HospitalInspections.org

Based on interview and record review, the facility failed to provide complete credentialing information for all medical provider personnel employed by the facility. Specifically, this was evidenced by no governing board approval signatures or medical staff meeting minutes acknowledgements for 3 of 12 primary medical staff members. Findings include:

During an interview on 09/16/15 at 4:20 p.m., staff member E, risk manager/credentialing coordinator, stated she was unable to locate the governing board approval of medical staff. Staff member E, stated the governing board's approvals were in the governing board meeting notes and she would fax the information to the state agency by 09/18/15 at 12:00 p.m.

A review of the facility's supplemental information on governing board approval for medical providers was received by the state agency via fax on 9/17/15. Governing board approval on medical staff was not completed for three staff members. Staff member M, PA, was approved in the hospital medical staff meeting minutes for the Tuesday, January 8, 2013 meeting; however there was no evidence of the governing board's signatures through the credentialing process forms. Staff member N, PA, and staff member O, PA, had no evidence of the governing board approval with signatures.

A review of the facility's medical staff bylaws section 6.4-4 reflected, "effect of medical staff or medical executive committee action (b) favorable recommendation, showed when the recommendation of the medical staff or medical executive committee is favorable to the applicant, the administrator shall promptly forward it, together with all supporting documentation, to the board. All supporting documentation includes the application form and its accompanying information and the reports and recommendations of the medical staff or medical executive committee and minority views."

A review of the facility's medical staff bylaws section 6.4-5 reflected, "board action (a) on favorable medical staff or medical executive committee recommendation, showed the board shall, in whole or in part, adopt or reject favorable recommendation of the medical staff or medical executive committee."

Based on record review and interview, the facility failed to ensure an annual review/revision was completed for their clinic service areas policies and procedures. Findings include:

Review of the Hospital By-Laws reflected the, "board of director conduct, manage and control the affairs and business of said corporation and to make rules and regulations not inconsistent with the by-laws of this Association and the State of Montana, for the guidance of the officers and employees and of the management of the affairs of the Association."

The board of directors will select and appoint a competent chief executive officer who will, "act as the duly authorized representative of the board of directors in all matters in which the board of directors has not formally designated to some other person."

During an interview on 9/15/15 at 3:00 p.m., staff member C, DON, stated the procedure for a policy review/revision included the policy committee membership involvement. The reviewed/revised policy needed to be accepted and signed by the medical director, FNP, CEO, and the department manager. Last, the board of directors would approve the policies. The approvals from the board of directors would be reflected in the Board of Director's Regular Meeting minutes.

Review of the Board of Directors Regular Meeting from July 2014 - August 2015 reflected five policy review/revisions:
-7/28/14, the complaint policy was accepted;
-8/27/15, the durable medical equipment was accepted;
-11/24/14, the occurrence reporting, credentialing and peer review was accepted;
-1/28/15, the DON reported the policy manual needed updating and the leadership team will begin work on this with assistance from the Billings Clinic.

During an interview on 9/15/15 at 4:10 p.m., staff member D, CEO, stated the annual review of the care policies was the responsibility of the DON. The CEO was the supervisor of the DON, so ultimately the CEO needed to ensure the annual review of the care policies were completed. The board of directors have the full responsibility in governing the CAH, but would not know all of the CMS Conditions of Participation. The board of directors would delegate the responsibility of ensuring the Conditions of Participation were followed, to the CEO.

Staff member D stated he had been employed as the CEO for the facility for six months, and did not know why the review of the care policies had not been completed annually.

Based on record review and interview, the facility failed to evaluate, review and/or revise the health care policies for radiology department, emergency department, surgery department, dietary department, rehabilitation department, and central supply department as part of the annual hospital-wide program evaluation. Findings include:

1. Review of the Radiology Policy and Procedure Manual reflected the policies and procedures of the most recent review was approved in 2010.

In an interview on 9/15/15 at 2:15 p.m., staff member A, radiology manager, stated the policies had not been updated since 2010.

