HospitalInspections.org

NOT CORRECTED FROM INSPECTION DATED 9/12/2013

Based on review of the Hospital Affiliation Agreement, review of the Network Agreement, review of the Quality Assurance Plan and staff interview, the CAH (Critical Access Hospital) failed to ensure that the Network Agreement and/or Hospital Affiliation Agreement included quality assurance. This failed practice had the potential to affect all patients of the CAH. The inpatient census from 7/1/11 to 6/30/12 was 262.
Findings are:

A. Review of the Quality Assurance plan under the section C-341 (revised 3/6/2012) revealed the following: "WHMH [West Holt Memorial Hospital] will provide a random sampling of charts representing Medical Staff Physicians for review by [name of a Nebraska Acute Care Hospital approximately 94 miles away from CAH and hereafter referred to as Network Hospital]".

B. Review of the Nebraska Critical Access Hospital Program Medicare Rural Hospital Flexibility Program Network Agreement with an effective date of 1/11/11, between West Holt Memorial Hospital and the Network Hospital revealed the agreement addressed Patient Referral and Transfers, Emergency and Non-Emergency Transportation, and Communication Systems; however, lacked any information concerning Quality Assurance.

Review of a second agreement titled Hospital Affiliation Agreement (effective date of 9/1/11) between West Holt Memorial Hospital and the Network Hospital revealed the agreement was for the Network Hospital to provide "administrator and certain management services'; however, lacked any information concerning Quality Assurance.

C. Interview with the CEO (Chief Executive Officer) on 12/11/13 at 2:35 PM confirmed the hospital is still under the Nebraska Critical Access Hospital Medicare Rural Hospital Flexibility Program Network Agreement and the Hospital Affiliation Agreement that lack any mention of Quality Assurance. The CEO stated that the new "Flex contract/agreement is at [the] Network Hospital's lawyers getting finished up."






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