| 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) |
| C0333 | PERIODIC EVALUATION CFR(s): 485.641(a)(1)(ii) [The evaluation is done at least once a year and includes review of--] a representative sample of both active and closed clinical records. This STANDARD is not met as evidenced by: Based on staff interview and review of policies and procedures and minutes of the medical staff meetings, the facility failed to select a representative sample of both active and closed records for review and to conduct those reviews in a timely manner. The findings were: During an interview on 11/16/11 at 9:50 AM, HIM clerk #1 stated the facility lacked formalized criteria for selecting medical records for review. She stated the only records she personally reviewed were those of patients with pneumonia, congestive heart failure, and heart attacks. Otherwise, HIM just picked records of patients who had a "...difficult stay." According to minutes from medical staff meetings for the past year, only six inpatient records were sent out for peer review, three in December 2010 and three in April 2011. Review of facility policy HIM-021 "Peer Review" revised 7/31/08 revealed "peer review is to assist in assuring quality of care of our patients and efficiency of services rendered." The policy goes on to state patient records "will be done on a regular monthly basis." |