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Based on review policies, meeting minutes, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the required group of professionals, including a physician and a mid-level provider reviewed all patient care policies for 22 of 22 patient care departments. (Respiratory Care, Cardiac Rehabilitation, Emergency Medical Service, Maintenance, Pharmacy, Emergency Department, Obstetrics, Laboratory, Surgery, Special Care Unit, Swing Bed, Central Sterile, Health Information Management, Med-Surg, Infection Prevention, Radiology, Diabetes Self Management, Emergency Plan, Safety, Housekeeping, Food Service, and Laundry) The CAH staff identified a current census of 11 patients at the start of the survey.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to address and develop policies for changing patient care needs not addressed in the CAH policies and/or opportunities to update the policies as needed.

Findings include:

1. Review of CAH policy/procedure titled "Policy and Procedures (Typing, Revising, Distribution)", dated January 2016, revealed in part, ". . . New and revised policies will be submitted for approval at the Critical Access Hospital (CAH) Advisory Board meeting annually. . . ."

Review of CAH policy/procedure titled "Critical Access Hospital Advisory Committee", dated January 2016, revealed in part, "Regional Medical Center (RMC) will maintain a committee of professionals to carry out a periodic evaluation of its total program. This evaluation includes a review of: . . . Review and revision as needed of patient care policies. . . Composition of the CAH Advisory Committee will include, at a minimum, . . . One (1) or more physicians of medicine or osteopathy, One (1) or more Physicians' Assistant (PA), Advanced Registered Nurse Practitioner (ARNP), or clinical nurse specialists. . . ."

2. Review of CAH & Governing Board Quality Committee Meeting minutes dated March 2, 2015 and October 5, 2015 contained documentation of approval of new or updated policies, not all patient care policies for Respiratory Care, Cardiac Rehabilitation, Emergency Medical Service, Maintenance, Pharmacy, Emergency Department, Obstetrics, Laboratory, Surgery, Special Care Unit, Swing Bed, Central Sterile, Health Information Management, Med-Surg, and Infection Prevention.

3. Review of policy and procedure manual cover sheets for Respiratory Care, Cardiac Rehabilitation, Emergency Medical Service, Maintenance, Pharmacy, Emergency Department, Obstetrics, Laboratory, Surgery, Special Care Unit, Swing Bed, Central Sterile, Health Information Management, Med-Surg, and Infection Prevention revealed "The policies in this manual have been reviewed and are approved by:. . . ." and signed by a physician and a mid-level provider.

Review of policy and procedure manual cover sheets for Radiology, Diabetes Self Management, Emergency Plan, Safety, Housekeeping, Food Service, and Laundry revealed "The policies in this manual have been reviewed and are approved by:. . . ." and signed by a physician and lacked a signature of a mid-level provider.

3. During an interview on 3/3/16 at 10:30 AM, Staff F, Chief Administrative Officer (CAO), stated the process of annual policy review was that all department leaders reviewed the department's policies and a list of any new or revised policies were taken to the CAH & Governing Board Quality Committee meeting for approval, not all policies were taken to the committee meeting for annual approval. Staff F acknowledged the policy and procedure manual cover sheets for Radiology, Diabetes Self Management, Emergency Plan, Safety, Housekeeping, Food Service, and Laundry were signed as approved by a physician and lacked a signature of a mid-level provider.

During an interview on 3/3/16 at 11:30 AM, Staff F acknowledged the CAH Committee structure changed for 2016 and did not include a mid-level provider for annual policy review and approval for Radiology, Diabetes Self Management, Emergency Plan, Safety, Housekeeping, Food Service, and Laundry.

During an interview on 3/7/16 at 1:50 PM, Staff I, Advanced Registered Nurse Practitioner, verified she reviewed new and revised policies during 2015 and did not review new and revised policies in 2016.

During an interview on 3/7/16 at 2:05 PM, Staff J, Physician, verified he did not review all patient care policies unless they were new or revised.

Based on observation, review of CAH (Critical Access Hospital) policy, and staff interview the CAH failed to ensure the protection of confidential patient information in medical records at the Pain Clinic. The CAH identified a census of 11 patients at entrance.

Failure to ensure the patient medical records are secure to protect confidential patient information could potentially result in an identify theft for the patient.

