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 531311 (X3) Date Survey Completed 11/17/2011
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, 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)
C0241 GOVERNING BODY OR RESPONSIBLE INDIVIDUAL
CFR(s): 485.627(a)

The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.


This STANDARD is not met as evidenced by:
Based on review of minutes from meetings of the governing body, staff interview, and review of the medical staff bylaws, the governing body failed to ensure the medical staff was accountable for the quality of care provided to patients. In addition, the governing body failed to ensure health care services were provided in a safe, effective manner. Finally, the governing body failed to ensure development of an effective, facility wide QAPI program and ensure policies and procedures for health care services were implemented, reviewed, evaluated, and revised as necessary. The findings were: Review of the July, August, September, and October 2011 minutes from meetings of the Board of Governors showed no indication the board members were aware of any of the concerns identified during the recertification and complaint survey conducted from 11/14/11 through 11/17/11. The review showed no evidence the medical staff kept the board apprised of physician concerns or peer review activities, (C257, C270) According to the "Medical Staff Bylaws and Rules & Regulations", it was "the responsibility of the medical staff and the Board of Directors of the hospital to safeguard the interests of the public..." Additionally, the purpose of the organized medical staff was to "provide a means whereby issues concerning the medical staff and the hospital...may be discussed by the medical staff with the governing body and chief executive officer." In addition there was no evidence the board was aware of the care issues identified at C295 and C297. Further review of the minutes showed the Board reviewed quality assurance indicators, but there was no follow-up with the departments. Refer to C331, C332, C333, C334, C336, C337, C338, C340, C341, and C342 for evidence related to quality assurance concerns. Finally, review of the policies and procedures revealed many had not been approved by the Board since 2008 (C271). Interview with the former chief financial officer, who attended every meeting, on 11/17/11 at 10:55 AM confirmed the board members did not discuss care issues.