HospitalInspections.org

Based on staff interviews and review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," the facility failed to ensure they were in compliance with Federal, state, and local laws and regulations requiring policy and procedures for Administration, Staffing, and Ancillary Services for four (4) of four (4) days of survey.

Findings Include:

During the Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technicians Supervisor, and Certified Registered Nurse Anesthetist (CRNA), the surveyor requested the facility's policy and procedures for Ancillary Services, Administration, and staffing.

An interview with the Interim Chief Executive Officer on 08/21/2023 at 2:46 p.m. confirmed the facility did not have Ancillary Services, Administration, and Staffing policies and procedures for review.

Review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," dated and signed by the CEO on 09/15/2023, reveals the facility attest to " ...currently meets and will continue to meet all of the requirements for Rural Emergency Hospitals set forth in the statute and implementing regulations in Subpart E of 42 code of Federal Regulations (CFR) part 485.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technicians Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on staff interviews and document review of the facility's Organizational Chart and the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," the facility failed to have an effective organized governing body or have an identified responsible individual who is legally responsible for the conduct of the Rural Emergency Hospital (REH) and failed to carry out specified functions required by the Governing Body or a responsible individual. This has the potential to affect the safety and quality of care for all patients who present to the facility for services since the enrollment and attestation that the facility meets the requirements for a REH on 09/15/2023 for four (4) or Four (4) days of survey.

Findings include:

During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technicians Supervisor, and Certified Registered Nurse Anesthetist (CRNA), the current Governing Body Bylaws, Medical Staff Rules and Regulations and Governing Body meeting minutes were requested for review.

The facility failed to present documented evidence of the "Governing Body Bylaws" and "Governing Body Meeting Minutes".

An interview on 08/22/2024 at 11:48 a.m. with the Emergency Technician Supervisor (ER Tech Supervisor), confirmed the facility has no documented evidence of Governing Body "Meeting Minutes" for review because the facility has not had a Governing Board meeting since the facility's enrollment and conversion to a Rural Emergency Hospital (REH).

An interview on 08/22/2024 at 12:02 p.m. with the Interim Chief Executive Officer (ICEO) confirmed the facility has not had a governing body meeting since the facility enrolled and converted to a REH and the ICEO further confirmed there is no documented evidence a Governing Body or a responsible individual legally responsible for the conduct of the REH has been appointed since the enrollment and conversion of the facility. The ICEO confirmed the facility's "Medical Staff Rules and Regulations," with an original date of July 2019 have not been revised/adopted since the conversion to the REH.

Review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," dated and signed by the CEO at the time of conversion on 09/15/2023, attest to the understanding the facility " ...must meet all the Conditions of Participation (CoPs) in 42 Code of Federal Regulations (CFR) part 485, subpart E...".

Review of the facility's "Organizational Chart," dated 08/01/2024 reveals the Interim Chief Executive Officer (ICEO) is the individual designated who oversees the operation of the facility. The "Organizational Chart" shows no documentation of a Governing Body over the Interim CEO.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technicians Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Cross reference O-146/485.510(a) and O-150/485.510(a)(5) for additional information.

Based on Staff interview, document review of the facility's "Organization Chart," dated 08/01/2024, "Medical Staff Rules and Regulations," dated July of 2019, and review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," dated 09/15/2023, the facility failed to ensure it has "Medical Staff Bylaws," and "Medical Staff Rules and Regulations" which have been approved by the Governing Body since enrollment and attestation that the facility meets the requirements for a Rural Emergency Hospital (REH) on 09/15/2023 for four (4) of four (4) days of survey.

Findings Include:

An interview on 08/22/2024 at 12:02 p.m. with the Interim Chief Executive Officer (ICEO) confirmed the facility has not had a governing body meeting since the facility enrolled and converted to a REH on 09/15/2024 and the ICEO further confirmed there is no documented evidence a Governing Body or an individual legally responsible for the conduct of the REH has been appointed since the enrollment and conversion of the facility. The ICEO confirmed the facility's "Medical Staff Bylaws," or "Medical Staff Rules and Regulations" have not been developed/adopted since the conversion to the REH. The only document presented for review was the facility's "Medical Staff Rules and Regulations" with and original date of July 2019 and no documentation of revision/adoption.

Review of the facility's "Organizational Chart," dated 08/01/2024 reveals the Interim Chief Executive Officer (ICEO) is the individual designated who oversees the operation of the facility. The "Organizational Chart" shows no documentation of a Governing Body over the Interim CEO.

