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)
C0308 PROTECTION OF RECORD INFORMATION
CFR(s): 485.638(b)(1)

The CAH maintains the confidentiality of record information and provides safeguards against loss, destruction, or unauthorized use.


This STANDARD is not met as evidenced by:
Based on observation, policy and procedure review, and staff interview, the facility failed to protect clinical records against loss and unauthorized use in 1 of 2 storage areas (the basement area). The findings were: Review of the "Record Access" policy last dated July 1, 2008 showed "Access to the medical records will be restricted to authorized personnel...". Keys for record storage areas are "logged out through administration and are not commercially reproducible." The policy further documented that the health information management (HIM) director shall be allocated a key to the archived records storage area. The following concerns were identified: a. Observation on 9/28/16 at 1:15 PM showed an area located in the basement with stored clinical records. The area was a room with 2 doors, one door from the hallway was locked, and was always kept locked according to HIM employee #1. The other door was accessed through an unlocked employee break room and was unlocked. b. Interview with HIM employee #1 during the observation revealed the door was kept unlocked so the clinic staff could access the room. Inside the room the clinical records were stored on open shelves in rows with no additional security or separation. The room also served as a food storage area for employees. Observation showed refrigerator and freezer storage units which contained employee food. c. Interview with HIM employee #1 on 9/28/16 at 1:30 PM verified the clinical records were not secured and were available to anyone who came into the room. She further revealed the policies and procedures related to the clinical records had not been reviewed or updated for several years.