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Mountain Communities
Healthcare District
Critical Access Hospital
Annual Hospital Evaluation
2019 for
Calendar Year 2018
2
To: Board of Directors 2019
From: Aaron Rogers, CEO
Re: Annual Critical Access Hospital Evaluation for 2018
Mountain Communities Healthcare District Mission Statement
The Mission Statement of Mountain Communities Healthcare District is to
ensure the availability of and accessibility to emergency medical, and primary
and preventative healthcare in a cost effective and fiscally responsible manner
to all the people in the communities we serve. The healthcare will be delivered
in a high quality method with attention to patient safety.
A review of Mountain Communities Healthcare District was conducted for the
year 2018 as required by the Center for Medicare and Medicaid Services (CMS)
Conditions of participation for Critical Access Hospitals. The annual report was
submitted to you for review and approval. This information was created by
each department manager and compiled by the Coordinator of Quality
Assurance. The report was reviewed by the Continuous Quality Improvement
Committee and the Medical Staff Executive Committee.
Introduction to Mountain Communities Healthcare District
Mountain Communities Healthcare District (MCHD) is located in rural Trinity
County. It consists of a 25 bed Critical Access Hospital, a 25 bed Skilled
Nursing Facility, Emergency Room, and two rural health clinics. MCHD
provides a variety of services including: emergency services, acute inpatient
care, inpatient and outpatient surgeries, laboratory testing, radiology, physical
therapy, respiratory therapy, swing bed care, home health care, preventive and
routine care.
In a rural environment such as Trinity County, access to healthcare is vital to
the well being of the community. The land area of Trinity County is 3,179.25
square miles with a population estimated at 12,709 making an average of 3.4
persons per square mile (US Census). This reflects an estimated decrease in
population of -7.8% compared to the national increase in population of 5.5%.
The population has a higher than average number of senior citizens and
disabled persons per capita as compared to the rest of the United States. The
United States Census Bureau shows that in 2016, it was estimated that those
65 years of age and older in the United States was 15.6% on average and
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26.2% for Trinity County. The United States Census Bureau also shows and
that people under the age of 65 with a disability is 5.6% higher than average.
Also of note is that the civilian labor force for persons age 16 or older is 15.7%
less than the national average and that the number of persons in poverty is
8.0% higher than the national average (US Census). With these specific
challenges, it puts even more emphasis on the importance of making quality
healthcare accessible to the residents of this county.
Indicator Trinity County United States Avg
65 years of age or older 26.2% 15.6%
Disabled under the age of 65 14.3% 8.7%
Civilian labor force age 16 or older 47.3% 63.0%
Persons in poverty 20.3% 12.3%
From http://www.census.gov/quickfacts/table/PST045215/00,06105
accessed 12/25/2018
MCHD ensures that local schools, businesses, government agencies, and
individuals have access to high quality healthcare. Emergency care is also
important for emergency workers, such as firefighters, who come to work in
Trinity County. The rural nature of Trinity County with its lakes, rivers and
wilderness areas, makes it a popular destination for people to participate in a
variety of outdoor sports such as camping, hiking, fishing, kayaking, boating,
horseback riding, swimming and biking. MCHD is able to facilitate the needs of
the tourists who require healthcare during their visit. MCHD also provides an
important economic role in Trinity County averaging 170 employees in 2018.
This is an increase from 2015 when the average number of employees was in
the 140’s .
Executive Summary
MCHD was able to independently recruit and contract with 15 emergency
physicians to provide care to the District. This allows MCHD to keep
consistent, talented physicians. This change was possible due to a dedicated
medical staff, understanding of the need for robust emergent care locally, and
the District’s strong financial position.
As promised during the 2016 Parcel Tax Assessment campaign, MCHD
continually evaluated the need for tax income. In 2018, the District was able to
decrease the tax 25% with hopes to be able to completely eliminate local tax
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subsidies no later than 2020. Continued increase in community use of MCHD
facilities is paramount in achieving this goal.
In 2018, Mountain Communities Healthcare District (MCHD) saw clinic visits
decrease from 2017 volumes, but expect to see a rebound due to a full staff of
permanent providers in both clinics and the completion of the clinic expansion.
Radiology and Laboratory saw increases in volume while Respiratory Therapy
and Physical Therapy saw moderate outpatient decreases. Physical Therapy
decrease was due to staffing shortage and the steady increase of the swing bed
program as allowed by CMS.
Average length of stay for acute inpatient services for 2018 is well under the 96
hour maximum average at 3.13 days. Average hospital acute days decreased
from 2.54 to 1.99 per day while swing days increased from 3.06 to 4.04, for a
combined increase from 5.6 to 6.03 patients per day. Skilled Nursing Facility
grew in 2018 to a census of 12 residents.
Main Report
Section 1: Financial
Gross accounts receivable as of 12/31/2018 is $5.95 million, which is $2.16
million more than the prior year. The increase of gross accounts receivable is
attributed to a delay in receiving approval from the State to bill for Skilled
Nursing services. The District received approval to bill 11/28/2018 and
revenue cycle staff diligently began the billing process. Management
anticipates a decrease in gross accounts receivable during 1st quarter, 2019.
Continued efficiency and integrity of the revenue cycle is a top priority for the
District. From the moment a patient steps through our front doors through
discharge and beyond, the revenue cycle is closely monitored to ensure that
any issue that puts this cycle at risk is identified and resolved.
Payor Mix
Analyzing the District’s payor mix illuminates the difficulties Critical Access
Hospitals experience maintaining a positive bottom line. The District has a
high government payor utilization (76.6% in 2018, a decrease of 1.1% from the
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prior year) in which reimbursement received is less than the cost of providing
care.
The following pie chart represents 2018 patient charges by payor:
Charity Care and Unsponsored Community Benefit
The District provides needed medical care to the community regardless of a
patient’s ability to pay. The evaluation of the necessity for medical treatment of
any patient is based upon clinical judgement, irrespective of financial status.
In 2018, total charity care provided to the community was $64k. The District
strives to assist patients, if qualified to receive financial assistance for their
care through available government programs. These programs reimburse the
District at substantial discounts from established rates, often below the actual
cost of providing services.
The District also provides a number of benefits and services to the community
for which it receives nominal or no reimbursement. These services include
community medical and wellness education programs, medical screenings and
support groups.
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Section 2: Volume and Utilization of Services
Capacity
The District has 25 beds available for Inpatient, Observation and Swing bed
patients. The District did not exceed 25 inpatient or observation patients at
any time during 2018.
