Friend Community Healthcare System

“Provision of services. CFR(s): (c) The policies must include the following: (1) A description of the services the REH furnishes, including those furnished through agreement or arrangement. (2) Policies and procedures for emergency medical services. (3) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the REH. (4) Policies and procedures that address the post-acute care needs of patients receiving services in the REH. This Condition is not met as evidenced by: 48575 Based on the rural emergency hospital (REH) action plan and attestation review, policy and procedure review, medical staff bylaws review, rules and regulations review, and administrative staff interviews the facility failed to have finalized medical staff bylaws, rules and regulations, and policies and procedures to address the post-acute care needs of observation patients receiving services at the REH. This failed practice has the potential to cause negative outcomes for all patients admitted for observation services provided by the REH. According to facility provided data the REH had 14 observation patients 1/11/2024 - 9/23/2024. Findings include: A. Review of the facility action plan and attestation to convert from a Critical Access Hospital (CAH) to an REH approved on 1/11/2024 revealed provision of services included observation services. The summary of conversion plan revealed discontinuation of inpatient services. B. Review of the facility policies and procedures lacked evidence of observation patient care and treatment. The facility was unable to provide observation patient care and treatment policies and procedures per REH regulations (that address the post-acute care needs of patients receiving services in the REH). Confirmed during an interview on 9/25/2024 at 3:00PM, the COO attempted to locate the REH facility observation direct patient care policies and procedures, unable to provide onsite. C. Review of the facility medical staff bylaws lacked evidence of a finalized approved copy. Confirmed by COO 9/24/2024 at 2:48PM. A Review of the facility medical staff rules and regulations lacked evidence of a finalized approved copy. Confirmed by COO 9/24/2024 at 2:48PM. D. During an interview on 9/24/2024 at 2:48PM, the COO revealed the medical staff bylaws and rules and regulations are in revision and are utilizing a third party to assist in the process since converting from a CAH to an REH on 1/11/2024.”

“Basic Requirements CFR(s): Participation as an REH is limited to facilities that - (a) Meet the definition in § 485.502. (b) Have in effect a provider agreement as defined at § 489.3 of this chapter to provide services. (c) Meet the conditions of participation set out in this subpart. This Requirement is not met as evidenced by: 48575 Based on medical record review, observation of facility bed location, facility floor map, administrative and staff interviews, the facility failed to meet the definition of a rural emergency hospital (REH) by admitting 1 patient (P5) categorized as a hospice inpatient which occupied 1/15 licensed observation hospital beds since 7/31/2024. This failed practice has the potential to cause regulatory negative outcomes related to care and services provided by the REH without a skilled nursing facility distinct part unit license. According to facility provided data the REH had 14 observation patients 1/11/2024 - 9/23/2024. Findings include: A. Review of P5’s medical record revealed, P5 presented to the REH on 7/31/2024 at 10:30AM as a direct admit (patient goes directly from a facility to another facility without going through the emergency department or clinic) from a long-term care facility for 24/7 hospice care. P5’s diagnosis revealed chronic myeloproliferative disease (bone marrow blood cancer). P5’s electronic medical record (EMR) revealed patient class as, “1-inpatient.” During an interview with COO on 9/24/2024 at 11:43AM, the COO confirmed the medical record for P5 class type reads, “1-inpatient,” and stated it should say observation but unable to change in the EMR. B. A tour of the observation hospital unit on 9/24/2024 at 2:18PM revealed the REH licensed observation hospital beds are rooms 1-15. P5 is located in Room 6 (1/15) licensed observation hospital bed and has been receiving 24/7 direct patient care from the REH since 7/31/2024. The REH facility contracted with a hospice service for a Registered Nurse (RN) to be onsite for designated days of the week to assess and coordinate care, and a Certified Nursing Assistant (CNA) to provide whirlpool baths, all other care and treatment is provided by the REH staff. Confirmed with RN-A on 9/24/2024 at 2:20PM. C. Review of the facility floor map revealed room 6 is an observation room. Confirmed by RN-A on 9/23/2024 at 2:50PM. D. During an interview on 9/24/2024 at 8:45AM, with CEO/CFO and COO revealed, the facility has been in contact with a third party to assist with the transition from a CAH to an REH since 1/11/2024. The CEO/CFO had a community meeting with the medical staff and governing body to discuss taking hospice patients. The board agreed that the facility is able to care for one hospice patient per year to keep the annual average length of stay under the 24-hour REH definition requirement.”

“Emergency department staffing. CFR(s): (a)The emergency department of the REH must be staffed 24 hours a day, 7 days a week by an individual or individuals competent in the skills needed to address emergency medical care. This individual(s) must be able to receive patients and activate the appropriate medical resources to meet the care needed by the patient. This Standard is not met as evidenced by: 16132 Based on record review, staff interview and review of the provider schedule, the facility failed to have 24 hour coverage of the emergency department (ED) on 1 day (3/7/24) out of 5 months reviewed. This failed practice had the potential to affect all patients coming to the ED. The Rural Emergency Hospital (REH) averages 25 ED patients per month. Findings are: A. Review of the facility provider (Physician; DO; Physician Assistant; Nurse Practioner) schedule for the Emergency Department from 1/1/24 through 6/6/24 identified that on 3/7/24 the facility lacked provider coverage for 9 hours and 45 minutes. Per the March 2024 provider schedule, on 3/7/24 the facility lacked coverage from 12:08 PM to 9: 53 PM. B. Interview with the Director of Nurses on 6/5/24 at 1:00 PM stated, “The local Rescue Squad was notified that there was not a provider available from 12:08 PM on 3/7/24, so the ambulance needed to divert (go to a different hospital) from this hospital. They were then notified that at 9:53 PM on 3/7/24 at 9:53 PM that the hospital is no longer on diversion. A provider was available at that time. C. Interview with the Interim CEO (Chief Executive Officer) on 6/6/24 at 10:28 AM, revealed that the CEO had been aware that there was a time on 3/7/24 without coverage. “I had tried myself to call agency providers, and a prior physician that had worked here. We were unable to find anyone.” When asked if any patients came to the Emergency Department during the time on 3/7/24 without coverage, “No, we didn’t have anyone come to the ED during that time.” D. Review of the policy titled “Emergency Department Physician Availability” reviewed 1/2024, identified that the facility Emergency Room Staff is to notify the on-call medical provider when a patient presents to the emergency room. The provider is to be available by telephone, on a 24 hour a day basis, a medical provider to receive emergency calls and provide medical direction in emergency situations. E. Review of the medical record for Patient 1, that was seen in the ED on 3/7/24, for complaint of diarrhea, and dehydration. The patient was admitted to observation following the ED visit on 3/7/24. The provider going off duty at 12:00 Noon gave observation patient care orders prior to going off duty. The medical record for Patient 1 identified the patient received IV (intravenous fluids) and was provided the prescribed medication, and meal by the nurse. F. Interview with the Chief Clinical and Operational Manager on 6/6/24 at 2:45 PM when asked, what were the nursing staff to do on 3/7/24 if the observation patient needed medical care when there was no available provider, “I would have had them take the patient back to the ED and use the e care telemedicine physician.” When asked if there is any type of plan in place if it would happen again that they are without a provider and have an observation patient, “Not in writing.””