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)
C0291 SERVICES PROVIDED THRU AGREEMENT/ARRANGEMENT
CFR(s): 485.635(c)(3)

The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided.


This STANDARD is not met as evidenced by:
Based on staff interview and review of patient services furnished under arrangements and agreements (radiology, laboratory, physical/speech therapy, pharmacy), the facility failed to maintain a list to describe the nature and scope of the services provided. The findings were: Agreement review showed the following patient services were provided under agreement: radiology, laboratory, physical/speech therapy, and pharmacy. However, a list of these services was not maintained which described the nature and scope of the services provided. Interview with the DON on 9/29/16 at 11:40 AM confirmed the facility failed to maintain a list with the services and descriptions.