HospitalInspections.org

NOT CORRECTED FROM THE SURVEY DATED 5/12/11

Based on review of credential files, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure that all documents required in the Administration policy and procedure for verification of credentials in accordance with the Medical Staff Bylaws were included in the credential file for 1 of 7 physician credential files reviewed (Physician P). The Facility Provider Listing provided by the facility listed 17 physicians, osteopathic physicians and/or podiatrists. Census was 1 swing bed patient and 2 respite patients. Findings are:

A. Review of the Administration Policy and Procedure with the objective of "To establish guidelines for the collection and verification of credentials in accordance with the Medical Staff Bylaws" with a reviewed /revised date of 6/21/11 revealed the following:
"Upon receipt of an application, all information will be reviewed by the Administrator....The following items shall be verified as outlined:
1) Professional/Medical License - Current copy of license shall be kept in the applicant's file. Internet verification to the State of Nebraska Bureau of Examining Boards and documented.
2) State and Federal DEA (Drug Enforcement Administration) - Current copies of State and Federal DEA certificates shall be maintained in the applicant's file.
3) Professional Liability Insurance - Current copy of applicant's Certificate of Insurance and documentation of participation in the Nebraska Excess Liability Fund (if applicable) will be kept in the applicant's file.
4) Continuing Medical Education - Documentation of a minimum of 10 (ten) CME [continuing medical education] hours in the past 12 (twelve) months will be kept in the applicant's file.
5) National Practitioner Data Bank - Queries shall be performed and kept on file.
6) Medicare Sanction Activity - Medicare Sanctions Report shall be reviewed and any sanctions documented.
7) References - Three written professional peer evaluations will be kept in the file."

B. Review of the credential file for Physician P revealed the following required documents were missing:
1) Internet verification of the physician's license,
2) Current copy of the Federal DEA license,
3) Query of the National Practitioner Data Bank,
4) No documentation of review of the Medicare Sanctions Report, and
5) No references.
This Credential File was cited for missing some of these same items during the survey dated 5/12/11.

C. Interview with the Administrator on 10/24/11 from 3:35 PM to 3:45 PM revealed that the only thing that had been done with the credential file for Physician P since the survey dated 5/12/11 was to update the privilege form. After looking at the credential file the Administrator confirmed that the above information was missing.

NOT CORRECTED FROM THE SURVEY DATED 5/12/11

Based on staff interview and lack of requested documents, the CAH (Critical Access Hospital) failed to have 1 of 3 required professional personnel (a person not on staff at the CAH) involved in the annual review of policies and procedures. Census was 1 swing bed patient and 2 respite patients. Findings are:

During the entrance conference with the Administrator on 10/24/11 from 1:15 PM to 1:30 PM, the surveyor provided a document titled Items Needed to Complete the Revisit. The eighth item on this list requested "Documentation that show the involvement of the nurse practitioner and a person not on staff at the hospital in policy and procedure review." The Administrator failed to provide the surveyor with documentation showing a person not on staff was involved in the annual review of policies and procedures. During interview on 10/24/11 from 3:35 PM to 3:45 PM the Administrator confirmed the lack of having a person not on staff at the hospital involved with the annual review of policies and procedures.