HospitalInspections.org

Based on a review of documentation and interview, the facility governing body failed to implement policies governing the CAH'S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment, as the facility failed to maintain current privileging delineation forms for medical staff members.

Findings included:

Facility bylaws stated in part,
"DEFINITIONS

The following definitions apply to the provisions of these Medical Staff Bylaws, the Medical Staff Rules and Regulations, and any related policies...

6. "Clinical Privileges" or "Privileges" means the permission granted by the Board of Directors to a Practitioner to provide those diagnostic, therapeutic, medical, or surgical services specifically delineated to the Practitioner.
7. "Complete Application" means an application that contains all necessary documentation to verify the applicant's qualifications for Medical Staff membership and/or clinical privileges. In general, this requires that (a) each question on the application has been answered; (b) all verifying information has been received; (c) the applicant has signed the forms; and (d) the applicant has provided all requested information regarding current valid license to practice in the State of Texas, DEA controlled substance registrations, and proof of liability insurance...

4.4 Reappointment Process...

4.4.2 Reappointment Application.
1. The Hospital shall send the Member an application for reappointment approximately six (6) months prior to the expiration of the term of appointment. The Member shall submit the signed reappointment application which shall include: (a) complete information and all documents necessary to provide current information listed in Medical Staff policies; (b) documentation of continuing education external to the Hospital since the last reappointment; ( c) new clinical privileges list; and ( d) any requests
for changes in Staff category...

ARTICLE VII
CLINICAL PRIVILEGES

7.1 Privileges...

7 .1.2 Every initial application and reapplication for staff appointment and reappointment contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the Applicant's education, training, experience, demonstrated competence, references, and other relevant information including an appraisal by the service in which such privileges are sought. The Applicant shall have the burden of establishing his/her qualifications and competency in the clinical privileges requested."

Review of the facility credentialing files, revealed 2 of 2 physicians (#16 and 17) did not have current delineation of privilege forms in their files:
* Physician #16 was re-appointed to the medical staff in February 2024. The last "Delineation of Medical Privileges Desired" form was completed on 01/27/07.
* Physician #17 was re-appointed to the medical staff in February 2024. The last "Delineation of Medical Privileges Desired" form was completed on 07/09/18.
* Neither physician had sedation approved on their "Delineation of Medical Privileges Desired".
* Both physicians had reappointment letters in their file stating, "Please accept this letter as my request for reappointment to Lillian M. Hudspeth Memorial Hospital and the Sutton County Hospital District. There have been no changes to my health status or my medical privileges. I am up to date on my CM E's and all other required certifications. I am requesting to maintain my privileges as originally requested."

Review of the facility credentialing files, revealed 2 of 2 Advanced Practitioners (staff member # 18 Physician Assistant and staff member # 19 Nurse Practitioner) had issues with delineation of privileges:
* Physician #18 was re-appointed to the medical staff in February 2024. The last "Delineation of Medical Privileges Desired" form was completed on 01/27/07. This Advanced Practitioner also did not have had sedation approved on their "Delineation of Medical Privileges Desired".
* Physician #19 (Nurse Practitioner) did not have any delineation of privileges in their credentialing file.
* Advanced Practitioner #18 had a reappointment letters in their file stating, "Please accept this letter as my request for reappointment to Lillian M. Hudspeth Memorial Hospital and the Sutton County Hospital District. There have been no changes to my health status or my medical privileges. I am up to date on my CM E's and all other required certifications. I am requesting to maintain my privileges as originally requested."

In interview on 07/22/25 with staff member #3 (who manages credentialing at the facility) was not aware of the privileging form required for reappointment or the lapse in obtaining an updated form with the reappointment of medical staff members.

The above findings were verified on 07/23/25, with staff members #1 and 2.