Service Mix
Service mix makes up the core of the District’s offerings. They are shaped by
community needs. The District has identified the following key service lines:
Inpatient Acute, Swing, Skilled Nursing Facility (SNF), Outpatient Services
including the Emergency Department (ER) and Ancillaries and Community
Health Clinics. The following pie chart represents total patient charges by
service line:
Utilization Review
All inpatients, observation patients, and swing patients are screened by the
Utilization Department to determine if the patient has been placed in the
correct status and if physician documentation supports the status.
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Discharge planning/ Utilization Review monitors all readmissions for all causes
within 15 and 30 day periods. The average amount of readmissions for 2018
was 1% within 15 days and 3% within 30 days.
Readmits 15 and 30 days all causes
Month / yr
Readmits 15
days
Total
admits %
Readmits 30
days
Total
admits %
January-18 1 28 4% 1 28 4%
February-18 0 32 0% 0 32 0%
March-18 1 26 4% 2 26 8%
April-18 1 20 5% 2 20 10%
May-18 0 31 0% 0 31 0%
June-18 0 25 0% 0 25 0%
July-18 1 33 3% 1 33 3%
August-18 0 18 0% 1 18 6%
September-18 0 22 0% 1 22 5%
October-18 0 19 0% 1 19 5%
November-18 0 20 0% 0 20 0%
December-18 0 20 0% 0 20 0%
Average: 0.3 24.5 1% 0.8 24.5 3%
Average Length of Stay
The OSHPD defined average length of stay for 2018 is 3.13 or 75.3hours. This
is a slight decrease from 2017 which was 3.39 or 81.36 hours. The average of
the year is below the threshold of 96 hours and is monitored by the Discharge
Planner, the Utilization Review Committee and the Continuous Quality
Improvement Committee.
Donor Network West
In 2018, MCHD was contracted with Donor Network West, an organ
procurement organization. MCHD’s tissue referral rate was 100%. The tissue
timeliness rate was 100% (this is defined as “whether or not a tissue only
referral was made within one hour of asystole or cardiac/circulatory time of
death”. A total of 12 tissue referrals were made.
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Section 3: Medical Record Review and Performance
Improvement
Medical Record Review
During the 2018 calendar year we met the 10% requirement of chart reviews
that are required. We have completed 10% chart audits or 30 charts (whichever
is greater) and will be reporting to the Quality Committee, Medical Executive
Committee and the MCHD Board of Directors
Hospital-Wide Indicators
For 2018, we developed hospital wide indicators that are being followed by the
Continuous Quality Improvement (CQI) committee. These were determined to
be areas that could see improvement and bring overall higher quality to MCHD.
For some of the measures, data was gathered from the Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) Survey. The
measures are as follows:
1) Before giving you any new medicine, how often did hospital staff tell you
what the medicine was for? (HCAHPS)
2) Before giving you any new medicine, how often did hospital staff describe
possible side effects in a way you could understand? (HCAHPS)
3) During this hospital stay, did you get information in writing about what
symptoms or health problems to look out for after you left the hospital?
(HCAHPS)
4) When I left the hospital, I clearly understood the purpose for taking each
of my medications. (HCAHPS)
5) Two patient identifiers used to identify patients (Name and Date of Birth)
(National Patient Safety Goal)
6) Important test results getting to the right departments
7) Hand Hygiene done appropriately
8) Surgery- right patient/ right place (National Patient Safety Goal)
9) Surgery- marked location (National Patient Safety Goal)
Medical Staff and Peer Review
The medical staff has established criteria for medical staff review for each
medical staff specialty. In addition, the medical staff reviews a representative
sample of records for each provider.
The Hospital has agreements with AllMed Healthcare Management and
California Critical Access Hospital Network (CCAHN) and Alliance network to
review records if a specialty is not represented on our staff. Currently we are
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sending 10 percent of surgical records for outside review since we only have
one surgeon on staff.
Section 4: Contract Services
Contracts:
A listing of contracts is being kept in administration and the Chief Executive
Officer (CEO) has reviewed all contracts in 2018. The CEO will continue to
review all existing contracts on an annual basis and upon renewal.
Section 5: Health Care Policies and Organizational Plans
Policies and Procedures:
Many clinical policies, including administrative and house-wide policies were
reviewed within the last year. These policies were reviewed by the individual
department manager. Clinical polices were also reviewed by the medical
director, Medical Executive Committee and the Chief Executive Officer.
Organization Plan
Many organizational plans have updated during the past year. Each plan was
reviewed and approved by senior leadership and the medical staff.
Section 6: Survey Readiness
State Survey
The State of California completed a Critical Access Survey in June 2017. This
was both a state and federal survey. Continued effort was to make sure that
deficiencies found on the survey continue to maintain compliance. These
efforts include, but are not limited to, staff in-servicing, 1:1 training, policy and
procedure review and updates, organized peer review, and chart audits
completed. There has not been a resurvey since 2017.
External Credentialing and Quality Review
California Critical Access Hospital Network (CCAHN) provided a credentialing
and quality survey through the company HealthTech S3 in March 2018. The
results were shared with the CEO, the Medical Staff Executive Committee and
the Board of Directors.
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Continuous Survey Readiness
Continuous survey readiness is a priority. A review by a HealthTech consultant
through CCAHN was completed in March 2018. A plan of correction was
created for each department, a scorecard was developed to address all
deficiencies found, and follow up was provided through the Continuous Quality
Improvement (CQI) Committee. The next evaluation is scheduled for early 2019.
Section 7: Review of Services
Patient Satisfaction Surveys
Staring with January 2017, MCHD contracted with Arbor Associates to
conduct the Hospital Consumer Assessment of Healthcare Providers and
Systems Survey (HCAHPS). A telephone survey is conducted to those who were
discharged from MCHD as an inpatient. In addition, MCHD has also contracted
with Arbor to survey MCHD’s swing patient discharges. Along with the scripted
HCAHPS questions, four additional questions were added. The results are
shared with staff, the Continuous Quality Improvement (CQI) Committee, the
Medical Executive Committee (MEC) and the Board of Directors (BOD). The
collected data is then used to develop performance improvement projects that
will contribute to patient safety and satisfaction.
In 2018, MCHD started a project looking at four specific questions from the
HCAHPS survey. The facility then implemented a new discharge binder to be
given to patients and then evaluated the outcome.
The baseline data was January 2017- January 2018 and the study measures
post binder implementation from February 2018- October 2018. The study
tracked “Always” responses.
How often did staff tell you what medication was for?
January 2017 – January 2018 66.7%.
February 2018-October 2018 81%.
How often did staff describe the possible side effects?
