| 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) |
| C0293 | SERVICES PROVIDED THRU AGREEMENT/ARRANGEMENT CFR(s): 485.635(c)(4)(ii) [The person principally responsible for the operation of the CAH under ยง485.627(b)(2) of this chapter is also responsible for the following:] ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This STANDARD is not met as evidenced by: Based on staff interview and review of the QAPI program, the CEO failed to ensure that all contracted services provided data that enabled the hospital to comply with the condition of participation for periodic evaluation and quality assurance review. The findings were: During an interview on 11/15/11 at 10 AM, the chairman of the quality assurance (QA) committee stated that the contracted services of occupation and physical therapies were not included in the QAPI program. In addition, on 11/15/11 at 10:35 AM the laboratory manager reported the contracted reference laboratory did not provide QA data for monitoring. At 2:15 PM on the same date, the radiology manager stated that the service contracted to over-read 100 percent of the radiology films did not provide QA data. Review of data collected for the QAPI program verified the statements. |