HospitalInspections.org

Based on facility records and staff interviews the Department determined that an Administrator failed to ensure that 4 out of 7 medical providers were credentialed and granted facility privileges according to the requirements in the facility's Medical Bylaws, Rules, and Regulations. This deficient practice poses a health and safety risk to the patient if the medical provider is treating patients without being appointed to the facility staff.

Hospital document titled "Medical Staff Bylaws, Rules and Regulations" revealed: "...Article III Membership ...3.1 Nature of Appointment. Staff appointment is a privilege extended by the institution, not a right of any practitioner. Appointment to the staff or exercise of temporary privileges shall be extended to professionally competent practitioners who continually meet the qualifications, standards, and requirements set forth in these Bylaws ...3.5 Terms of Appointment. Appointments shall be made by the Board of Directors, as set forth in Article V Section 5.1 of these bylaws, after the recommendation of the Medical Staff and shall be for a period of up to two (2) years ...3.6 Procedure for appointment. 3.6.1. Appointment and reappointment to the Medical Staff begins with completion of the application form. Each applicant is appraised by the Medical Executive Committee. Applicants approved by the Medical Executive Committee are considered by the Board of Directors at their next regular meeting. Additionally, the applicant shall be responsible for the submission of ...B. Peer references familiar with the applicant's professional competence and ethical character ...3.7 Reappointment 3.7.1 Recommendations for reappointment shall be considered at a Medical Executive Committee meeting preceding expiration of an appointment so that timely action may be taken by the Board of Directors ...Procedure for Reappointment. 3.8.1 ...Only after all information required as set forth in these Bylaws, Rules, and Regulations has been received will an application be considered complete. The Medical Executive Committee shall review information and, obtain additional information it deems needed, and make a recommendation to the Board of Directors ... 3.10 Extension of Appointment. If an application for reappointment has not been fully processed by the expiration date of a member's appointment, the staff member shall maintain membership status and clinical privileges for up to four (4) months until the processing is completed, unless the delay is due to the member's failure to provide timely documentation or cooperation, in which case the appointment may lapse. At that point, the reappointment application may be closed and the applicant may be required to submit a new initial application in order to rejoin the Medical Staff ...3.11 Failure to file reappointment application. Failure to file a timely completed application for reappointment may result in suspension of the member's privileges ...."

Document titled "Facility Plan of Correction" submitted to Arizona Department of Health Services, 1/02/2024, revealed the process that the facility will take to ensure how the deficiency that was cited the previous year 12/14/2023, is to be corrected on both a temporary and permanent basis. The facility failed to follow through with the process. " ...d. Any provider that has not completed process within 120 days of the due date will be reported to the CEO and Medical Staff President for further action, including voluntary relinquishment of privileges until the application is complete. 2. Anticipated date the correction will be completed. 2/8/2024.

A review of Medical Provider Credentialing Files revealed that 4 out of 7 providers have not been re-credentialed within the required time.

Employee # 35 confirmed during an interview conducted on 12/04/2024, that the providers fail to submit the required peer review letters in a timely fashion, which holds up the credentialing process.

Employee # 35 confirmed during an interview conducted on 12/04/2024, that 4 out of 7 physician files revealed that the physician privileges are out of date. In January 2024, the Governing Body decided to extend temporary privileges to the physicians who were not fully credentialed. The temporary privileges would be extended to April 2024.

Employee # 35 confirmed during an interview conducted on 12/04/2024, after a review of the Medical Executive Committee Meeting Minutes dated 01/09/2024, 02/13/2024, 03/12/2024 for 2024, 05/14/2024, 06/11/2024, 08/13/2024, 09/10/2024 and the Governing Body Meeting Minutes dated 02/28/2024, 04/24/2024, 06/26/2024, 08/28/2024, and 10/25/2024, there was no further mention of the providers whose privileges have lapsed or what the plan will be going forward.

Employee # 4 and Employee # 35 both confirm that providers # 1, # 2, # 5, and # 6 have been practicing at the facility without privileges since April 2024.