January 2017 – January 2018 41%
February 2018-October 2018 71.4%
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On discharge, received information in writing about symptoms/ health problems
to look out for?
January 2017 – January 2018 82.2%
February 2018-October 2018 85.4%
On discharge, clearly understood the purpose for each of my medications?
January 2017 – January 2018 =Strongly Agree: 58.5% Agree: 36.9%
(Total 95.4%)
February 2018-October 2018 =Strongly Agree: 56.3% Agree: 40.6%
(Total 96.9%)
Surveys are still being preformed in house for the Emergency Room, Trinity
Out Patient (TOP) care program and Surgeries, but a very small amount of
surveys are returned.
Annual Housewide Competencies
The Annual Housewide Competencies, which is required for all employees to
complete yearly, was updated to be compliant with MCHD policy, State and
Federal rules and regulations. This was a large undertaking that required
considerable effort from many departments. In addition, this update was
moved to a new online learning platform. This platform is now being used for
other online classes such as New Employee Orientation (NEO) and other
nursing education. This platform allows for updates in regulations to be
incorporated into staff education and rolled out quickly. This process will
continue to be refined in the coming year.
Administration
Administration is responsible for organizational management of the healthcare
district and provides leadership while maintaining a positive image for the
organization and effective public relations within the community.
Admissions
Members of the Admitting Department aim to serve the District’s patients and
their families with courtesy, respect and privacy. Registrars are often a
patient’s first contact with the Hospital and are the beginning of the revenue
cycle. They are responsible for collecting, organizing and registering each
patient’s information so that medical professionals can provide care. Financial
information is obtained and verified to ensure accurate billing and point of
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service collections for services rendered. In 2018, the District processed
32,040 patient admissions; this is an average of 88 patient visits per day.
Biomed / Environmental Services (EVS) / Maintenance
Biomed: Biomed is responsible for performing safety checks on equipment.
This may be annually or biannually depending on the equipment. All new
equipment that has patient contact must have a safety check by biomed before
it is put into use. A new Biomed Service was contracted in 2018. At the start of
their contract, every piece of medical equipment was inspected and logged.
EVS: Staffing has continued to be an issue with much staff turnaround.
Laundry for the Skilled Nursing Facility’s residents is done in house. A revision
of the documentation of the Operating Room cleaning and locking of the facility
has been put into process with success. The recent forest fires have highlighted
a potential supply issues due to possible road closures. Therefore, the facility is
now keeping on hand an extra supply of linens and paper products.
Maintenance: In addition to the day to day work orders, preventative
maintenance, and other routine jobs, the Maintenance Department has taken
on additional projects. Room remodeling has been completed on the MedSurg
unit. Inside and outside lighting is in the process of being switched to energy
efficient LEDs. Regulations required that the door in the corridor to Skilled
Nursing be relocated. This was completed by the Maintenance department
within the guidelines of OSHPD. In addition, policies were updated to meet
new Life Safety rules and regulations. The Maintenance department has
continued to educate staff on safety issues such as keeping hallways, fire
extinguishers, and exits clear. They also provide fire drills on a regular basis to
maintain safety readiness.
Business services:
Business Services is responsible for daily billing and collections that play a
critical role in the organization’s financial viability. Business Services
customer-focused approach integrates relevant data and processes throughout
the organization to help ensure both customer satisfaction and revenue
integrity. Services include insurance eligibility, verification and billing, denial
management, financial counseling, revenue reporting, insurance and
government program contracting, insurance and government program
credentialing and cash collections from insurance companies, patients, grants
and contributions, federal and state funding and miscellaneous non-operating
cash collections.
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Emphasis was placed on maintaining efficient cash flow by obtaining timely
compensation for services rendered. In pursuit of this goal, errors, both
human and electronic are unfortunately unavoidable. In 2018, the
department’s quality improvement project focused on analyzing clean claims
processing rates, root cause analysis and outcomes.
Discharge Planning / Utilization Review:
The purpose of Case Management is to assure post-acute hospitalization needs
are addressed and met per the patient’s preference, ability and willingness.
Patients are evaluated for return to the pre-hospital environment and also
offered a range of realistic options to consider for post-hospital care.
The purpose of Utilization Management is to assure the appropriate use of
hospital facilities and the timely communication of information to third party
payers. It is also to review services furnished by the institution and by
members of the medical staff to patients entitled to benefits under Medicare
and Medicaid programs.
Discharge planning/ Utilization Review are monitoring all readmissions for all
causes within 15 and 30 day periods with an average goal of less than 12% for
both measures annually.
The Discharge planning/ Utilization Review department added a Discharge
Planning Assistant in the fourth quarter of 2018.
Clinics:
Trinity Community Health Clinic (TCHC) is a community clinic in Weaverville
that provides primary healthcare as well as acute care. We have multiple
specialty services available through our telemed program.
Trinity Community Hospital Clinic is continuing to look for opportunities to
expand services and meet the needs of our community.
14
TCHC Total visits 2018 2017 2016 2015
Total 9,728 12,190 12,053 10,277
Hayfork Community Health Clinic (HCHC) is a community clinic that provides
primary healthcare as well as acute care. We have multiple specialty services
available through our telemed program.
HCHC is continuing to look for opportunities to expand services and meet the
needs of our community.
TCHC Total visits 2018 2017 2016 2015
Total 4,964 5,828 5,487 4,227
0
2000
4000
6000
8000
10000
12000
14000
2015 2016 2017 2018
Me
als
serv
ed
TCHC total visits
TCHC total visits
Trendline (linear)
0
1000
2000
3000
4000
5000
6000
7000
2015 2016 2017 2018
Me
als
serv
ed
HCHC total visits
HCHC total visits
Trendline (linear)
15
Diagnostic Imaging:
Our goal is to provide high quality Diagnostic Imaging Services with the best
patient care possible to the people of Weaverville and surrounding
communities.
Diagnostic Imaging Department
Hours of operation are Monday through Friday, 8:00 AM to 5:30 PM.
The department provides “call” coverage after hours and weekends for
Radiology and CT.
This department provides:
1) General Radiology: chest, feet, hands, ankles, spine, etc.
2) CT scans (Cat Scans): low dose, full body, head, chest, abdomen, lung
cancer screening, CT angiography, etc.
3) Ultrasound Services:
a. General Diagnostic: Abdomen, Pelvis, Thyroid, OB, and endo-
cavity procedures.
b. Vascular: Carotid, Venous Doppler extremity.
4) Echocardiogram: The evaluation of how the heart is functioning,
evaluation for valve disease, how the muscle is contracting, congenital
defects, clots, etc.