Findings include:

1. Observation on 3/7/16 at 10:45 AM, during the tour of the Pain Clinic with Staff E, Surgery Manager, showed open shelving in the pain clinic staff office that held approximately 900 patient medical records. The patient medical records contained patient names, date of birth, social security numbers, diagnosis and treatments provided. The pain clinic staff office had a key lock to enter the room.
2. During an interview on 3/7/16 at 10:45 AM, Staff E, the Surgery Manager said the housekeeping staff and maintenance staff had a key to the pain clinic staff office and could access the office when the pain clinic staff were not present. The housekeeping staff cleaned the office early in the morning prior to pain clinic staff reporting for work. Staff E acknowledged the housekeeping and maintenance staff should not have a key to the office allowing them access to the patient medical records.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure the periodic evaluation of its total CAH program included a review of the CAH's patient care policies and procedures. The CAH staff identified a current census of 11 patients at the start of the survey.

Failure to include a review of patient care policies as part of the CAH's total program evaluation could potentially result in the failure of staff to evaluate and update policies as needed to improve patient care and meet the needs of the patient and the community.

Findings include:

1. Review of policy/procedure titled "Critical Access Hospital Advisory Committee", dated January 2016, revealed in part, "Regional Medical Center (RMC) will maintain a committee of professionals to carry out a periodic evaluation of its total program. This evaluation includes a review of: . . . Review and revision as needed of patient care policies. . . The purpose of this evaluation is to determine whether the utilization of services was appropriate, the established policies were followed and any changes are needed. . . ."

Review of document titled "Annual CAH Total Quality Program Evaluation Fiscal Year 2015 (FY15)", dated October 2015, failed to include the review of the policies as part of the Annual Critical Access Hospital report.

2. During an interview on 3/3/16 at 8:50 AM, Staff G, Chief Nursing Officer (CNO), Staff F, Chief Administrative Officer (CAO), and Staff H, Administrative Assistant, acknowledged the CAH failed to include a review of policies as part of the Annual CAH Total Quality Report.

Based on review of documentation and staff interviews, the Critical Access Hospital (CAH) failed to develop, evaluate and implement an effective Quality Improvement Program to evaluate and improve the quality and appropriateness of patient care and to improve quality on a continuous basis including all the services offered at the CAH. Concerns with 18 of 19 department to report quality measures (Surgery, Anesthesia, Emergency Room, Cardiac Rehabilitation, Pain Clinic, Respiratory Therapy including Pulmonary Rehabilitation and Sleep Study, Radiology including CT, MRI, Ultrasound, Bone Density, Food Service, Obstetrics, Health Information Services, Pharmacy, Nursing, Infection Prevention, Diabetes Self Management, Physical Therapy/Occupational Therapy/Speech Therapy, Stereotactic Breast Biopsy, Housekeeping and Maintenance) The CAH staff identified a current census of 11 patients at the start of the survey.

Failure to have an effective quality improvement program that included involvement of all of the CAH's departments to improve quality on a continuous basis could result in failure to ensure patient care problems were identified, monitored, addressed and improved in each patient care area through the efforts of all involved departments.

Findings include:

1. Review of CAH "Total Quality Management Program (TQM)", dated February 2015, revealed in part, ". . . Each department will determine their criteria for appropriateness of service. . . An action plan will be initiated to improve on good/adequate, or less than adequate performance. . . ." The Program included the CAH would utilize the methodology of Plan, Do, Study, and Act (PDSA).

2. Review of the CAH's Quality Management/Case Management Committee Meeting minutes dated May 21, 2015 to February 18, 2016 revealed the following information:

a. The CAH lacked reports concerning problem prevention and identification, corrective action taken, and outcome of effective action from the following departments: Surgery, Anesthesia, Emergency Room, Cardiac Rehabilitation, Pain Clinic, Respiratory Therapy including Pulmonary Rehabilitation and Sleep Study, Radiology including CT, MRI, Ultrasound, Bone Density, Food Service, Obstetrics, Health Information Services, Pharmacy, Nursing, Infection Prevention, Diabetes Self Management, and Physical Therapy/Occupational Therapy/Speech Therapy.

b. The CAH lacked reports on issues involving patient care from the following departments: Stereotactic Breast Biopsy, Housekeeping and Maintenance.

3. During an interview on 3/7/16 at 2:30 PM, Staff K, Quality Services Manager, and Staff L, Quality Nurse confirmed not all departments report to quality problem prevention and identification, corrective actions taken and outcome of effective actions. Staff K and Staff L also confirmed not all departments reported on issues involving patient care.