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Based on observation, staff interview, documentation review and policy and procedure review, the Governing Body failed to ensure dietary policies were implemented and dietary personnel were qualified; to ensure a blood bank services contract is in place for the provision of blood products; to ensure the hospital environment is maintained and safe for patients; to ensure a doctor of medicine or osteopathy is in charge of respiratory therapy services and respiratory personnel are qualified; and to develop, maintain, and implement a hospital wide quality assessment and performance improvement program, during two (2) of two (2) days of survey.

Findings Include:

Review of the facility "Bylaws of the Hospital" revealed "...Article III Governing Board ...Section II. Powers: The property, funds, affairs and business of the hospital shall be managed by the trustees acting as a board. The Board shall have, and is vested with, unlimited powers and authority ...Article IV Institutional Management Section I. Administrator: ...He shall have the responsibility for the day to day operation of the hospital and he shall the power to accomplish this responsibility ...Section II. Authority and Duties of the Administrator: ...C. To maintain all physical properties in a good state of repair and operating condition."

Cross Refer to A-0263 for the Governing Body's failure to ensure the hospital has an effective, hospital wide quality assessment and performance improvement program.

Cross Refer to A-0528 for the Governing Body's failure to ensure qualified staff supervise radiology services and administer radiologic procedures.

Cross Refer to A-0576 for the Governing Body's failure to ensure a blood bank services contract is in place for the provision of blood products.

Cross Refer to A-0618 for the Governing Body's failure to ensure dietary policy and procedures are followed and dietary services are directed and staffed by qualified staff.

Cross Refer to A-0701 for the Governing Body's failure to ensure the hospital environment is maintained and safe for patients.

Cross Refer to A-1151 for the Governing Body's failure to ensure a doctor of medicine or osteopathy is in charge of respiratory therapy services and respiratory personnel are qualified.

Based on document review, policy review and staff interview, the facility's Governing Body failed to develop, maintain, and implement a hospital wide Quality Assessment and Performance Improvement (QAPI) program as evidenced by no documented policies, no current quality assessment plan or minutes and no documented performance improvement projects during two (2) of two (2) days of survey.

Findings Include:

On 12/02/14 at 10:10 a.m. and at 4:10 p.m, staff was requested to provide documented evidence of the facility's QAPI program. No documents were provided.

In an interview on 12/03/14 at 9:30 a.m., the Director of Nursing (DON) confirmed the facility had no QAPI Program, no Performance Improvement Projects and no quaility meetings in over a year.

Review of the last Quality Assessment minutes revealed a date of 11/13/13.

Review of the facility's 2014 Governing Body Minutes revealed no documented evidence of discussion of QAPI.

Review of the last facility's Organizational Quality Improvement Plan (last revised 09/04 and last reviewed/approved on 04/22/09) revealed it's purpose is to ensure that the Governing Body, medical staff, and professional service staff demonstrate a consistent endeavor to deliver care that is optimal in an environment of minimal risk.

During an interview with the Administrator, on 12/03/14 at 10:00 a.m., the facility's Governing Body Minutes and QAPI Program were discussed. The Administrator stated that he did not have any more documents to provide. "There are things in boxes, but I don't know where they are."

During the exit conference on 12/03/14 at 11:30 a.m., these findings were discussed. No further documentation was provided.

Based on personnel record review and staff interview, the facility failed to ensure qualified staff supervise radiology services and ensure qualified personnel are designated to administer radiologic procedures during two (2) of two (2) days of survey.

Findings Include:

Review of personnel record documentation revealed there was no documented evidence of qualified radiology staff.

During an interview on 12/02/14 at 4:15 p.m. the Radiology Director stated, "Staff personnel files are kept in administration."

During an interview on 12/03/14 at 10:40 a.m. the Administrator stated, "I don't have these (personnel files) at this time. They were all in a box at one time and I can't find them." A request was made for a copy of the facility policy outlining the contents of the personnel files. No facility policy or personnel file was submitted for review.

Based on policy and procedure review and staff interview the facility failed to ensure a blood bank services contract is in place for the provision of blood products to meet the needs of patients.