Accomplishments Goals and Projects
Installations of new 32 slice Siemens CT Somatomgo.UP, March 2018.
Annual Physicist Survey of department and final CT inspection
scheduled February 2019.
Due to slow of transmission of images, connected directly to MDI PACS
(picture archiving and communication system). Reduced transmission
time from 4-5 minutes to 60 seconds.
3/12 work schedule. Evaluation proved to be a decrease in personnel
expense and decrease in “call back”.
o The graph below represents the decrease of the weekday call backs
from 8:30 PM to 12:00 PM.
16
Imaging Department
Projects Currently Underway
General X-ray replacement of our 30+ year old system with a DR (direct
computer imaging) system. Final recommendation is in progress.
Architectural and Structural Engineering to meet OSPD and OSHA regulations.
Continue comparing annual procedure. The focus is to identify trends
in referral patterns from ER, IP and OP Below represents the comparison
from 2016 through 2018 and specifically the increase/decrease from
2017 to 2018.
The following comparison grafts are not to question, suggest, or promote
the utilization of unnecessary imaging procedures and or questions any
provider’s patient care.
0
20
40
60
80
100
120
140
160
2018 2017 2016 2015 2014
Call Back X-ray /CT
00:00 - 07:59
20:30 - 23:59
Linear (00:00 - 07:59)
Linear (20:30 - 23:59)
17
Imaging Department Combined Modalities
ER: Decrease: (5% ) IP: Decrease (16%) OP Increase: 8% Overall: Increase 4%
General Radiology
ER: Decrease: (11%) IP: Decrease: (31%) OP: Increase: 6% Overall increase:2%
2,373
429
3,139
5,941
2,493
508
2,899
5,900
2,349
505
3,073
5,927
0
2,000
4,000
6,000
8,000
ER IP OP TOTAL
Comparison procedures
2018 2017 2016
2,372
426
3,141
5,939
2,423
535
2,928
5,886
2,349
505
3,073
5,927
0
2,000
4,000
6,000
8,000
ER IP OP TOTAL
General Radiology
2018 2017 2016
18
CT Procedures
ER: Increase: 3% IP Decrease: (14%) OP: Increase: 7% Overall: Increase 4%
NOTE:
1) New Siemens Somatom go.UP installed March 2018. Software problems
delayed up time by three days.
Ultrasound Procedures
ER: Increase: 27 % IP: Decrease: (29 %) OP: Increase: 12% Overall: Increase 4%
657
71 265
993
613
88 249
950
540
89 280
909
0
500
1,000
1,500
ER IP OP TOTAL
CT Procedures
2018 2017 2016
137 49
726
912
99 68
648
815
89 54
527
670
0
500
1,000
ER IP OP TOTAL
US Procedures
2018 2017 2016
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Echocardiogram Procedures
ER: Decrease:
(41 %)
IP: Increase: 19 % OP: Increase: 13% Overall: Increase 15%
Echocardiogram Chart 2
March 2018, the procedure count for echocardiogram adjusted from 3 per
procedure to 4 per procedure. Chart 2 reflects a true comparison from
previous years.
Echocardiogram Procedures
ER: Increase: 18% IP: Decrease: (19%) OP: Decrease: (17%)
Overall: Decrease: (15%)
52
165
258
475
34
162
243
439
12
136
252
400
0
100
200
300
400
500
ER IP OP TOTAL
Echocardiogram Procedures
2018 2017 2016
40
131 202
373
34
162
243
439
0
100
200
300
400
500
ER IP OP TOTAL
Echocardiogram chart 2
2018 2017 2016
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Projects Upcoming
General Radiology: Prepare to replace existing diagnostic radiology
equipment. New guidelines are coming. These guidelines are address the
elimination of x-ray film developing using chemicals, and upgrading to
digital imaging from CR (cassette), our current system, to DR (Direct)
computer imaging.
o Penalties will be formulated resulting in a decrease of
reimbursement. CAH’s may be given additional time for transition.
RIS (Radiology Information System)/EHR/PACS: IT evaluation of
imaging modules to interface with current EHR and contracted
Radiologist groups RIS (Radiology Information System).
Statistics: Continue to accumulate statistics to identify trends. Identify
patterns of utilization.
CT Accreditation: American College of Radiology re-certification: Upon
the installation of our new Siemens CT scanner, I will begin the process
for Accreditation.
Brief
We are committed to the challenges of providing imaging services 24 hours.
The Imaging Department personnel include, four registered Radiologic
Technologist, a Registered Diagnostic Medical Sonographer (RDMS) and a
registered Cardiovascular Technologist (RCVT).
We will continue to evaluate imaging services to add and/or implement
changes that will enhances our services or improve our efficiency of the
Imaging Department. This includes Bone Density (DEXA), increasing
cardiology services to include stress test, Ultrasound training to provide
peripheral arterial extremity services.
Services: Our focus is to provide better than or equal image quality provided
west and east of Weaverville.
Dietary:
Dietary provides nutritional and therapeutic Diets for patients, residents,
Doctors and employees. A total of 20,478 meals were served in 2018.
Dietary is participating in performance improvement projects. One project
includes reviewing a sample of temperatures of food as it leaves the kitchen.
21
Another project monitors tray check for correct diets being sent. MCHD started
a contract with a new dietitian in May 2018.
Employee Health:
The purpose of the Employee Health Program is to ensure that staff is
compliant with the organizations requirements for annual physicals, TB
testing/screening and annual N95 mask fit testing.
Employee health establishes an employee health record for each new hire that
includes verification of passing the hiring physical, TB clearance, 2-step TB
testing if needed, N95 mask fit testing, and review of required immunizations
that the organization must offer.
Annually staff is required to complete TB testing/screening and N95 mask fit
testing. Staff with direct patient care responsibilities also have an annual
physical. These are all done during the staff’s birthday month.
Upon hire and annually, the general hand hygiene policy, personal protective
equipment (PPE) procedures specific to the employee’s work environment and
infection control principles are reviewed.
0
5000
10000
15000
20000
25000
2016 2017 2018
Me
als
serv
ed
Meals served
Meals served
Trendline (linear)
22
PPE / Infection Control Training Completed
1st quarter 2018 95%
2nd quarter 2018 98%
3rd quarter 2018 97%
4th quarter 2018 93%
Financial Services:
The Financial Services team’s mission is to provide quality customer service by
giving complete and accurate financial and decision support in an efficient and
timely manner. The department is responsible for development and
implementation of a comprehensive financial management system for the
District to include centralized accounting, financial reporting and budget
services. The department additionally is responsible for payroll administration,
accounts payable, Medicare and Medi-Cal cost reports, State Controller
Reporting, OSHPD quarterly and annual financial reporting, all financial
audits, charge master, charge capture, capital assets reporting, activity based
costing, budget management and administration, Special District parcel tax
collection activities including liens, patient trust accounting and providing
accounting services to the Hospital Foundation, Districtwide policy
administration.