Cross reference to O-140/485.510 additional information.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), ER Tech Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on staff interviews and document review of the facility's "Organizational Chart" and the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," the facility's Governing Body or the identified responsible individual who is legally responsible failed to appoint a qualified individual experienced in infectious diseases/antibiotic stewardship and failed to ensure the facility developed, implemented, and maintained an ongoing Rural Emergency Hospital (REH) wide data driven quality assessment and performance improvement (QAPI) program. Failure to implement an Infection Control and QAPI program has the potential to affect the safety and quality of care for all patients presenting to the facility since enrollment and attestation the facility meets the requirements for a REH on 09/15/2023.

Findings Include:

During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), surveyor requested the facility's Infection Prevention and Control Plan, Infection Control Committee meeting minutes and the facility's Quality Assessment and Performance Improvement (QAPI) Program's Scope of Improvement Indicators, the facility's data tracking, the measurement and analysis, and program activities including medical errors and adverse patient events since enrollment and conversion to a Rural Emergency Hospital Facility.

The facility failed to present any documentation of a QAPI Plan, improvement indicators, measurement and analysis documentation of tracked data or documentation of any program activities the facility has implemented since the facility's enrollment and conversion as a REH.

The facility failed to present any documentation of an Infection Prevention and Control and Antibiotic Stewardship Program, surveillance data, measurement and analysis of data, or program activities the facility has implemented since the facility's enrollment and conversion.

An interview on 08/21/2024 at 12:26 p.m. with the Interim Chief Executive Officer (ICEO) confirmed there is no documented evidence the facility has a ICP and QAPI program and they do not have a program coordinator for QAPI or ICP.

An interview with the Administration Clerk on 08/21/2024 at 2:33 p.m. confirmed the facility does not have anyone assigned to the tasks for QAPI. The Administration Clerk also confirmed there has been a large volume of staff turn overs in the past year and no one has resumed responsibility as this time.

Review of the facility's "Organizational Chart," dated 08/01/2024 reveals no documentation of a QAPI Coordinator or an ICP Program Coordinator.

Cross reference to O-140/485.510 for additional information.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on observation, staff interview, review of the Food Establishment Inspection Report, review of the service agreement between the contracted food services management company and the facility, and email correspondence, the governing body/responsible individual failed to ensure the contracted dietary services for the facility were provided in a safe manner. This had the potential to affect the safety and health of all individuals who were provide food services since the last inspection report expired on 10/13/2020, for three (3) of four (4) days of survey.

Findings include:

An interview with the Dietary Manager on 08/20/2024 at 10:22 a.m. confirmed the Food Establishment Inspection Report, dated 10/13/2019, is valid for one (1) year. He further confirmed it has been a long time since the last dietary inspection from the state department of health.

An interview with the Dietary Manager on 08/20/2024 at 3:06 p.m. confirmed there is no policy for the dietary department available for review. He further confirmed he does not know who is responsible for making sure inspections are done but will contact the state agency to see why food inspections have not been performed since 10/13/2019.

An interview with the Interim Chief Executive Officer (ICEO) on 08/21/2024 at 5:05 p.m. confirmed he will have a payment sent to MSDH and request a food services inspection. The ICEO confirms he has only been a part of the facility for about two (2) months and was not aware the dietary department had not had an annual food services inspection.

Review of the facility document, "Service Agreement," between the contracted food services management company and the facility, effective March 1, 2019, reveals, " ...15. Compliance with Applicable Law ...this provision shall not be construed to require ..." the contracted food services management company " ...to assume the cost associated with bringing Client into regulatory compliance ...the Client is solely responsible for any cost reporting or other compliance with state or federal agencies under Medicare/Medicaid programs ...".

Review of the facility document from the state agency, "Food Establishment Inspection Report/Permit to Operate", permit date 10/13/2019, revealed permit valid for one (1) year from the Permit Date.

Review of an email provided by the Dietary Manager, dated 8/21/2024 at 1:58 pm from the state agency revealed " ...According to our audit ..." the facility's " ...FOOD PERMIT ...is past due ... for the following years 2021-2023 ...Last permit payment received on this permit was on 11-17-2020 ...".

Cross reference to O-140/485.510 for additional information.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director, Chief Human Resource Officer, and Emergency Room Technician Supervisor, and Chief Executive Officer, survey findings were discussed, and no further documentation was submitted for review.

