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Based on medical staff and governing bylaws review, medical staff meeting minutes, credentialing document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend the appointment /reappointment/privileges for 1 of 1 hospital's (Hospital #1) physicians reviewed who provided services to the CAH through telemedicine. Failure of the medical staff to recommend appointment/reappointment/privileges of telemedicine medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Medical Staff Bylaws of the Nelson County Health System" occurred on 01/22/25. These bylaws, effective 10/25/22, stated,
". . . Article IV
Procedures for Appointment and Reappointment . . .
Section 2 Appointment Process
Subsection 1 . . . the Medical Staff shall review the competed [sic] application and make a recommendation to the governing body that the applicant be either appointed to the Medical Staff or rejected.
Section 3 Reappointment Process
Subsection 4 . . . the Medical Staff shall review the information for reappointment and make written recommendations to the governing body through the administrator, concerning the reappointment, non-reappointment and/or clinical privileges of each practitioner . . .
Article IX
Officers and Committees
Section 2 Duties of Officers
Subsections 1 . . . The Chief-of-Staff: Call and preside at all meetings of the Medical Staff and shall be a member exofficio, of all NCHS [Nelson County Health System] committees. . .
Addendum H
Article VIII Medical Staff Categories
Section 6 Telemedicine Staff . . . Individuals providing telemedicine services from a 'distance site' must be appointed to the Telemedicine Staff . . ."

Review of the governing body's "Corporate Bylaws of the Nelson County Health System" occurred on 01/22/25. These bylaws, effective 05/06/03, stated,
". . . Article 6. . . .
Section 9(a). Medical Staff. Appointments to the medical staff shall be made by the Board of Directors of the Corporation. . . . The board delegates to the medical staff the authority to recommend and evaluate regarding professional competence, appointments, re-appointments and staff privileges generally. . . ."

Review of providers' 2023-2024 credentialing files occurred on 01/22/25 and indicated the following:
- Physician #1 lacked evidence of reappointment by the Chief -of-Staff for August 2024
- Physician # 2 lacked evidence of reappointment by the Chief-of-Staff for initial appointment November 2024.

Review of the Medical Staff meeting minutes failed to provide evidence the chief of staff was present at the medical staff meeting on 08/19/24 when Telemedicine Physician #1 was recommended for reappointment/privileges and on 11/18/24 when Telemedicine Physician #2 was recommended for initial appointment.

Upon request on 01/22/25 and 01/23/25, the CAH failed to provide evidence of written recommendation from the Chief of Staff for Telemedicine Physician #1's reappointment and Telemedicine Physician #2's Initial Appointment.

During an interview on 01/23/25 at 11:30 a.m., two administrative staff members (#7 and #8) confirmed the CAH did not have evidence the Chief of Staff of the Medical Staff completed written recommendation to the governing body for approval of reappointment and initial appointment/privileges for Telemedicine Physicians #1 and #2.

Based on medical staff and governing bylaws review, medical staff meeting minutes review, credentialing document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend the reappointment/privileges for 1 of 1 distant-site entity's (Telemedicne Entity #3) physicians reviewed who provided emergency care services to the CAH patients through telemedicine. Failure of the medical staff to recommend reappointment/privileges of a telemedicine medical staff member placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Medical Staff Bylaws of the Nelson County Health System" occurred on 01/22/25. These bylaws, effective 10/25/22, stated,
". . . Article IV
Procedures for Appointment and Reappointment . . .
Section 2 Appointment Process
Subsection 1 . . . the Medical Staff shall review the competed [sic] application and make a recommendation to the governing body that the applicant be either appointed to the Medical Staff or rejected.
Section 3 Reappointment Process
Subsection 4 . . . the Medical Staff shall review the information for reappointment and make written recommendations to the governing body through the administrator, concerning the reappointment, non-reappointment and/or clinical privileges of each practitioner . . .
Article IX
Officers and Committees
Section 2 Duties of Officers
Subsections 1 . . . The Chief-of-Staff: Call and preside at all meetings of the Medical Staff and shall be a member exofficio, of all NCHS [Nelson County Health System] committees. . .
Addendum H
Article VIII Medical Staff Categories
Section 6 Telemedicine Staff . . . Individuals providing telemedicine services from a 'distance site' must be appointed to the Telemedicine Staff . . ."

Review of the governing body's "Corporate Bylaws of the Nelson County Health System" occurred on 01/22/25. These bylaws, effective 05/06/03, stated,
". . . Article 6. . . .
Section 9(a). Medical Staff. Appointments to the medical staff shall be made by the Board of Directors of the Corporation. . . . The board delegates to the medical staff the authority to recommend and evaluate regarding professional competence, appointments, re-appointments and staff privileges generally. . . ."

Review of providers' 2022-2024 credentialing files occurred on 01/22/25 and indicated the following:
- Physician #3: lacked evidence of reappointment by the Chief-of-Staff for March 2024.

Review of the medical staff meeting minutes failed to provide evidence the chief of staff was present at the medical staff meeting on 03/18/24 when Telemedicine Physician #3 was recommended for reappointment/privileges.