90919293949596979899
1st quarter 2nd quarter 3rd quarter 4th quarter
%
Training completed
Training completed
23
Purchasing:
The mission of the Purchasing Department is to provide efficient and
responsive procurement services and to obtain high quality goods and services
at reasonable costs.
Health Information Management
The Health Information Management (HIM) department is responsible for
maintaining the integrity of the patient medical record. All patient information
comes through this department and gets scanned into the electronic health
record. This allows the physicians access to the information to aid in their
decisions regarding patient care and the patient’s access to their records for
continued health care. Health Information is an integral part of the revenue
cycle, coding all claims in a timely fashion so that Business Services can
bill. HIM protects the privacy of the patient according to all Health Insurance
Portability and Accountability Act of 1996 (HIPAA) rules and confidentiality
laws and principles.
The HIM department now processes all release of information (ROI) requests
and issues for the entire Mountain Communities Healthcare District, including
the hospital and both clinics. The department continually works on expanding
coding and ROI knowledge and skill set through trainings, webinars and
assessments. All members of the HIM department are cross-trained for
excellent interdepartmental coverage.
Home Health:
The Home Health department’s main goal is to assist a patient to return to
baseline without complications, be independent at home, as well as assisting
patients to remain in their homes with their family members at bedside at the
end of life.
Home Health provides a variety of services for the patients of Trinity County.
This includes personalized education about their end of life care or current
health issues, medication management and social issues impacting their
health. Some of the services provided include: lab draws, Port a Cath
maintenance, insertion and care of urinary catheters, Peripheral inserted
central catheter (PICC) line management, and wound care.
Home Health patients are seen with a variety of diagnosis. These include:
medical diagnosis (15), End of Life Care (9), Wound Care (4), and Surgical (2).
24
Due to the lack of Home Health Physical Therapists and Home Health Nurses,
MCHD Home Health has not been able to accept all referrals or travel to the
outlying areas as reflected in the following graphs.
Home Health also coordinates the TOP CARE (Trinity Out Patient Care)
program which enables patients to have procedures done that are not available
in the Clinics and not appropriate for the ER.
Below are some graphs to help define the Home Health structure.
02468
10121416
SURGICAL WOUNDS MEDICAL PALLIATIVECARE
Home Health Diagnosis
Diagnosis
0
5
10
15
20
25
Home Health Referral Source
HH Referral Source
Physician
Health Clinics
Rehab Center
Hospitals
25
Home Health Volume
2018 2017 2016 2015
446 497 619 867
0
5
10
15
20
25
30
Weaverville Lewiston Douglas city JunctionCity
Home Health Area Served
Home Health Area Served
0
200
400
600
800
1000
2015 2016 2017 2018
Ho
m H
ela
th V
olu
me
Home Health Volume
Home Health Volume
Trendline (Linear)
Home Health Patients by Payor
Medicare
Medi-Cal
Partnership
BlueCross
Insurance
26
Human Resources:
The Human Resource (HR) department continues to focus on employee
turnover rate as a continuous improvement quality measure. The average
employee turnover rate for 2018 remains at just over 2%, which continues to
be an industry low rate. HR continues to improve recruiting efforts by
attending career fairs at local colleges as well as maintaining a focus on hiring
employees that are qualified and committed to a long-term career with the
hospital. In addition to the low turnover rate, the average number of employees
working at MCHD has increased by over 30 employees since January 2015. We
are excited to be growing as we expand our services to the community.
The Human Resource department is working with Trinity Together: Cradle to
Career Partnership through a Career Experience Program with Trinity High
School students. One of the few options for students to participate is through
Shasta Community College with a worksite learning opportunity wherein high
school students can earn one college credit while volunteering and observing
the inner workings of their local hospital. Our goal is to not only assist these
students in learning soft skills, such as reporting to work on time, following
through on commitments, following policies, etc., but also to expose local
students to the many different opportunities our facility has to offer in hopes
that they will return as educated adults looking for a career.
Infection Control:
Infection Control activities throughout the organization are both passive and
active looking for hospital associated infections related to indwelling catheters
(CAUTI), surgical site infections (SSI) and monitoring of infection control
precautions. Annual training is provided to all employees during their birthday
month on hand hygiene, donning/doffing PPE and general infection control
review.
Charts are reviewed for indicators that are suspect for indwelling catheter
infections or central line infections. All blood cultures and MRSA nasal swabs
are reviewed. The hospital MRSA screening policy was updated to reflect the
SB1058 requirements. Emergency Room log book is monitored for possible
surgical site infections presenting to the ER.
Mandated reporting is made to the National Healthcare Safety Network (NHSN)
through the on-line reporting system. There is also quarterly reporting to the
Continuous Quality Improvement (CQI) Committee and the hospital Infection
Control Committee.
27
2018 Infection Control goals based on infection control hazard vulnerability
assessment and approved by Infection Control Committee:
1. 44% probability of Environmental smoke secondary to wildfire.
Action: Provided training in preparation for fire season on use of
HEPA filters, inventory of spare filters and maintain good relationship
with local health department for use of large industrial HEPA filters if
needed.
2. 33% probability of contaminated surgical instruments.
Action: Incorporated ATP (Adenosine Triphosphate) testing on
autoclaved instruments into monthly surveillance activities – all tests
were clear.
3. 22% probability of hospital acquired C. Diff (Clostridioides difficile)
infection.
Action: Infection Control Nurse compared the number of patients on
Med/Surg for the past two years to evaluate community acquired
verses hospital associated. The overwhelming numbers of cases of C.
Diff were admitted from the community. This is further evidence that
the antibiotic stewardship program is active and antibiotics are used
only when necessary.
Study of C. Diff cases Community Acquired vs Hospital Acquired
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total
2017
CA 1 1 2 0 0 1 1 0 0 1 2 0 9
HAI 0 0 0 0 0 0 0 0 0 0 1 0 1
2018
CA 0 0 1 1 2 0 2 0 0 0 0 0 6
HAI 0 0 1 1 0 0 0 0 0 0 0 0 2
CA: Community Acquired HAI: Hospital Acquired Infection
Information Technology
The Information Technology (IT) Department completed several large
infrastructure projects including legacy storage upgrades which replaced aging
28
data storage units. New state of the art systems and protocols were installed
which provide a nimble and flexible storage fabric for the future.
