HospitalInspections.org

Repeat Deficiency

Based on document reviews and interviews, the hospital failed to ensure that all Providers who provided care to patients were evaluated consistent with the "York Hospital Medical Staff, Bylaws, Rules & Regulations" for seven (7) of eight (8) Providers (Provider #2 - #8).

Findings:
During a previous complaint survey, which was completed on 3/27/19, it was determined that a Vascular Surgeon, who was on call for the hospital, had performed surgery on a patient and was not licensed in the State of Maine to practice and the hospital's Medical Staff Bylaws had not been followed. As a result, the hospital was cited for its failure to ensure all providers, who provided care to patients, were evaluated consistent with the "York Hospital, Medical Staff, Bylaws, Rules & Regulations" for 1 of 1 physician. The hospital's plan of correction (POC), dated 4/19/19, indicated the following: the Medical Staff would be educated on the need for Maine licensure even in emergent situations; the Medical Bylaws would be revised to clarify that in all cases, including emergency situations, the providers at York Hospital must be legally authorized (licensed) to practice within the State of Maine; all credentialed providers would attest that they understood Maine licensure requirements and process for emergency privileges; and the updated bylaws would be distributed to each remember of the Medical Staff, with a memo noting the specific requirement of Maine licensure. The POC indicated that the hospital would be in compliance with this regulation by 5/10/19.

The "York Hospital Medical Staff Bylaws, Rules & Regulations" were reviewed and states in part ... following:

"Article II: Medical Staff Membership
-Section 1. Medical Staff Appointment stated, Appointment to the Medical Staff of York Hospital is a privilege which shall be extended only to competent professional who continuously meet the qualifications, standards, and requirements set forth in these Bylaws, Rules & Regulations, and associated policies of the medical Staff and Hospital...In addition, all Medical Staff - are required to comply with all applicable State and Federal Regulations, and Policies of the Medical Staff and any other applicable departmental or divisional rules, regulations and policies."

- Section 2: Qualifications for Membership
A. Only providers with Doctor of Medicine or Doctor of Osteopathy Degrees, Dentists, Oral Surgeons, Podiatrists, or RNFA's, NP's, PA's, CNM's, FNP's, ANP's and APRN's, holding a license to practice in the State of Maine, who can document their current licensure, background, experience, relevant training and or licensure, judgement, individual charter, and demonstrated current competence, physical and mental capabilities and health status, adherence to the ethics of their profession, and ability to work with others with sufficient adequacy to ensure the Medical Staff and the Board of Trustees that any patient treated by them in Hospital will be given a high degree of patient care, shall be considered for appointment to the Medical Staff."

On 7/11/2024, eight (8) Provider ("PV") credentialing files were reviewed with Administrator (ADM) #1. This review revealed the following:

- PV #2, PV #3, PV #5, PV #7, and PV #8 credentialing file fail to include a signed Requested Privileges form by Department Chief, Bylaws & Credentials Committee, Medical Executive Committee or Board of Trustees.

- PV #4 and PV #6 credentialing files did not have evidence of a National Provider Bank verification form.

- PV #3 credentialing failed to contain an Advanced Practice Registered Nurse independent practice license.

The above findings were confirmed with ADM #1 at the time of review.

On 7/11/2024 at 1:25 PM, PV #3 confirmed during a telephone interview that she failed to petition the Maine State Board of Nursing for independent practice. She also confirmed that she did not currently have a supervising physician.

Based on document reviews and interviews, the hospital failed to ensure that Providers accurately completed the history and physical documentation for six (6) of ten (10) patients reviewed (Patient #6, #10, #11, #12, #14 and #15).

