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)
C0340 QUALITY ASSURANCE
CFR(s): 485.641(b)(4)

[The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that--] (4) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by-- (i) One hospital that is a member of the network, when applicable; (ii) One QIO or equivalent entity; (i) One other appropriate and qualified entity identified in the State rural health care plan; (ii) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH's patients under a written agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH's patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (b)(4)(i) through (iii)of this section; and


This STANDARD is not met as evidenced by:
Based on staff interview and review of medical records, the facility staff list, and quality assurance (QA) meeting minutes, the facility failed to ensure the QA program evaluated the quality and appropriateness of physician services. The facility staff included 2 physicians. The findings were: Review of 20 medical records (#1 - #20) showed each had received some care from a physician. Review of physician and mid-level staff list showed the facility had 2 physicians. The following concerns were identified: a. Medical record review for 20 sample patients showed no evidence the records were reviewed by an outside entity. b. Review of QA meeting minutes for 10/7/15, 11/10/15, 12/29/15, 1/26/16, and 7/14/16, showed no evidence services provided by physicians had been reviewed by an outside entity. c. Interview with the DON on 9/29/16 at 11:40 AM confirmed the QA committee failed to ensure services provided by physicians were reviewed by an outside entity.