Based on Staff interview, document review of the facility's "Organization Chart," dated 08/01/2024, "Medical Staff Rules and Regulations," dated July of 2019, and review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," dated 09/15/2023, the facility failed to have medical staff operating under current facility Bylaws approved by a designated Governing Body or appointed individual legally responsible for the conduct of the Rural Emergency Hospital (REH) to ensure the quality of medical care provided to its patients. This has the potential to affect all patient's safety and quality of care since the facility enrolled and attested that the facility meets the requirements for a REH on 09/15/2023 for four (4) of four (4) days of survey.

Findings include:

During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), the surveyor requested the current "Governing Body Bylaws" and "Governing Body Meeting Minutes" for the past twelve (12) months or since the facility enrolled and converted to a REH.

An interview on 08/22/2024 with the Emergency Technician Supervisor (ER Tech Supervisor) at 11:48 a.m., confirmed the facility's "Medical Staff Bylaws" have not been updated since 2019 and the facility has not had a Governing Body meeting for the past twelve (12) months since the facility began service as a Rural Emergency Hospital on November 1, 2023.

An interview on 08/22/2024 at 12:02 p.m. with the Interim Chief Executive Officer (ICEO) confirmed the facility has not had a governing body meeting since the facility enrolled and attested that the facility meets the requirements for a REH on 09/15/2023 and the facility's "Medical Staff Bylaws," have not been developed/adopted since the conversion to the REH. The interim CEO also confirmed the "Medical Staff Rules and Regulations" have not been updated since 2019 and the facility does not have any "Governing Body Meeting Minutes" for review since the facility enrolled and converted to a REH.

The facility failed to present documentation of the "Governing Body Bylaws" and "Governing Body Meeting Minutes". The facility presented its "Medical Staff Rules and Regulations" which were approved and adopted on 07/12/2019 with no revisions/updates or adoptions since the facility enrolled and attested to the facility's compliance with the requirements for a REH on 09/15/2023.

Review of the facility's "Organizational Chart," dated 08/01/2024 reveals the Interim Chief Executive Officer (ICEO) is the individual designated who oversees the operation of the facility. The "Organizational Chart" shows no documentation of a Governing Body over the Interim CEO.

Cross Reference to O-140/485.510 for additional information

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on staff interviews and review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," the facility failed to ensure the facility developed/approved/adopted required policies and procedures for a description of the services it furnishes including those furnished through agreement or arrangement; polices for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished; and policies and procedures that address the post-acute care needs of patients receiving services in the Rural Emergency Hospital (REH).

Findings Include:

During an Entrance Conference, beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), a request for the facility's policy and procedures for services it furnishes to include those furnished through agreement or arrangement; polices for the medical management of health problems, consultation or referral, maintenance of health care records, and procedures for the periodic review and evaluation of the services provided and discharge planning.

An interview with the Interim Chief Executive Officer on 08/21/2023 at 2:46 p.m. confirmed the facility did not have policy and procedures for services it furnishes, medical management of health problems, consultation or referral, maintenance of health care records, and procedures for the periodic review and evaluation of the services provided and discharge planning.

Review of the facility's "Attestation of Compliance for Rural Emergency Hospital Enrollment and Conversion," dated and signed by the former CEO at the time of conversion on 09/15/2023, reveals the facility attest to " ...currently meets and will continue to meet all of the requirements for Rural Emergency Hospitals set forth in the statue and implementing regulations in Subpart E of 42 code of Federal Regulations (CFR) part 485.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on observation, staff interviews, email review, and facility invoice review the facility failed to have an operational call light system for 11 out of 11 patient exam rooms in the Emergency Department (ED) and six (6) out of 6 rooms in the Observation Unit. (ED patient care rooms #1 through #11 and Observation Unit patient care rooms #1, #2, #3, #4, #5, #6)

Findings Include:

During a tour on 08/20/2024 at 10:15 a.m. of the ED with the ED Director, it was observed that 11 of 11 ED patient exam rooms did not have a functional call light system.
During a tour on 08/20/2024 at 10:55 a.m. of the Observation Unit with the ED Director it was observed that six (6) of six (6) patient care rooms did not have a functional call light system.

An interview on 08/20/2024 at 11:00 a.m. with the ED Director confirmed the call light system was not operational. The ED Director reported the facility was aware the call lights did not work.

During an interview on 08/21/2024 at 10:33 a.m. with the ED Tech Supervisor it was confirmed the facility does not have a policy for the call light system. The ED Tech Supervisor also confirmed the call light system is not working at this time.

An interview on 08/21/2024 at 4:28 p.m. with the Interim Chief Executive Officer (ICEO), confirmed he was aware the call light system was not operational. The ICEO reported a new system was purchased, but he has been unable to find anyone to install it. The ICEO reported the past due invoice had been paid for the call light system but could not show proof of payment.

