HospitalInspections.org

Based on policy review, committee meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel review the CAH's health care policies for 1 of 1 year (2024) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH's ability to ensure the policies were current and followed regulations and standards of practice.

Findings include:

Review of the policy "Policies & Procedures: Development, Revision, & Deletion" occurred on 01/09/25. This policy, revised 02/2023, stated, ". . . Procedure: 1. All [facility name] policies are to be reviewed by the Policy Review Committee every two (2) years. . . 3. The Policy Review Committee will consist of at minimum . . . b. Advanced practice provider . . ." The policy failed to define the advanced practice provider as a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Review of the CAH's policies occurred on all days of the survey. The policies lacked evidence of review in 2024 by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Review of the Policy Review Committee meeting minutes occurred on 01/07/25. The 2024 minutes lacked evidence of attendance by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Upon request on 01/07/25, the CAH failed to provide evidence a physician assistant/nurse practitioner/clinical nurse specialist reviewed the CAH's policies.

During interview on the afternoon of 01/07/25, an administrative staff member (#1) confirmed the CAH failed to have a physician assistant/nurse practitioner/clinical nurse specialist review the CAH's policies.

Based on professional reference review and staff interview, the Critical Access Hospital (CAH) failed to develop an infection prevention and control program, as documented in its policies and procedures, that employed methods for preventing and controlling the transmission of infections for 3 of 3 days of survey (January 6-8, 2025). Failure to develop and implement a water management program for Legionella, develop policies and procedures to reduce the risk of growth and spread of Legionella, and conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system placed staff and patients at risk of developing Legionella infections.

Findings include:

Information from the Centers of Disease Control, found at https://www.cdc.gov/control-legionella, stated, ". . . The Centers for Medicare & Medicaid Services (CMS) requires healthcare facilities develop and adhere to ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) - compliant water management programs (WMPs). WMPs minimize the risk of growth and spread of Legionella [a type of bacteria that causes Legionnaires' disease and Pontiac fever] and other pathogens in building water systems. . . ."

Upon request on 01/06/25, the CAH failed to provide evidence of a risk assessment and policies/procedures for a Legionella water management program.

During interview on 01/07/25 at 7:45 a.m., an environmental services supervisor (#3) confirmed the facility failed to complete a risk assessment and develop policies/procedures for a Legionella water management program.