2. Review of the Surgery Policy and Procedure Manual reflected the policies and procedures of the most recent review was approved in 2009.

In an interview on 9/16/15 at 9:30 a.m., staff member B, RN, stated she was not sure who was responsible to complete the reviews and she would discuss this with the DON. Staff member B stated she believed the reviews probably had not been done since 2009 as reflected in the manual.

3. Review of the Emergency Policy and Procedure Manual reflected the policies and procedures of the most recent review was approved in 2009.

In an interview on 9/16/15 at 10:15 a.m., staff member C, DON, stated the facility was in the process of reviewing and revising all policies and procedures facility-wide. Staff member C stated the emergency department policy and procedures had not been reviewed since 2009.



33810

4. Review of the Organ Donation policy and procedures reflected 7/15/00 as the last revision date, and had three signatures dated 4/20/02, 6/25/03, and 5/13/13.

During an interview on 9/10/15 at 10:20 a.m., staff member C, stated the Organ Donation policy and procedures were "outdated."

5. Review of the Pharmacy Policy and Procedure Manual reflected 12 individual policies and procedures. Six of the 12 policies and procedures reflected approval dates of 2011. Two of the 12 policies and procedures reflected approval dates of 2013.

During an interview on 9/16/15 at 10:05 a.m., staff member C stated the current Pharmacy Policy and Procedure Manual did not have dates or signatures for policy reviews.

6. Review of the Management Guideline for Consultation and Referral policy reflected an approval date of 2002.

7. The two Quality Improvement policies reflected approval dates of 2002.

8. The Nurse Practitioner/Physician Assist [sic] Peer Review policy reflected an approval date of 2013.

9. The Care Plan policy reflected an approval date of 2005.

During an interview on 9/15/15 at 3:00 p.m., staff member C stated the policies and procedures for the clinical areas had been reviewed and revised at different dates.

Staff member C stated initially, as a new director of nursing, she did not fully understand all of the conditions of participation, but the facility had started a serious revision of the policies and procedures six months ago. Staff member C stated the total program review needed to be "worked on."

Staff member C stated the procedure for a policy review or revision included the departmental committee members' involvement. The reviewed or revised policy needed to be accepted and signed by the medical director, FNP, CEO, and the department manager. Last, the board of directors would approve the policies. The approvals from the board of directors would be reflected in the Board of Director's Regular Meeting minutes.

Review of the facility's current plan to revise the facility's policy reflected:
- Policy chart development plan;
- Calendar for department reviews;
-Template for written policies;
-Revised policies awaiting board approvals (Infection Control/8-27-15, Emergency Medical Services/8-27-15, Contact of Personnel/8-27-15, Dietary/8-27-15, and Pharmacy/8-27-15).


34675

10. Review of the dietary department policies and procedures manual reflected the policies and procedures of the most recent review was approved in 2015 for two policy subjects, however this did not cover all 38 policies and procedures in the dietary department.

During an interview on 9/15/15 at 11:35 a.m., staff member R, DM, stated she did not have a current facility approval of all policies and procedures for the dietary department. Staff member R, stated she did complete an audit tool in 2014 and 2015 for each policy in her department.

11. Review of the rehabilitation department policies and procedures manual reflected the policies and procedures of the most recent review were approved in 2011.

During an interview on 9/16/15 at 10:35 a.m., staff member S, PT, stated she did not know of a current facility approval of all policies and procedures for the rehabilitation department. Staff member R, stated her supervisor was out of town that morning, and policies and procedures were located in the blue binder and could be found on the facility computer.

12. Review of the central supply department policies and procedures manual reflected the policies and procedures of the most recent review were approved in 2009.

During an interview on 9/16/15 at 2:23 p.m., staff member B, RN, stated the OR procedure manual is viewed as old information and would need updating due to many surgical procedures in the facility not being performed anymore. The only surgeries that occurred in the facility at the time were occasional carpel tunnel surgeries and lipoma removals.