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Mountain Communities

Healthcare District

Critical Access Hospital

Annual Hospital Evaluation

2019 for

Calendar Year 2018

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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.

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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

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HCHC total visits

HCHC total visits

Trendline (linear)

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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.

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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)

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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

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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.

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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)

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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

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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