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Based on record review and staff interview, the facility failed to develop a process to verify that the Credentialing Company maintained the current requirements for Personnel in accordance with the Vendor's Contract. This resulted in the facility's failure to be able to ensure proper training of the various Vendor Personnel. This was evident in one (1) of one (1) Vendor Personnel File reviewed.

Findings:

The facility's Contract with Intraoperative Neurophysiologic Monitoring Services, dated September 1, 2014, revealed that the Neurophysiologic Monitoring Technologist had, as a minimum qualification, a current Certification in Neurophysiologic Intraoperative Monitoring by the American Board of Registration of EEG (Electroencephalogram) and EP (Electrophysiology) Technologists.

Review of the Neurophysiologic Monitoring Technologist Personnel Profile (Dashboard) obtained from the Credentialing Company's onsite Kiosk, did not contain the current registration described above.

An interview with the Director of Materials Management at 12:30PM on 05/21/15 found that the third party Credentialing Company validates each Vendor's required documentation for the different categories of Personnel. The Health Care System does not request that the Personnel information, such as the current registration, be available in the Kiosk for review. The system is not set up to show that information, and the Health Care System does not have a process to verify that the information held by the Credentialing Company meets the Contracted Vendor's requirements.
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