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)
C0336 QUALITY ASSURANCE
CFR(s): 485.641(b)

The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that --


This STANDARD is not met as evidenced by:
Based on staff interview, review of the QAPI program, and review of minutes from meetings of the Board of Governors, the facility failed to establish an effective, facility wide quality assurance program. The findings were: a. Refer to C337 in regard to the facility's failure to evaluated all services effecting patent care. b. Refer to C338 in regard to the facility's failure to effectively evaluate infection control information. c. Refer to C340 in regard to the facility's failure to evaluate the quality and appropriateness of diagnosis and treatment provided by physicians. d. Refer to C341 in regard to the facility's failure to provide evidence recommendations were evaluated and a corrective action plan developed during the peer review process. e. Refer to C342 in regard to the facility's failure to take remedial action to address problems found through the QAPI process.