Edge device upgrades were completed in concert with robust end point security
upgrades to combat the evolving risk in the CyberSecurity landscape.
The Information Technology technical committee guided purchasing decisions
and was instrumental in forming an EHR steering committee. The Steering
Committee will investigate potential EHR replacement candidates due to the
changing regulatory requirements for Hospitals and Rural Clinics.
The Information Technology Support Services maintained all response and
resolution thresholds while operating within the complexities of an
infrastructure in motion due to large scale upgrades across the Enterprise.
Laboratory:
Description/Scope including any new services or modalities: A 24/7
operation. The laboratory provides services for Inpatient, Skilled Nursing, ER
and Outpatients. The Laboratory is open for outpatients Monday through
Friday 0730-1730 and weekends from 0730-1400.
The Lab performs a variety of testing: Hematology, Chemistry,
Immunochemistry, Immunology, Urinalysis, Coagulation, Arterial Blood Gases,
Blood Bank and Microbiology, including Molecular testing. Employer drug
screens are available by appointment Monday through Friday. We also provide
Drug collections for Federal and Non-federal Drug Testing. Chemistry and
immunochemistry testing is performed on a multiplatform analyzer. This
means, one analyzer with multiple platforms. Testing is more efficient and
there is an improvement in turn-around-time.
In the first quarter of 2018 the lab replaced the old hematology analyzer with a
new Hematology Analyzer. Also, the lab completed correlation testing of Tumor
Markers: Carcinoma Embryonic Antigen (CEA) and Carbohydrate Antigen 19-9
(CA-19-9)) along with Testosterone, Follicle Stimulating Hormone (FSH),
Luteinizing Hormone (LH) and Estradiol. These tests are currently sent out to
a reference lab, current volume indicates that they may be performed in-house
rather than referred. The lab is always looking at ways of increasing revenue
with the addition of more molecular testing and other additional testing. If
feasible, RSV molecular testing will be then next addition to the test menu. The
lab’s goal is to go into the community and provide health screening for
cardiovascular disease, Diabetes, and Prostate Cancer on a quarterly basis as
well as participate in community-wide health fairs.
29
Volume/Activity: The laboratory performed 205,013 tests; a slight increase by
2.7% compared to 2017. There was a decrease in inpatient and an increase in
outpatient utilization. There was an decrease in inpatient and slight increase in
outpatient utilization of Red Blood Cells (RBC), total transfused 64 units of
Leuko-reduced Red Blood cells, and 0 Fresh Frozen Plasma and 1 Platelet
Pheresis in 2018.
Laboratory
Tests
2018 2017 2016 2015 Percent
Increase/(Decrease)
Inpatient 34,915 36,610 40,052
41191
(4.6)
Outpatient 170,098 163,091 158,762
164974
4.3%
Transfusions
Inpatient 34 42 43 44 (19.0)
Outpatient 30 23 28 12 30.4
Laboratory utilization trends include the total number of inpatient and
outpatient tests per year. Total number of laboratory tests increased by 2.7%
compared to 2017.
190,000
195,000
200,000
205,000
210,000
2015 2016 2017 2018
Nu
mb
er
of
test
s
Laboratory tests Total
Laboratory tests, total
Trendline (Linear)
30
Laboratory Tests 2018 2017 2016 2015
In Patient 34,915 36,610 40,052 41,191
Out Patient 170,098 163,091 158,762 164,974
Total 205,013 199,701 198,814 206,165
Collected Statistics:
Department
/ Topic
Bench-
mark
Target
%
Target
Date
Monthly Results Next
Target
Date
(if
differen
t)
Conclusion
/ Follow
up Oct
%
Nov
%
Dec
%
TAT Ave HR/24 HR (in
Minutes)
CONTRACT QUALITY INDICATORS
TAT 3 days 3 1/01/20 4437/1 4713/1 4624/1 04/1/2 Continue
30,000
35,000
40,000
45,000
2015 2016 2017 2018
Nu
mb
er
of
test
s
Laboratory Tests Inpatient
Inpatient
Trendline (Linear)
150,000
155,000
160,000
165,000
170,000
175,000
2015 2016 2017 2018
Nu
mb
er
of
test
s
Laboratory Tests Out Patient
Inpatient
Trendline (Linear)
31
LabCorp
Send-out
testing
Actual TAT
days 19
440 440 440 019 to monitor
Days
3.08
Days
3.27
Days
3.21
Percentage
of send-out
tests back
within 3
days
85 85
01/01/2
019
TAT within 3 day/total
occurrences
04/1/2
019
Continue
to
monitor.
269/31
4
229/26
3
194/24
2
85.7% 87.1% 80.2%
Shasta
Pathology
Onsite
consultatio
n reports
100
%
01/01/2
019
100% 100% 100%
04/1/2
019
Written
report
received
post
Pathologis
t visit
Vitalant
(Bloodsourc
e)
01/01/2
019
100% 100% 100% 04/1/2
019
Quarterly
Report
submitted
Beckman-
Coulter
01/01/2
019 N/A
N/A N/A 04/1/2
019
Informatio
n not
provided
Ortho
Clinical
01/01/2
019
NA NA NA 04/1/2
019
Informatio
n not
provided
Department / Topic Bench-
mark
Targ
et %
Target
Date
Monthly Results Next
Target
Date
(if
differen
t)
Conclusion/
Follow up OCT
%
NO
V
%
DEC
%
Numerator/
Denominator
Blood Culture
Contamination Rate.
