A:
-Had not known if there had been medications in the totes.
-Thought a delivery person would come in the morning to pick-up the totes.
-Thought the same person would drop off a tote that contained medications.

Observation on 7/18/19 at 8:30 a.m. of the nurses desk revealed the totes were gone.

Observation and interview with the pharmacy technician on 7/18/19 at 8:45 a.m. revealed:
*The pharmacy door had been open.
*She had been on the other side of the pharmacy with her back facing the door.
*Staff, visitors, and patients could walk right in.
*A medium gray tote was sitting in the unlocked entry to the pharmacy approximately one foot from the entry.
*The tote had a red plastic zip lock on top that secured it.
*She had picked up the tote from the nurses' station when she had arrived at work and placed it in the pharmacy entry.
*She stated the tote contained medications for the pharmacy and for the automatic medication dispenser.
*She had not known how long the pharmacy tote with the medications in it had sat unsecured at the nurses' station.
-Agreed the pharmacy tote had not been secured when it was at the nurses' station.
-Agreed the tote had not been secured in the entry to the pharmacy.
*She stated:
-The pharmacy totes used to be kept locked in the laboratory, but the lab staff had stopped that process.
-The nurse manager had told her she could leave the totes at the nurses' station.

Interview on 7/18/19 at 10:30 a.m. with the nurse consultant from Regional Health, main facility revealed she agreed:
*The pharmacy totes that held medications left at the nurses' station had been unsecured.
*The pharmacy tote in the unlocked pharmacy had been unsecured.

Review of the provider's May 2019 Load to ADS Medications policy for network sites revealed:
*"b. Lead Deadwood Hospital
1. Regular fill 1845.
2. Tote pick up from RCH [Rapid City Hospital] Monday-Friday 0600/1200 and Saturday-Sunday not scheduled.
3. Tote arrivals Monday-Friday 0800/1400 and Saturday-Sunday not scheduled (approximate times)."

Based on interviews and document reviews, the provider failed to ensure:
*A comprehensive facility wide Quality Assurance Performance Improvement (QAPI) program was developed for 13 of 13 reviewed (nursing services, social services, activities, environmental services, dietary services, contracted vendors, emergency department, pharmacy department, rehabilitation department, diagnostic services, laboratory services, outpatient services, and swing bed services) departments and/or services.
*All peer reviews for mid-level practitioners and physicians were incorporated in the facility's QAPI program.
*The emergency preparedness (EP) plan had been incorporated into the facility's QAPI program, implemented, and maintained.
*A review was completed for all of the CAH's policies and procedures (P/P).
*All contracted services were reviewed and evaluated by the QAPI committee.
*A peer review was completed for all practitioners.
*Evaluations of MD/DO diagnosis/treatment apart from those who worked at the facility.
*Reviews and evaluations of all contracted services.
*A utilization review (UR) was completed for the provider.
Findings include:

1. Record review and interview on 7/17/19 at 10:00 a.m. with the supervisor for safety and quality from another provider within the hills market revealed:
*There was a standard template for QAPI for the regional market.
*Within that regional market each CAH was responsible for their own QAPI plan. But there were no records to indicate a QAPI had been maintained at the facility.
*It had been discovered last fall the last collaborative QAPI had been 7/30/11. She had been asked to help with the provider's QAPI in April 2019.
*Credentialing reviews such as MDs, DOs, certified nurse anesthetists, physician assistants, and nurse practitioners had not been part of a collaborative QAPI committee.
*EP had not been part of the QAPI committee.
*The provider's healthcare policy/procedures (P/P) were evaluated and reviewed by the administration but were not part of the QAPI committee.
*All of the provider's contracted services were not reviewed by the QAPI committee.
*There was no distinction for QAPI projects between long term care and acute care.
*The last peer reviews had been conducted over a year ago.
*There had been no UR since 2014.

Interview on 7/18/19 at 10:30 a.m. with the supervisor of health information management and coding revealed:
*When she had started in the late spring of 2016 she had discovered the utilization review had not been done for months.
*She had no information of when the last QAPI committee had met or who had any notes.
*She had spoken with two physicians in the fall of 2018. They were not aware of any UR or QAPI being conducted at the facility.
*Several times last fall and in February 2019 she had spoken with the president/administrator and was told the same thing: "The UR and peer review was now being conducted by the network to which the provider belonged."
-There had been a few meetings with a physician of the network, but nothing concrete had happened.
*The physicians with the provider had wanted to start their own UR and peer review but had been told no by the network.
*There was a policy in place for UR but no UR reviews had been done according to the policy.

Review of the network's March 2019 Utilization Review policy revealed: "All patients, regardless of insurance, source of payment or level of admission to a Regional Health hospital, are monitored for appropriate utilization of resources."

Interview on 7/18/19 at 3:10 p.m. with the president/administrator revealed and confirmed:
*There was no QAPI committee. Some departments had their own QAPI, but they did not bring their findings to a collaborative committee.
*No one reviewed the contracted services when their contract was up for review.
*An annual provider review had not been completed since 2014.
*The hospital had no utilization plan.
*Yearly peer reviews had not been completed.
*There was no QAPI policy.
*He was not aware the provider had received a similar tag for utilization review on the 12/10/14 survey.

Based on observation, record review, interview, and policy review, the provider failed to ensure:
*A qualified person was in place to direct the activity program.
*An activities schedule was available for five of five sampled swing bed patients (1, 2, 3, 4, and 5).
Findings include:

1. Review of patients 1, 2, 3, 4, and 5's swing bed medical records revealed there was no documentation regarding:
*Individual activity assessments having been completed for patients 1, 2, 3, 4, and 5.
*Activities having been provided to the above individual patients based on their assessments.

