| 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) |
| C0337 | QUALITY ASSURANCE CFR(s): 485.641(b)(1) 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- all patient care services and other services affecting patient health and safety are evaluated. This STANDARD is not met as evidenced by: Based on staff interview and review of the QAPI program, the facility failed to evaluate all services affecting patient care, health, and safety. The findings were: Interview with HIM clerk #1 and the CNO on 11/15/11 at 10:00 AM revealed contracted services were not included in the QAPI program. These services included physical and occupational therapy, the reference laboratory, and the contractor providing over-reads for all radiology films. During an interview on 11/16/11 at 12:05 PM, physical therapist #1 revealed her company had a contract with the hospital to provide inpatient physical therapy. She also stated the physical therapy contracted services had never been involved or participated in the hospital's QAPI program. The laboratory's quality assurance (QA) program was reviewed on 11/15/11 at 10:20 AM with laboratory technician #1. The documents showed the laboratory conducted quality assessment activities for its internal services, but failed to include any data or monitoring of its contracted reference laboratory. The technician stated in interview on 11/15/11 at 10:35 AM that the reference laboratory did not routinely provide any QA data for review and the laboratory did not actively monitor the quality of these contracted analytic services. Review of QA program for the radiology department on 11/15/11 at 2:10 PM showed the department collected and reported information to the hospital QAPI committee related to the quality of its internal services. There was, however, no assessment of the quality of its contracted radiology services. Interview with radiology technician #1 on 11/15/11 at 2:15 PM confirmed the facility did not actively monitor the quality of x-ray reads or timeliness of services provided by the contracted radiologists. She further stated the contractor provided all definitive x-ray readings for the hospital. Review of the Annual Contract Quality Review information showed the medical records department had a system for annually reviewing contracted services for the appropriateness of the services rendered and compliance with the existing terms of the contract. Further review showed the system was last implemented on 6/16/10 (seventeen months ago). Interview with HIM clerk #1 on 11/17/11 at 8 AM confirmed the quality review tool had not been implemented annually. The clerk also stated this review should be done at least annually to ensure the quality of the services provided by contracted individuals. 21849 |