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 09/29/2016
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)
C0272 PATIENT CARE POLICIES
CFR(s): 485.635(a)(2), (a)(4)

§485.635(a)(2) The policies are developed with the advice of members of the CAH's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §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 policy review and staff interview, the facility failed to ensure patient care policies met the annual review requirements. The annual reviews were lacking for 7 of 7 department policy and procedure manuals reviewed (emergency department, swing bed, acute nursing services, infection control, radiology, laboratory, clinical records). The findings were: Review of department policy and procedure manuals for emergency, swing bed, acute nursing services, infection control, radiology, laboratory, clinical records showed they lacked evidence of annual review by the group of professionals. Interview with the DON by phone on 9/29/16 at 11:40 AM confirmed the group of professionals including a physician and mid-level practitioner had not completed the annual reviews. The review dates included: a. Review of the policy book with titles, "Acute Care", "Emergency Department", "Swing Bed", and "Medications" showed the most recent date of review was 9/26/11. b. Review of the policy book with titles, "Acute Care/Emergency Department" and "Blood Glucose Testing and Monitoring" showed the most recent date of review was 12/26/13. c. Review of the policy book titled, "Swing Bed" showed the most recent date of review was 6/29/12. d. Review of the policy book titled, "Infection Control and Exposure Manual" showed the most recent date of review was 12/16/11. Review of the policy book titled, "Laboratory Policies/Procedures" showed the most recent date of review was 7/20/12. e. Review of the policy manual for radiological services and interview with the radiology director on 9/27/16 at 10:15 AM revealed she reviewed the policies annually; however, they had not been reviewed annually by a physician or mid-level practitioner.