Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531310 (X3) Date Survey Completed 05/03/2012
Name of Provider or Supplier Powell Valley Hospital Street Address, City, State 777 Avenue H, Powell, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0271 PATIENT CARE POLICIES
CFR(s): 485.635(a)(1)

The CAH's health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law.


This STANDARD is not met as evidenced by:
Based on observation, review of policies and procedures and staff interview, the facility failed to ensure surgical services maintained and implemented policies and procedures that were consistent with national standards of care for that service. The findings were: 1. Review of the policy and procedure manual for surgical services revealed many necessary policies and procedures were lacking. These included, but were not limited to, alcohol-based skin preparations, flash sterilization, management of malignant hyperthermia, personnel designated as allowed to administer anesthesia, and "Do Not Resuscitate" orders. 2. In addition, policies and procedures were lacking for tracking pass/fail test results per individual endoscope and tracking individual patient usage of endoscopes. Interview with the interim surgical manager and the central processing technician on 5/2/12 at 10:10 AM revealed the test results were not documented even though the pass/fail tests were run. Furthermore, the manager and technician thought the computer system documented endoscope usage per each individual patient; however, immediate observation of the computer program with them showed either the information was not recorded or they did not know how to access it. 3. Several of the policies in the manual were also inaccurate. Some examples were: a. "Environmental Cleaning of the Surgical Area" reviewed/revised 6/09: "After each surgical procedure, a safe, clean environment will be reestablished." However, further review showed it was only necessary to clean the floor around the surgical field "when it is visibly soiled." b. "Operating Room Sanitation" reviewed/revised 6/09: "Prior to the first schedule of the day; a) Areas contaminated by organic debris (such as blood) during the procedure will receive immediate attention..." This was contradictory to the statement "Floors will be mopped completely..." at the completion of each day's schedule. c. "Temperature and Humidity" reviewed/revised 1/12: "4. Humidity must fall between 20% and 60%. Further review showed the case would be cancelled, rescheduled, or delayed if the humidity was out of range "by greater than 5%." However, the 2010 Guidelines published by the American Society of Healthcare Engineers (ASHE) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE), endorsed by the Associate for Professionals in Infection Control & Epidemiology (APIC) establishes 20-60% relative humidity as an acceptable safety standard for operating rooms. 4. Review of information in "2010 Perioperative Standards and Recommended Practices" showed "Policies and procedures for environmental cleaning and disinfection should be written, reviewed annually, and readily available in surgical practice settings." 5. On 5/2/12 at 9:20 AM the interim surgical manager confirmed the policy and procedure manual was incomplete and inaccurate.