| 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) |
| C0301 | RECORDS SYSTEMS CFR(s): 485.638(a)(1) The CAH maintains a clinical records system in accordance with written policies and procedures. This STANDARD is not met as evidenced by: Based on review of policy and procedure, medical record review, and staff interview, the facility failed to ensure the clinical records system was maintained based on established policy and procedures. The findings were: Review of 20 clinical in-patient records showed they were maintained by a combination of paper and electronic medical record documents. Interview with health management employee (HIM) #1 on 9/28/16 a 1:10 PM verified there were two electronic record systems with information as well as some paper documents. The original electronic medical record system was initiated in 2014 and in January 2016 the system was changed to a new electronic program. Review of the policy and procedures related to the clinical records showed the most current date of review was 12/19/13. This review was signed by the department head and board representative. Further, review of the manual showed there were no policies and procedures developed related to the use/safeguards for the electronic medical records system. Interview with HIM employee #1 on 9/28/16 at 1:10 PM verified the policies were in need of review and revision, and there were no policies and procedures related to the use of the electronic systems. |