HospitalInspections.org

Based on interview and document review, the critical access hospital (CAH) was not in compliance with 485.620 Condition of Participation for Number of Beds and Length of Stay. The cumulative effect of this systemic problem resulted in the Critical Access Hospital's inability to ensure they were able to meet this condition.

Findings include:

See C212: Based on interview and document review, the critical access hospital (CAH) failed to comply with the inpatient length of stay requirements. The North Valley Health Center CAH was determined to have exceeded 96 hours average length of stay during a Fiscal Intermediary review in December of 2015. These findings were confirmed during a desk audit review on 9/6/16.

Based on interview and document review, the critical access hospital (CAH) failed to comply with the inpatient length of stay requirements. This practice had the potential to affect any CAH inpatients who receive care from the CAH.

The findings include:

The North Valley Health Center CAH was determined to have exceeded 96 hours average length of stay during a Fiscal Intermediary review in December of 2015.

The hospital's Chief Financial Officer was interviewed on 9/6/16 and verified the hospital had exceeded the average length of stay in fiscal year 2015. The CFO stated the hospital's length of stay in 2015 had exceeded the required 4 days, and their length of stay had increased to 4.10 days (greater than 96 hours).

The CFO verified the hospital had become aware of the issue and had brought it forward for discussion at the 12/22/15 Governing Board Meeting. At 10:33 a.m., the CFO forwarded the Governing Board Meeting minutes for review.

The 12/22/15 Governing Board Meeting minutes were reviewed and included, ..."brought to my attention that he has concern on the average length of stay for our acute care patients. Up through October [2015] our average length of stay is 4.28 days...the average length of stay should not be over 4 days..."