Findings Include:

Review of the facility "Manual of Operations Department of Laboratory" policy (revision date 11/4/14 and signed by the Administrator, Medical Director and Laboratory Director) revealed: "...A. Purpose: Specifically, this policy and procedures will ensure that the (hospital) provides laboratory services to its patients on a 24-hour, 7-days per week basis, while maintaining compliance with federal and state regulations ...C. Responsibility: The Laboratory Director of the (hospital) has the ultimate authority in determining the adequacy of this policy to address the laboratory services needs of the (hospital) patients. The laboratory manager and hospital administration may recommend amendments and addendums to policy ...Addendum to Outsourced Lab Test Nov. 4, 2014. Blood Bank services are no longer offer at (hospital) and (outsourced lab). If any patient should need these services, the health care provider will transfer the patient if an inpatient to a facility of his choosing ...E. (Hospital) will ensure that the laboratory services provided by (outsourced lab) on behalf of the (hospital) is reliable, timely, and in compliance with all applicable requirements for clinical laboratories ...G. Quality Assurance ...This quality assurance is implemented with emphasis on the following: ...Compliance with licensure and federal regulations ...".

During an interview on 12/02/14 at 3:50 p.m., the Laboratory Director confirmed the facility does not provide (give) blood products anymore. "Our policy states this." When asked to review the personnel files, she stated, "They are kept in Administration."

During an interview on 12/03/14 at 10:40 a.m., the Administrator stated, "I don't have these (personnel files) at this time. They were all in a box at one time and I can't find them." No further documentation was submitted for review.

Based on observation, staff interview, documentation review, and policy and procedure review, the facility failed to ensure freezer temperatures were zero (0) degrees and below, failed to ensure the dishwasher and dishwashing temperatures were recorded, and failed to ensure qualified employees during two (2) of two (2) days of survey.

Findings Include:

Observation on 12/03/14 at 10:05 a.m., revealed the large number one (1) freezer temperature was 18 degrees and contained multiple variety of foods. Review of the "Refrigerator and Freezer Control Record" for this freezer revealed: "Date: 12/2/14 and 12/3/14 - Temperature: 10 degrees; Checked By: Dietary Director."

During an interview on 12/03/14 at 10:08 a.m. the Dietary Director was asked what the freezer temperature should be. She stated, "0 degrees or below." When asked to see the temperature log for the large number one (1) freezer for the prior six (6) months, the Dietary Director stated, "We don't keep our logs. We destroy them. It (freezer) has a problem maintaining temperature." When asked if maintenance had been made aware of the problem, she stated, "Yes, I told maintenance the seal needed to be looked at and fixed."

Review of the documentation for "Requisition For Maintenance" revealed no documented evidence a work order was submitted for the "Large Number One (1) Freezer".

Observation on 12/03/14 at 10:10 a.m. revealed three (3) sinks and a dishwasher were located in the kitchen. During the observation the Dietary Director was asked how the staff monitor the wash and rinse temperatures, she stated, "We don't." When asked for the dietary staff personnel and employee health documentation, the Dietary Director stated, "I don't have it. It is kept in Administration."

Review of personnel records revealed there was no documented evidence of qualified dietary staff.

During an interview on 12/03/14 at 10:40 a.m., the Administrator stated, "I don't have these (personnel files) at this time. They were all in a box at one time and I can't find them." The Administrator was also asked for a copy of the facility policy outlining the contents of the personnel files. No facility policy or personnel file was submitted for review.

Review of the facility Dietary Department "General Food Preparation and Handling" policy revealed, "Policy ...Procedure:..2. Food Storage: a. Foods are received, check and stored properly as soon as they are delivered. b. Potentially hazardous food is refrigerated or frozen except when being handled ...".

Review of the facility's Dietary Department "Food Storage" policy revealed: " ...16. Frozen Foods: a. Temperatures for the freezer should be 0 degree F (Fahrenheit) or below and should be checked at least two times each day ... ".

Review of the facility's Dietary Department "Food Safety and Sanitation" policy revealed: "Policy ...Procedure: ...2. Employees: a. All staff will be in good health, ...b. All staff should have physical exams and a Mantoux test (TB Skin Test) prior to beginning work. Thereafter, an annual physical exam and TB Skin Test are required ...".

Review of the facility's Dietary Department "Cleaning Dishes/Dish Machine" policy revealed "Policy ...Procedure: ...Note: Check the dish machine gauges throughout the cycle to assure proper temperatures ... ".

Review of the facility's Dietary Department "Dish Machine Temperature Log" policy revealed "Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1.The food service manager will provide the dishwashing staff with a log to be posted near the dish machine ...2. The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. 3. Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. 4. The food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures ...".

Based on documented review, policy review, personnel file review and staff interview, the facility failed to ensure a doctor of medicine or osteopathy is in charge of respiratory therapy services and respiratory personnel are qualified for two (2) of two (2) days of survey.

Findings Include:

Review of the facility's "Department Heads" list revealed there is no assigned department director for Respiratory Care Services.

During an interview on 12/03/14 at 10:40 a.m., the Administrator stated, "I don't have these (personnel files) at this time. They were all in a box at one time and I can't find them." No facility policy or personnel files were submitted for review.

