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 04/28/2022
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)
C1008 PATIENT CARE POLICIES

§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 biennially 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 and procedure review, staff interview, and medical staff meeting minutes review, the facility failed to ensure policies were reviewed every 2 years in a variety of areas (dietary, emergency, acute care). The findings were: 1. Review of the 1/25/22 medical staff meeting minutes showed the facility had an organized medical staff team. The following concerns were identified: a. Review of the 1/25/22 medical staff meeting minutes showed no documentation regarding review of facility policies and procedures. b. Review of facility policies and procedures revealed the following policies were not reviewed at least every 2 years: "Heparin (Thromboembolism)" effective 11/21/19 and last reviewed 11/21/19, "EMTALA Guideline" effective and last reviewed 12/18/18, "Trauma Activation Patient Guideline" effective and last reviewed 3/21/19, "Employee Health-Infection Control" effective and last reviewed 1/23/19, "OSHA Exposure to Blood borne Pathogens Standard" effective and last reviewed 8/1/16, "Discharge Planning" last reviewed 8/19/08, and with 1 exception ("Diet/Nutrition Care Manual"approved March 2022) the dietary policies in the electronic system had review dates of 2018 and 2019. c. Interview with the DNS on 4/27/22 at 1:38 PM confirmed the policies were not all up to date or reviewed every two years. The process was to have each department include their policies in an electronic program to then be revised, reviewed and retrieved as needed. The DNS verified there was not a specific committee that reviewed hospital policies, instead there was a policy review approval workflow that showed who reviewed each department's policies for approval. She also confirmed the Acute Care policies were out of date and had not yet been included in the electronic program for review. d. Review of the undated policy approval workflow information showed the Acute Care policies were managed by the DNS and reviewed and approved by the medical director; Emergency Department policies were managed by the DNS and the ED director and were reviewed and approved by the medical director. The Dietary policies were managed by the dietary supervisor and the dietitian, there was no one included to further review or approve these policies.