Review of an email from the former Director of Clinical Operations to the ED Director dated June 14, 2024, revealed " ...These changes will take effect after the following have been addressed: 1. Call light system purchased and installed (purchased-need installation estimate) ..."

Review of invoice from medical device company reveals the invoice was noted past due on 06/13/2024 for a call light system.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), ER Tech Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on the staff interviews and review of the facility's "Organizational Chart" the facility failed to establish a facility-wide Infection Prevention and Control Program for the surveillance, prevention and control of healthcare-associated infections and other infectious diseases and the facility also failed to implement an Antibiotic Stewardship Program to optimize the use of antibiotics to ensure the facility follows nationally recognized prevention and control guidelines. Failure to establish and implement and facility wide Infection Prevention and Control Program and an Antibiotic Stewardship Program has the potential to effect the safety and quality of care for all patients presenting to the facility for care and treatment since the facility attested to meeting the requirements for a Rural Emergency Hospital (REH) on 09/15/2023 for four (4) of four (4) days of survey.

Findings Include:

During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technicians Supervisor, and Certified Registered Nurse Anesthetist (CRNA), surveyors requested the facility's Infection Prevention and Control Plan, Infection Control Committee meeting minutes for the past twelve months or since the facility's conversion to a Rural Emergency Hospital Facility.

The facility failed to present any documentation of an Infection Prevention and Control and Antibiotic Stewardship Program, surveillance data, measurement and analysis of data, or program activities the facility has implemented since the facility's enrollment and conversion to a REH.

An interview on 08/21/2024 at 12:26 p.m. with the Interim Chief Executive Officer (ICEO) concerning documentation of the facility's Infection Control and Prevention (ICP) Program not provided to the surveyor, confirmed the ICP Program documentation requested does not exist and further confirmed the facility does not have a designated ICP Program Coordinator to implement/manage the program.

Review of the facility's "Organizational Chart," dated 08/01/2024 reveals no documentation of an Infection Control Program Coordinator.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technicians Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.

Based on the staff interviews and review of the facility's "Organizational Chart." the facility failed to develop, implement, maintain, and demonstrate an effective ongoing facility-wide data driven Quality Assessment Performance Improvement Program (QAPI), in which the Governing Body ensures the program reflects the complexity of the REH and focuses on improved health outcomes and the prevention/reduction of medical errors. Failure to implement and manage a facility wide QAPI Program has the potential to affect the safety and quality of care for all patients presenting for care and service since the facility attested to meeting the requirements for a Rural Emergency Hospital (REH) on 09/15/2023 for four (4) of four (4) days of survey.

Findings Include:

During an Entrance Conference, on 08/19/2024 beginning at 1:23 p.m. with the Interim Chief Executive Officer (ICEO), Chief Human Resource Officer (CHR) Emergency Department Director of Nursing (ED DON), Emergency Department Technician Supervisor, and Certified Registered Nurse Anesthetist (CRNA), surveyors requested the facility's Quality Assessment and Performance Improvement (QAPI) Program's scope of Improvement Indicators, the facility's tracking, measurement and analysis of data, and program activities including medical errors and adverse patient events since enrollment and attestation the facility meets all of the requirements of a Rural Emergency Hospital (REH) on 09/15/2024.

The facility failed to present any documentation of a QAPI Plan, improvement indicators, measurement and analysis documentation of tracked data or documentation of any program activities the facility has implemented since the facility's enrollment and conversion to a REH.

An interview with the Administration Clerk on 08/21/2024 at 2:33 p.m. confirmed the facility does not have anyone assigned to the tasks for QAPI. The Administration Clerk also confirmed there has been a large volume of staff turn overs in the past year and no one has resumed responsibility as this time.

An interview on 08/21/2024 at 12:26 p.m. with the Interim Chief Executive Officer (ICEO) concerning documentation of the facility's QAPI Program not provided to the surveyor, confirmed the QAPI Program documentation requested does not exist and further confirmed the facility does not have a designated QAPI Coordinator to implement/manage the program.

Review of the facility's "Organizational Chart," dated 08/01/2024 reveals no documentation of an QAPI Program Coordinator.

During exit conference on 08/22/2024 at 12:00 p.m. with an Administration Clerk, Emergency Department Director (EDD), Chief Human Resource Officer (CHRO), Emergency Department Technician Supervisor, and the Interim Chief Executive Officer (ICEO), survey findings were discussed, and no further documentation was submitted for review.