| 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) |
| C0332 | PERIODIC EVALUATION CFR(s): 485.641(a)(1)(i) [The evaluation is done at least once a year and includes review of--] the utilization of CAH services, including at least the number of patients served and the volume of services. This STANDARD is not met as evidenced by: Based on staff interview and review of QAPI data, the facility failed to conduct a yearly review of their total program to determine if the utilization of services was appropriate. The findings were: During an interview on 11/15/11 at 10 AM, the CNO and HIM clerk #1 stated there had not been an evaluation of the total health care program during the past year. The clerk reported MR/UR (medical records/utilization review) review was not being routinely conducted as part of QAPI. She stated the determination of appropriateness of services was not always correct as there were times acute care patients should have been changed to swing bed status. Review of QAPI data verified the lack of an evaluation of the total health care program. |