Findings:

The "York Hospital Medical Staff Bylaws, Rules & Regulations", last reviewed on 05/2019 states, in part, following ...:

"History and Physical (H&P) requirements for admissions:
a. A complete H&P must be done within 30 days of admission
b. A new H&P is required for any H&P older than 30 days
c. It must be placed on the medical record and updated within 24 hours of admission. The history and physical may be hand-written in the progress note but must be labeled as such. If dictated, it must be completed within 16 hours of admission to allow for transcription of the dictated report.
d. A complete history and physical contains documentation of:
-Chief complaint
-Present illness
-Family history
-Psychological status/social history
-Past medical history, allergies and medications
-Review of systems"

And ... "Brief History and Physical for uncomplicated ambulatory outpatients:
a. A short form may be used for uncomplicated ambulatory patients.
b. It must be completed no more than 30 days prior to outpatient surgery and updated withing 24 hours, but prior to surgery
c. The H&P must be on the medical records prior to an invasive procedure.
d. A brief history contains documentation of :
-Chief complaint
-Present illness
-Family history
-Psychological status/social history
-Past medical history
e. A brief physical exam contains documentation of findings regarding a focused physical exam.
f. In addition, a history and physical contains documentation of conclusions/impressions and plan of care ... ."

On 7/09/2024 at 3:00 PM, ten (10) patient medical records were reviewed with Administrator ("ADM") #2 and revealed the following:

-Patient #6's history and physical failed to document a review of systems;
-Patient #10's history and physical failed to document conclusions/impressions and plan of care;
-Patient #11's history and physical failed to document a chief complaint;
-Patient #12's history and physical failed to document a family history;
-Patient #14's history and physical failed to document a family history and current medications; and
-Patient #15's history and physical failed to document a chief complaint.

The above findings were confirmed with ADM #2 at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure that Emergency Department policies were reviewed and updated for seventeen (17) of twenty-one (21) policies reviewed.

Findings:

On 07/09/2024 at 4:10 PM, a request was made for the policy regarding the frequency and management of hospital policies. The Director of Quality and Director of Corporate Compliance and Privacy stated they use a software that prompts the facility to review policies and procedures.

On 7/09/2024 and 7/10/2024, Emergency Department ("ED") policies were reviewed with the Director of Quality and Director of Corporate Compliance and Privacy.

The following policies have not met the hospital expectation for policy review:
- Safe Haven for Abandoned Infants Dropped Off at Hospital, last approved on 02/2012, next to be reviewed by 01/2015;
- Violence: Physical Assault, last approved on 09/2018, next to be reviewed by 08/2021;
- Restrictions of Procedures Performed, last approved on 10/2019, next to be reviewed by 10/2022;
- Management of Critically Ill Children, last approved on 11/2011, next to be reviewed by 10/2014;
- Triage Guidelines, last approved on 11/2018, next to be reviewed by 10/2021;
- Suture Removal, last approved on 12/2019, next to be reviewed by 10/2022;
- Review of Lab/Radiology Reports last approved on 01/2020, next to be reviewed by 01/2023;
- Legal Claim of Evidence, last approved on 01/2020, next to be reviewed by 01/2023;
- Guidelines for Transfer from Wells Emergency or Walk-In Care, last approved on 12/2018, next to be reviewed by 11/2021;
- Procedural & Deep Sedation, last approved on 12/2019, next to be reviewed by 12/2022;
- Emergency Patients in Radiology, last approved on 10/2019, next to be reviewed by 10/2022;
- Care of the Patient with Suicidal/Homicidal Ideation, last approved on 05/2018, next to be reviewed by 04/2021;
- Domestic Violence, last approved on 12/2019, next to be reviewed by 12/2022;
- Controlled Medications and Pyxis Access, last approved on 10/2018, next to be reviewed by 09/2021;
- Blood Alcohol Samples : Consent and Drawing, last approved on 07/2019, next to be reviewed by 06/2022;
- Helicopter Transfer, last approved on 01/2020, next to be reviewed by 01/2023; and
- Capacity Management Plan Code Purple (Surge Capacity), last approved on 06/2011, next to be reviewed by 05/2014.

The above findings were confirmed at the time of the review with the Director of Quality and Director of Corporate Compliance and Privacy. The Director of Quality and Director of Corporate Compliance and Privacy stated that they are "Not organizationally ready. We have a program/software for policies. Our committee will be resurrected when culturally appropriate."