During an interview on 12/03/14 at 10:59 a.m. the Director of Nursing (DON) stated, "Nursing is in charge of Respiratory."

Based on document review and staff interview, the facility failed to ensure on going program that shows measurable improvements unn indicators withh evidence that it will improve health outcomes during two (2) of two (2) days of survey.

Findings Include:

During the survey requests x3 were made for documented evidence to indicate the hospital measures, analyzes and tracks quality indicators that can assess care. No documented evidence was submitted by the facility.

During the exit conference on 12/03/14 at 11:30 a.m. these findings were presented. No further documentation was submitted for review.

Based on document review, staff interview and policy and procedure review the facility failed to identify opportunities for improvement and changes that will lead to improvement for Quality Assessment and Performance Improvement (QAPI) during two (2) of two (2) days of survey.

Findings Include:

In an interview on 12/03/14 at 9:30 a.m. the Director of Nursing (DON) stated the facility had no Quality Assessment program, no Performance Improvement Projects and no policies and procedures for QAPI. She also stated, "There has been no quality meetings for over a year. "

Review of the Quality Assessment minutes revealed the facility's last minutes provided were dated November 13, 2013.

There was no documented evidence provided that any indicators involving focus on high volume, high risk or problem prone areas were being monitored.

These findings were presented in an exit conference on 12/03/14 at 11:30 a.m. No further documentation was presented for review.

Based on document review and staff interview, the facility failed to ensure patient Infection Control issues are addressed in the hospital Quality Assurance and Performance Improvement Program during two (2) of two (2) days of survey.

Findings Include:

Review of the facility's Quality Plan revealed there had been no update since 2004. The Plan was accepted as it was in writing in 2009.

During an interview on 12/02/14 at 11:05 a.m., the Infection Control Nurse stated that the facility's Quality Assurance and Performance Improvement Committee had not met in 2014.

Based on observation, staff interview, and policy review, the facility failed to conduct performance improvement projects as evidenced by the lack of documentation for two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0273 for the facility's failure to ensure a Quality Assessment Performance Improvement (QAPI) Program with documented evidence of policies, data collection, and tracking of quality indicators for the entire hospital

Cross Refer to A-0283 for the facility's failure to ensure performance improvement projects and written policies and procedures for QAPI.

Based on document review, staff interview, and policy and procedure review, the governing body failed to ensure a comprehensive program which reflects the complexity of the hospital's organization and services during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0263 for the Governing Body's failure to ensure the hospital had a comprehensive program that reflected the hospital's orgnanization and services.

Based on policies and procedure review, document review and staff interview, the facility failed to ensure pharmaceutical services to meet patient needs during two (2) of two (2) days of survey.

Findings Include:

On 12/02/14 between 3:00 p.m. and 3:17 p.m., a telephone interview was held with the Consultant Pharmacist. He stated that he could not be present at the hospital because he was "covering a pharmacy in another town today". He stated that he was part-time and when needed, the hospital calls him or the doctor who is close. He explained how/where they obtain the medications. He also stated that his Job Description was in the main office, that they have a Pharmacy and Therapeutics (P&T) Committee that meets quarterly but that they haven't met in quite a while, and that the Formulary was established by the medical staff.

In an interview on 12/03/14 at 10:15 a.m., the Administrator stated that he could not locate the Pharmacy policies and procedures, any minutes of meetings involving the pharmacy, the Job Description of the pharmacist or anything about a Formulary.
There was no documented evidence that the hospital's Quality Committe met in 2014.

Review of the Medical Staff and Governing Body minutes for the past year revealed no documented evidence of Pharmacy review or issues.

Based on observation, staff interview, and review of policy and procedures, the facility failed to ensure that drugs were stored according to accepted professional principles during two (2) of two (2) days of survey.

Findings Include:

Tour of the medication area, with Licensed Practical Nurse (LPN) #1 on 12/02/14 at 10:55 a.m., revealed there were four (4) bottles of insulin stored in the refrigerator. Review of the refrigerator temperature log revealed that the refrigerator had registered between 28 and 32 degrees Fahrenheit (F) from 11/09/14 and 12/02/14. During this observation the LPN was asked at what temperature would maintenance be notified that the refrigerator was out of range? She stated, "I'm not sure." The Director of Nursing (DON) was asked for the policy and procedure for the storage of medications and range of temperature for the refrigerator. She stated, "When copies were made, the temperature range was cut off. I can give you a copy of that." No other policy and procedure was received duriing the survey.

Review of the acceptable range for storage of refrigerated medications revealed that the refrigerator should be between 35.6-46.4 degrees (F).