Upon request on 01/22/25 and 01/23/25, the CAH failed to provide evidence of a written recommendation from the Chief of Staff for Telemedicine Physician #3's reappointment.

During an interview on 01/23/25 at 11:30 a.m., two staff members (#7 and #8) confirmed the CAH did not have evidence the Chief of Staff of the Medical Staff completed a written recommendation to the governing body for approval of reappointment for Telemedicine Physician #3.

Based on medical staff and governing bylaws review, credentialing record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure granting of reappointment followed the bylaws for 2 of 4 providers' (#4 and #5) files reviewed. Failure to follow the bylaws for reappointment placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the governing board's "Corporate Bylaws of the Nelson County Health System" occurred on 01/22/25. These bylaws, dated 05/06/03, stated,
". . . Article 5. Board of Directors . . .
Section 9. Medical Staff. Appointment to the medical staff shall be made by the Board of Directors of the Corporation. . . . The board may re-appoint by written notification all members of the medical staff for a further period of two (2) years provided that such renewal is without written objection by a majority of other members of the medical staff. . . ."

Review of the "Medical Staff Bylaws of the Nelson County Health System" occurred on 01/22/25. These bylaws, effective 10/25/22, stated,
". . . Article IV Procedures for Appointment and Reappointment . . .
Section 3. Reappointment Process . . .
Subsection 4. At least 30 days prior to the final scheduled governing body meeting in the medical staff year, the Medical Staff shall review the information for reappointment and make written recommendations to the governing body through the administrator, concerning the reappointment, non-reappointment and/or clinical privileges of each practitioner . . . Reappointment shall be for two (2) years. . . ."

Review of providers' 2023-2024 credentialing files occurred on 01/22/25 and indicated the following:
- Provider #4: the governing body approved reappointment on 08/28/24. Previous appointment was dated 07/21/22 (over 2 years).
- Provider #5: the governing body approved reappointment on 08/28/24. Previous appointment was dated 06/04/22 (over 2 years).

During an interview on 01/23/24 at 11:45 a.m., two staff members (#7 and #8) confirmed the CAH failed to complete Provider #4 and #5's reappointments as per medical staff and governing bylaws and confirmed Provider #4 treated patients between 07/21/24 and 08/28/24 and Provider #5 treated patients between 06/04/24 and 08/28/24.

Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel review the CAH's health care policies for 1 of 1 year (2023) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH's ability to ensure the policies were current and followed regulations and standards of practice.

Findings include:

Review of the policy "Nelson County Health System Policy/Procedure Review" occurred on 01/22/25. This undated policy, stated, ". . . Policy: All department policy and procedure manuals will be completely reviewed on an annual basis and reported to the NCHS [Nelson County Health System] QA [Quality Assurance] committee indicating completion. . . 3. All departments should include departmental staff in the policy/procedure review along with a medical provider (MD) and a [sic] Allied Health Professional (AHP). Signatures are required as noted. . . ."

Review of the CAH's policies occurred on all days of the survey. The policies lacked evidence of review in 2023 by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel).

Upon request on 01/22/25, the CAH failed to provide evidence a physician assistant/nurse practitioner/clinical nurse specialist reviewed the CAH's policies.

During interview on 01/23/25, at 3:12 p.m., an administrative staff member (#1) confirmed the CAH failed to have a physician assistant/nurse practitioner/clinical nurse specialist review the CAH's policies.


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Based on review of a facility policy and staff interview, the Critical Access Hospital (CAH) failed to assess it's discharge planning process on a regular basis for 19 of 22 closed records (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) reviewed. Failure to perform an ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, may result in the development of discharge plans that fail to respond to the patients' post-discharge needs.

Findings include:

Review of the policy "Discharge Planning Process" occurred on 01/23/25. This undated policy, stated, ". . . It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the patient's discharge goals, the preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. . . ."

During an interview on 01/24/25 at 9:13 a.m., when asked if the CAH assessed it's discharge planning process, including for patients readmitted to the facility, to ensure the patients' post-discharge needs were met, an administrative nurse (#1) stated, "No, [we] don't reassess the discharge planning process or patients who were readmitted" and added, "We have had a few."

Based on staff interview, the Critical Access Hospital (CAH) failed to develop an organ procurement training program in cooperation with their designated tissue and eye bank.
Failure to work in conjunction with the tissue and eye bank limited the facility's ability to ensure staff members were knowledgeable about donation issues, including how to work with the tissue and eye bank and their duties/roles.

Findings include:

Upon request on 01/22/25, the facility failed to provide a policy on organ procurement that addressed the training program they developed in cooperation with their designated tissue and eye bank.

During an interview on 01/24/25 at 11:50 a.m., an administrative nurse (#1) indicated each staff nurse received training on organ procurement "during orientation and with each death," but failed to provide documentation of the training provided.

During an interview on the morning of 01/24/25, a human resource staff member (#9) also indicated she was unable to locate any documentation of the training provided during orientation.