5 01/01/2
019
0/2
0
2/2
7
3/3
7
04/1/2
019
0% 7.40
%
8.11
%
MRSA Colonization 5 01/01/2 2/2 4/2 2/2 04/1/2
32
019 5 9 7 019
8.0
%
13.8
%
7.4
%
MRSA Positive
Cultures
(All cultures with
growth of a
pathogen)
5 01/01/2
019
3/8
8
5/6
1
1/8
6
04/1/2
019
3.4
%
8.2
%
1.2
%
CLIA Proficiency testing:
Microbiology
2018
80
80
01/01/2
019
1st 2nd 3rd 04/1/201
9
Regulatory
Requirement
95 100 100
Routine
Chemistry
2018 80 80
01/01/2
019 96
96.5
98.5
04/1/201
9
Regulatory
Requirement
Endocrinology
2018 80 80
01/01/2
019 100 100
100
04/1/201
9
Regulatory
Requirement
Toxicology
2018 80 80
01/01/2
019
92.5 100 100
04/1/201
9
Regulatory
Requirement
Hematology
2018
80 80 01/01/2
019 100 98.3 100
04/1/201
9
Regulatory
Requirement
Microscopy
2018
80 80 01/01/2
019 100 100 100 04/1/201
9
Regulatory
Requirement
Urinalysis
2018
80 80 01/01/2
019 100 100 100 04/1/201
9
Regulatory
Requirement
Diagnostic
Immunology
2018
80 80 01/01/2
019 100 100
100 04/1/201
9
Regulatory
Requirement
Blood Bank
2018
100 100 01/01/2
019 100
100
100 04/1/201
9
Regulatory
Requirement
33
Nursing
Medical Surgical (Med/Surg) Unit
Trinity hospital Medical Surgical Unit provides acute care and Swing Bed care
services, which are provided for qualifying patients who require extended care
beyond acute. In 2018, our acute patient days were 724 which is a decrease of
191 days from previous year. Swing bed patient days for 2018 are 1,422 which
is an increase of 319 from previous year. In 2018 swing bed patient days
increased by 319. Staffing goal is to have three nurses (two RN’s and one LVN)
on Med Surg around the clock which has been mostly successful. During the
Carr Fire staff shared their homes, and even slept in available rooms within the
facility to continue to work. Many of our staff members were under evacuation
orders and continued working throughout this hardship. The dedication and
versatility of the staff was inspiring. As of 10/01/2018, a new Chief Nursing
Officer was appointed and has also taken place as the interim Director of
Nursing for SNF.
0
500
1,000
1,500
2,000
2,500
3,000
2015 2016 2017 2018
Day
s
Total Census Days
Days
Trendline (Linear)
0
200
400
600
800
1000
1200
2015 2016 2017 2018
Day
s
Acute Inpatient Census Days
Days
Trendline (Linear)
34
Census Days 2018 2017 2016 2015
Acute 724 915 974 1039
Swing 1,422 1103 1676 976
In Patient
Surgery 1 4 2 9
Observation 16 45 42 146
Total Patient
days 2,163 2,067 2,694 2,170
Emergency Department (ED/ER)
Trinity Hospital Emergency Department provides emergency medical services to
our community. Basic emergency care services are available 24 hours a day. ER visits decreased by 291 from 2017 bringing this year’s total to 4,331.
0
500
1000
1500
2000
2015 2016 2017 2018
Day
s
Swing Patient Census Days
Days
Trendline (Linear)
3500
4000
4500
5000
5500
2015 2016 2017 2018
Vis
its
Emergency Room Visits
Visits
Trendline (Linear)
35
2018 2017 2016 2015
Emergency room Visits
4331 4622 4752 5178
Operating Room (OR)
Trinity Hospital Surgical Department provides select procedures such as endoscopic procedures and other minor surgical procedures. These procedures
are scheduled as outpatient, are minimally invasive and patients typically discharge home the same day. Surgeries and procedures together have reduced by 14 from 2017 to 2018.
400
420
440
460
480
500
520
2015 2016 2017 2018
Nu
mb
er
Surgeries / Procedures, Total
Surgeries/ Procedures
Trendline (Linear)
0
20
40
60
80
100
120
140
2015 2016 2017 2018
Nu
mb
er
Surgeries
In Patient
Out Patient
Trendline (Linear)
Trendline (Linear)
36
Surgeries 2018 2017 2016 2015
InPatient Surgeries
1 7 5 9
Out Patient
Surgeries 78 90 116 123
In Patient
Procedures 1 9 15 14
Out Patient
Procedures 402 390 303 358
Total Surgeries
and Procedures 482 496 439 504
TOP Care Program (Trinity Outpatient Program)
Home Health coordinates the TOP CARE out patient program which enables
patients to have procedures done without traveling long distances. Some of the
services TOP CARE program offers: wound care, urinary catheter care, PICC
line and Port a Cath management, therapeutic phlebotomy, blood transfusions,
Rhogam, IV Antibiotics, rabies vaccinations and specialty medications for
oncology and infectious disease.
In 2018, 233 patients were served through the hospitals Top Care Outpatient
program. If not for this program many of these patients would have to travel
hours to receive these services.
0
100
200
300
400
500
2015 2016 2017 2018
Nu
mb
er
Procedures
In Patient
Out Patient
Trendline (Linear)
Trendline (Linear)
37
Top Care Visits 2018 2017 2016 2015
233 306 290 316
Pharmacy:
Trinity Hospital is licensed as a Hospital Pharmacy. The pharmacy provides
pharmaceutical services to the ED, OR, Med/Surg, Home Health, and
Radiology as well as to MCHD’s Health Clinics.
The pharmacy is responsible for the evaluation and approval of all medication
orders within the Hospital, Pharmacy policies and procedures to ensure safe
medication administration and the ordering, procurement, stocking and
monitoring of all pharmaceuticals.
The Pharmacist is a member of the Pharmacy and Therapeutics/Medication
Error Reduction Program (MERP)/Antimicrobial Stewardship (ASP) Committee
and is an active participant the MCHD Quality Program.
0
50
100
150
200
250
300
350
2015 2016 2017 2018
Vis
its
Top Care Visits
Top Care Visits
Trendline (Linear)
38
Medications Dispensed
2018 2017 2016 2015
44,844 49,692 48,585 50,133
Pharmacy and Therapeutics / Medication Error Reduction Program
(P&T/MERP):
The P&T/MERP Committee is composed of the Pharmacist, the Pharmacy
Medical Director, Chief Executive Officer (CEO), Chief Nursing Officer (CNO),
Quality Assurance Coordinator and other staff representatives as appropriate.
The purpose of the P&T Committee is to review Pharmacy policies, procedures,
Medication Errors, Formulary, and ASP activities - updating as needed with
Medical staff recommendations and approval, provide pharmaceutical
resources to physicians and nursing staff and to oversee the Pharmacy
operations in order to provide quality monitoring of medication ordering,
administration, procurement, and stocking.
The MERP, following what was done in 2014 subsequent to a California
Department of Public Health (CDPH) survey, is currently being evaluated for
2018.
The P&T/MERP meets at least quarterly. The committee convened monthly
over the first quarter of 2018, then met quarterly over the remainder of 2018.
The ability to track medication errors remained consistent in 2018, and the
ability to track pharmacist acknowledgment of orders within 24 hours was
optimized through automation and is being reported quarterly to Continuous
Quality Improvement (CQI).
