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)
C0340 QUALITY ASSURANCE
CFR(s): 485.641(b)(4)

[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--] (4) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by-- (i) One hospital that is a member of the network, when applicable; (ii) One QIO or equivalent entity; (i) One other appropriate and qualified entity identified in the State rural health care plan; (ii) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH's patients under a written agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH's patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (b)(4)(i) through (iii)of this section; and


This STANDARD is not met as evidenced by:
Based on staff interview, review of policies and procedures, and review of peer review recommendations and the medical staff bylaws and rules and regulations, the facility failed to ensure the quality and appropriateness of diagnoses and treatments furnished by physicians were evaluated. The findings were: Interview with the CNO and HIM clerk #1 on 11/16/11 at 9:50 AM revealed a physician from another hospital reviewed medical records to determine the appropriateness of the diagnoses and treatments provided by the facility's physicians. During the interview, the clerk stated that although the reviews were to be done monthly, she last sent records "several" months ago. According to the facility policy, HIM-021 "Peer Review," revised 7/31/08, patient records "will be done on a regular monthly basis." Although the facility had a system for peer review, perusal of minutes from the medical staff meetings for the past year revealed only six inpatient records had been sent for review, the last in April 2011. Both the CNO and the clerk stated, "The system is broken."