Interview on 7/17/19 at 9:00 a.m. with the director of swing beds and occupational therapist (OT) revealed:
*They had been short staffed, so activities had not been what they should have been.
*There was no activity calendar.
*The OT stated, "They just kind of have individual activities until a dedicated person is hired." "I am not in charge of activities any longer."
*The director agreed with the above statement.

Random observations on 7/17/19 between 11:00 a.m. and 5:00 p.m. and again on 7/18/19 between 8:30 a.m. and 5:00 p.m. revealed the activities swing bed patients 1, 2, 3, 4, and 5 had been involved in were:*Television.
*Visitors for two of the patients.
*Coloring for patient 3.

Interview on 7/17/19 at 11:30 a.m. with the director of nurses of the regional market revealed they were working on an activities policy for Lead Deadwood hospital. In the meantime, they used one from another hospital.

Review of the provider's March 2018 Activities Program policy revealed:
*The hospital: "Will provide an ongoing activities program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychological well-being of each swing bed patient."
*"A Swing Bed Activities assessment is completed by the Activity Assistant or designee upon admission to the Swing Bed program. The assessment will include social activities preferred, lifestyle, capabilities, and deficits in mobility. A program priority is determining what the patient wished to accomplish in their activity program."
*"A facilities activity calendar will be placed in the patient's room as soon as possible after admission to the Swing Bed Program."
*"The Activities Assistant or designees will facilitate patient participation in activities of a recreational, divisional, religious, social, intellectual, or work type nature to meet the needs of each patient."

Based on record review, interview, and policy review, the provider failed to ensure five of five sampled swing bed patients (1, 2, 3, 4, and 5) had assessments and care plans. Findings include:

1. Review of patients 1, 2, 3, 4, and 5's medical records revealed:
*There had been no assessments or care plans identified.
*The care plans had only addressed the patient's admission diagnosis.
*There had been no assessments or care plan contributions from nursing, dietary, activities, or social services.
*Discharge planning had not been addressed in the care plans.

Interview on 7/18/19 at 2:00 p.m. with the patient care coordinator/swing bed coordinator/social services person regarding patients 1, 2, 3, 4, and 5's care plans and discharge plans revealed:
*Assessments and care plans had been incomplete or missing entirely.
-There were no patient specific interventions.
-Dietary, social services, and activities were not addressed.
-Goals were incomplete or missing.
*Care plan reviews of a swing bed patient had been completed during morning rounds.
-That review involved all disciplines during rounds.
-A formal sit down care plan had not been done for any of the above residents.
-The care plans were not completed nor updated by each discipline following those morning rounds.
-She agreed as the swing bed coordinator she had been responsible to lead the care plans and ensure assessments had been completed.
*She stated she usually just entered an interdisciplinary progress note after the care plan rounds.
*She stated she had a licensed social worker to consult, but she had seldom talked with them.

Review of the provider's October 2016 Swing Bed Assessment policy revealed:
*"A Discharge Planning/Care Coordination assessments done within 7 days."
*"A representative from nursing will attend the weekly care conference if available."
*"Rehabilitation services will attend the weekly care conference."
*"Social Service designee (SWD) will be notified of the patient's admission/transfer to SSB [swing bed]. SWD will consult the facility Medical Social Worker consultant as needed and appropriate."
*"The SSD will participate in the weekly Care Conference."
*"Care coordination will include new Swing Bed admissions in the weekly care conference."
*"Care plans will be initiated upon admission to Swing Bed. Utilize the 'Process Plans' tab on the right side of the Status Board, then 'enter care plan'. Nursing will review, prioritize and address these care plans every shift. This will also be discussed at the care conference."

Based on record review of the emergency preparedness (EP) binder and interview, the provider failed to develop and implement a comprehensive emergency preparedness program that:
*Was based on a community-based and facility-based all hazards assessment.
*Included all required policies and procedures based on events identified in an all hazards risk assessment.
*Included an annual review of EP policies and procedures.
*Included a process for cooperation and collaboration with local, state, tribal, and federal emergency preparedness officials.
*Included a process for subsistence needs for staff and patients.
*Included a process that preserved patient information and patient confidentiality.
*Contracted with other critical access hospitals or other providers to receive patients in the event of an emergency.
*Included information for a communication plan for primary and secondary means of communication; and the development of an internal and external contact information list.
*Ensured initial and annual EP training was completed for all staff categories identified in an emergency preparedness plan.
*Included two training exercises (a full-scale community-based exercise and one additional exercise) annually.
Findings include:

1. Record review of the EP binder and interview on 7/17/19 at 10:00 a.m. with the supervisor for safety and quality from another provider within the Regional Health Hills market revealed:
*There was a standard template for EP for the regional market.
*Within that regional market each provider was responsible for their own EP plan.
*She had been asked to help with the provider's EP in April 2019 as the prior person had vacated that position.
*She had not been able to find any past staff training or testing for emergency preparedness.
*The provider had not created a policy or procedure for staff training and testing of the emergency preparedness plan.

Interview on 7/18/19 at 3:10 p.m. with the president/administrator revealed and confirmed he was aware some of the requirements for the EP program were not implemented in the facility. He had asked for outside help within the regional health market for assistance with the EP program earlier this spring.