| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531311 | (X3) Date Survey Completed 11/13/2013 |
| 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) |
| C0280 | PATIENT CARE POLICIES CFR(s): 485.635(a)(4) These policies are reviewed at least annually by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This STANDARD is not met as evidenced by: Based on staff interview and review of infection control activities, the facility failed to review and update it policies and procedures for mandatory disease reporting at least annually. The findings were: The hospital's policy and procedure for reporting diseases and conditions to the Wyoming Department of Health was reviewed on 11/13/13 beginning at 9:10 AM. The procedure was annotated to show it was last reviewed and updated 3/25/09. The policy was discovered to reference outdated reporting requirements (citing 2006 documents) and failed to include sufficient information and direction to direct staff in completing mandatory reporting requirements. The infection preventionist confirmed in interview on 11/13/13 at 10:30 AM that the policy and procedure reviewed was the most current document and, further, acknowledged there had been no review since 2009. |