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)
C0342 QUALITY ASSURANCE
CFR(s): 485.641(b)(5)(ii)

[The program requires that--] the CAH also takes appropriate remedial action to address deficiencies found through the quality assurance program.


This STANDARD is not met as evidenced by:
Based on staff interview, review of QAPI data, and review of minutes from meeting of the medical staff and governing body, the facility failed to take remedial action to address problems found through the QAPI process. The findings were: The QA process for the HIM department was reviewed with HIM clerk #1 on 11/15/11 at 10 AM. The summarized data showed selected QA indicators, such as timely completion of history and physical examinations and dated/timed physician signatures, were consistently below the quality baseline established by the hospital. During the interview, the records clerk stated that the low compliance rate was presented to the physicians at medical staff meetings; however, there was no documentation to show improvement of the quality indicators. Review of the July, August, September, and October 2011 minutes from meetings of the governing body showed the board members reviewed data from the QAPI program. However, there was no evidence suggesting the board discussed any results, even when departments monitored the same indicators for years or reported they were dropping an indicator because the goal could not be met. Further, the facility was unable to produce evidence that remedial action was taken to address problems identified through the QAPI process.