Based on personnel record review and staff interview, the facility failed to ensure a qualified Radiologist is available to supervise radiology services.

Findings Include:

Cross Refer to A-0528 for the facility's failure to ensure the availability of a qualified Radiologist to supervise radiology services.

Based on personnel record review and staff interview, the facility failed to ensure qualified personnel are designated to administer radiologic procedures.

Findings Include:

Cross Refer to A-0528 for the facility's failure to ensure qualified radiology staff.

Based on policy and procedure review and staff interview, the facility failed to ensure a blood bank services contract is in place for the provision of blood products.

Findings Include:

Cross Refer to A-0576 for the facility's failure to ensure a blood bank services contract.

Based on personnel record review and staff interview, the facility failed to ensure the Dietary Director is qualified by experience and training during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0618 for the facility's failure to provide documented evidence of a qualified Dietary Director.

Based on personnel record review and staff interview, the facility failed to ensure the Dietitian is qualified by experience and training during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0618 for the facility's failure to ensure employment of a qualified Dietician.

Based on personnel record review and staff interview, the facility failed to ensure dietary staff are qualified by experience and training.

Findings Include:

Cross Refer to A-0618 for the facility's failure to ensure employment of a qualified dietary staff.

Based on observation, the facility failed to ensure the hospital environment is maintained and safe for patients during two (2) of two (2) days of survey.

Findings Include:

Observation during the laboratory tour with the Director on 12/02/14 at 3:45 p.m., revealed the light is not working in the patient bathroom.

Observation during the radiology tour with the Director on 12/02/14 at 4:00 p.m., revealed the paint is chipped and peeling on the ceiling in the x-ray room. The light was not working in the patient bathroom.

Observation during the tour of the patient care area with the Director of Nursing (DON) on 12/03/14 at 10:45 a.m., revealed the following: 1)The "A Hall" had: a) peeling wall and/or ceiling paint in Room #5 and #9; b) the lights were not working in Room #5 and #6; and c) the metal vent had cracked, missing and stained (brown colored) ceiling tiles surrounding the vent. 2) The "C Hall": a) clean linen closet had an uncovered light bulb with linen stored in plastic bags less than eight (8) inches from the light; b) Room #17 had approximately 30 wasp noted on the floor; and c) the exit door by the linen closet had rolled towels placed at the bottom of the door.

Observation during the environment tour on 12/03/14 at 11:03 a.m., with the Maintenance Director, revealed there were four (4) bulk unsecured oxygen tanks on the west end of the building.

Based on observation and interview, the facility failed to ensure that the equipment was maintained to ensure an acceptable level of safety and quality during two (2) of two (2) days of survey.

Findings Include:

During observation of the blood glucose monitor used by the facility on 12/03/14 at 11:35 a.m., the Director of Nursing (DON) was asked if the monitor was approved for hospital use. The DON stated, "I'm not sure."

The manual for the device was retrieved, and customer service was called to verify multi-patient use. Telephone interview with a company representative at 11:43 a.m. revealed that the glucometer was not approved for hospital use.

Based on record review and policy review, the facility failed to ensure that a discharge planning evaluation was provided for nine (9) of 20 patients reviewed (Patients #11, #12, #13, #14, #15, #17, #18, #19, #20).

Findings Include:

Review of medical records for Patients #11, #12, #13, #14, #15, #17, #18, #19, #20 revealed no documented evidence that a discharge planning evaluation had been completed.

Review of the facility's Policy and Procedure Manual revealed no documented evidence of a policy and procedure for discharge planning.

Based on document review, policy review, personnel file review and staff interview, the facility failed to ensure a doctor of medicine or osteopathy is in charge of respiratory therapy services.

Findings Include:

Cross Refer to A-1151 for the facility's failure to ensure a doctor of medicine or osteopathy is in charge of respiratory therapy services and respiratory personnel are qualified.

Based on document review, personnel file review, policy review and staff interview, the facility failed to ensure respiratory personnel are qualified.

Findings Include:

Cross Refer to A-1151 for the facility's failure to provide documented evidence of respiratory personnel qualifications.

Based on review of the facility's policy and procedure manual and employee interview, the facility failed to ensure the provision of Social Services, Specialized rehabilative services and Dental services.

Findings Include:

Interview with the Administrator on 12/03/14 at 12:05 p.m. revealed, "We do not admit patients to swing bed anymore. We have not admitted to swingbed in about two years." When asked if the facility had policy and procedures for the swingbed unit, he stated that they did not. When asked how they would provide Social Services, Activities, Dental Services or Rehabilative services to patients if they admitted to swingbed, he stated "We do not have these services available."