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)
C0341 QUALITY ASSURANCE
CFR(s): 485.641(b)(5)(i)

[The program requires that--] the CAH staff considers the findings of the evaluations, including any findings or recommendations of the QIO, and takes corrective action if necessary.


This STANDARD is not met as evidenced by:
Based on staff interview, review of recommendations from peer review, and review of the minutes from the medical staff meetings, the facility was unable to provide evidence recommendations were evaluated and a corrective action plan developed for the QAPI program. This failure included 6 of 6 records evaluated during the peer review process. 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. The clerk stated HIM selected and sent the records for review and the results were sent to the medical staff for review at their meetings. The clerk stated no information related to corrective actions was included in the medical staff minutes or sent to the QAPI program. Review of minutes from the medical staff meetings for the past year revealed only six inpatient records had been sent for review, three in December 2010 and three in April 2011. A "Hospital Peer Review" form was filled out by the consultant physician after each chart was reviewed. Each form had multiple comments, recommendations and suggestions. Review of minutes of the medical staff meetings failed to show if any of these comments, recommendations or suggestions were discussed or acted upon.