42000
44000
46000
48000
50000
52000
2015 2016 2017 2018
Nu
mb
er
of
Me
ds
give
n
Medications Dispensed
Medication given
Trendline (Linear)
39
Antimicrobial Stewardship:
The antimicrobial stewardship program has been ongoing since July of 2015.
The measure being looked at and reported to CQI is the proportion of positive
cultures that have an appropriate antibiotic, according to culture antibiotic
sensitivities, within forty-eight hours of producing the culture. This number
has steadily improved since 2016. The primary outcome for the program is
reported to CQI every quarter.
Physical Therapy:
The Physical Therapy department evaluates and treats Inpatients, Swing
patients, Skilled Nursing residents (included as Outpatient visits), and
Outpatients. Physical therapy is a specialty that remediates impairments and
promotes mobility, function, and quality of life through examination, diagnosis,
prognosis, and physical intervention (therapy using mechanical force and
movements).
Physical Therapy utilization includes total visits per year. In 2018, the total
utilization of this service per 2 therapist was 2,458 compared the 2,791
patients seen by 3 therapist during the previous year.
0
500
1000
1500
2000
2500
3000
3500
2015 2016 2017 2018
Nu
mb
er
of
visi
ts
Physical Therapy Visits Total
Physical Therapy VisitsTotal
Trendline (Linear)
40
Physical Therapy 2018 2017 2016 2015
IP 126 135 190 131
Swing 843 616 852 448
SNF - 31 45 79
Home Health - - 58 103
Out Patient 1,489 2,009 936
TOTAL 2,458 2,791 2,144 761
Quality Assurance/ Risk Management:
The Quality Assurance and Risk Management programs are used to evaluate
and increase patient and employee safety and satisfaction by helping to
implement and monitor continuous quality improvement throughout the
facility and reduce potential risk through education and training. Risk
Management works with the Continuous Quality Improvement (CQI) Committee
and the Safety Committee to look at safety issues and trends with the goal of
reducing risk. The Committees get reports on safety issues such as medication
errors, transfusion reactions, adverse drug events, falls, infection control
issues, staff and volunteer injuries, and reported safety issues.
Starting at the end of 2014 and throughout 2015-2018 years, the Quality
assurance program has continued to be refined to improve the quality and
meet regulatory standards. Quality reports have been reviewed by state
0
500
1000
1500
2000
2500
2015 2016 2017 2018
Nu
be
r o
f vi
sits
Physical Therapy Visits by Patient Type
Inpatient
Swing
Outpatient
SNF
Home Health
41
surveyors and consultants and suggestions given have been put into place. A
new high level overview report of the four main lines of MCHD (Hospital,
Clinics, Home Health, and Skilled Nursing Facility), was put into place.
Training for the Continuous Quality Improvement (CQI) Program with
department heads is ongoing. There was active participation by the Board of
Directors in the CQI process throughout the 2018 calendar year. With the
change of board membership, a new board member became part of the CQI
Committee.
Every new employee is given education regarding the quality improvement and
risk management processes at New Employee Orientation. Components for the
Quality Assurance and Risk Management program have been added to the
annual house-wide competencies that are completed yearly. A Quality
Assurance and Risk Management Monthly newsletter to the whole organization
was started at the end of 2015 and has continued throughout 2018.
Respiratory Therapy (RT):
Respiratory therapists, provide care for patients with heart and lung disease
acute and/or chronic. They often treat people who have asthma, chronic
obstructive pulmonary disease, restrictive lung disease, emphysema, cystic
fibrosis and sleep apnea, but also those experiencing a heart attack or suffering
a stroke. The therapist performs MetaNeb therapy treatments; pre and post
bronchodilator spirometry; nebulizer treatments; assesses oxygen requirements
and consults with the physicians when indicated recommending mode of
oxygen treatment by mask, nasal cannula, continuous positive airway pressure
(CPAP) or Bi-level Positive Airway Pressure (BIPAP); incentive spirometry, peak
flow meter, home oxygen qualifications, procedures to screen for Chronic
Obstructive Pulmonary Disease (COPD), performs Arterial Blood Gas
collections (ABG) and interpretation, electrocardiogram (EKGs); patient
education, intubation assist, and ventilation assistance.
Volume/Activity: 7,974 treatments were performed by Respiratory Therapy in
2018. Volume decreased from 2017 to 2018
Respiratory Therapy utilization includes total treatments for the year. There is
a numerical decrease in the number of treatments due, in part, to the number
of allowed treatments that can be billed to Medicare in 2018, but does not
accurately reflect how many treatments were actually performed.
42
Respiratory Therapy volume
2018 2017 2016 2015
7,974 8,208 8,788 10,384
Skilled Nursing Facility:
2017 ended with a total of 9 residents in the facility. SNF received the
Welcome Letter from CMS on 11/28/2018 that was dated 11/19/2018. The
year ended with a total of 12 residents and 3,634 patient days. A federal
survey was conducted in October of 2018 with correctable deficiencies related
to policy updates and resident satisfaction specifically to the quality and
availability of coffee at all hours. As of October 1, 2018 the new Chief Nursing
Officer accepted the interim position of Director of Nursing. Efforts are
currently in place to recruit a permanent DON.
0
2000
4000
6000
8000
10000
12000
2015 2016 2017 2018
Nu
mb
er
of
tre
atm
en
ts
Respiratory Therapy Volume
Respiratory TherapyVolume
Trendline (Linear)
0
1000
2000
3000
4000
5000
6000
7000
2015 2016 2017 2018
Day
s
SNF Census Days
SNF Census Days
Trendline (Linear)
43
SNF Census
Days
2018 2017 2016 2015
3,634 1,903 1,448 6,623
Staff Development:
The primary focus of the Director of Staff Development’s (DSD) responsibility
involves providing needed nursing in service for continuing education credit
and the needed 16 hours of in-service prior to working on the floor.
The current DSD is providing classes for the nurses’ aides. Hours are flexible
and vary week to week.
The DSD continues to provide annual required classes to all staffed CNA’s per
regulations. 24 hours per year, including minimum 3 abuses and 5 dementia.
16 hour required orientation provided to all new CNA hires. Currently SNF
only hires CNA’s. Mini in-service’s provided when needed.
Currently Trinity Skilled Nursing Facility is waiting for their in-service and
orientation renewal. This is a requirement for all Skilled nursing facilities to
renew every two years. This was submitted 1/31/2019 by email and by mail.
All current CNA’s submitting for their renewal is taking approximately one to
two weeks.
44
References
U.S. Census Bureau. QuickFacts. Retrieved from
http://wwwcensus.gov/quickfacts/table/PST045215/00,06105
Retrieved 12/25/2018
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