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Based on record review and interview, the hospital failed to meet the definition of a hospital being primarily engaged in providing inpatient services.


From 01/01/18 through 10/12/18, the average daily census (ADC) was 1 patient. The average length of stay (ALOS) was 9 days. The facility had 7 outlier stays with lengths of stay ranging from 10 to 55 days. The facility admission criteria is based upon established Interqual criteria. InterQual® is an evidence-based clinical decision support solution to help payers, providers, and government agencies make clinically appropriate medical utilization decisions. However, the CNO stated, the hospital did not have access to the Interqual system. The CNO stated the facility actively recruits charity and homeless patients; the patients remain inpatients until the facility is able to provide placement following care.


Outlier stays included:

Admission 04/06/18, discharge 04/20/18 (charity-no insurance): 14 days

Admission 04/26/18, discharge 05/06/18 (IHS with no authorization): 10 days

Admission 04/17/18, discharge 05/05/18 (Medicare): 18 days

Admission 06/09/18, discharge 07/10/18 (Medicaid): 31 days

Admission 06/29/18, discharge 07/26/18 (Medicaid): 27 days

Admission 07/12/18, discharge 08/07/18 (Humana): 26 days

Admission 07/12/18, discharge 09/05/18 (Medicare): 55 days


Staff E stated, their computer system no longer had the capability of providing census reports and was unable to distinguish between an inpatient and an observation patient. The hospital provided hand written lists of patients as inpatients, observation, and outpatients. The number of inpatients between 01/01/18 and 10/12/18 were 37 inpatients, 28 observation patients, and 84 outpatients. A total of 133 surgical cases were performed for this time period.


Staff A and Staff E (10/12/18 at 11:00 am) stated, they stand behind the current lists of patients provided. They went through each patient record to determine the correct admit and discharge dates and times.


The number of admissions by month for 2018 were as follows:
January: 0
February: 1
March: 1
April: 5
May: 7
June: 10
July: 5
August: 1
September: 4
October (for the first 12 days of the month only): 3


The average length of stay (ALOS):
January: 0
February: 0.1
March: 0.1
April: 1.3
May: 1.2
June: 2
July: 2.7
August: 1.6
September: 0.6
October (for the first 12 days of the month only): 2.6


A review of admission and discharge patterns by day of the week from 01/01/18 through 10/12/18 were as follows:
Monday: 4 admissions and 4 discharges
Tuesday: 7 admissions and 4 discharges
Wednesday: 6 admissions and 6 discharges
Thursday: 9 admissions and 8 discharges
Friday: 8 admissions and 4 discharges
Saturday: 3 admissions and 5 discharges
Sunday: 0 admissions and 2 discharges


The Nursing Unit is established primarily for the purpose of providing nursing care to those patients who are scheduled for or who have undergone surgery (policy titled Admission Criteria - Inpatient Nursing Unit) although the hospital does provide non-surgical care including wound care and IV antibiotics therapy.

Staffing schedules revealed a minimum of 1 RN scheduled for each 12 hour shift when no patients were in the hospital on the nursing unit. An additional RN, LPN or Aide was added when admitted patients were more than 1. Additional staff were assigned to the OR and PACU. Surgical services were provided Monday through Friday. An additional RN was staffed for any observation patients kept in the PACU.


Patient #4 stated, she had been at the hospital since 10/02/18 (10 days). She had surgery at another facility and came here for wound care. She does not receive IV medications or fluids. She does not receive physical therapy although she thought that was a good idea. She was receiving daily dressing changes.


Staff F (10/12/18 at 10:45 am) stated patient #4 was not receiving PT, she was only receiving daily dressing changes. Staff A stated, the plan was to discharge the patient to home with home health care for daily dressing changes. She was unable to locate an agency that will accept the patient since payment was pending an outstanding lawsuit and the physician wanted the patient discharged with PT and OT. Surveyor asked why the patient was not receiving PT and OT while an inpatient, Staff A stated, it was because the hospital did not have a contract with PT.


Surveyor asked if staff were able to get medications and supplies timely and in a quantity to treat patients. Staff F stated, that sometimes the deliveries were slower than he/she would like, but they did have the medications and supplies needed to treat patients.


Surveyor asked about food services for the patients. Staff F stated, they contract with a company located on the 2nd floor of the building. Patients were able to select from a menu and appropriate food was delivered at various times throughout the day. Patient #4 stated, the food was good and she had no complaints with food. Patient #1 stated, she had celiac disease and had not had any problems getting appropriate food.