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Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure that catheterization laboratory personnel maintained current credentials as required by the Cardiac Catheterization Technologist job description in one of two personnel files reviewed. (PF1, PF2)

Findings include:

Review of the "Job Description/Review Form" for the position of "Cardiac Catheterization Technologist" dated January 2007, stated "Minimum Requirement: ... if not registered at the time of transfer/hire, must obtain RCIS Registry within two years of hire/transfer."

Review of the "Scope of Practice for the Invasive Cardiovascular Professional" dated October 2002, stated "The Society of Invasive Cardiovascular Professionals (SICP) maintains that all invasive cardiovascular professionals, with or without formal cardiovascular training should demonstrate knowledge and competence through education and certification in advanced cardiac life support (ACLS/ECC) and the achievement of invasive cardiovascular credentials RCIS (Registered Cardiovascular Invasive Specialist). The credential RCIS offered by Cardiovascular Credentialing International (CCI), has been recognized as the cardiac cath lab credential of choice by the American College of Cardiology (ACC) and by the Society of Cardiac Angiographers and Interventionalists (SCA & I), an organization founded by the pioneers of cardiac catheterization, Mason Sones and Melvin Judkins to ensure proper training an the maintenance of high standards in invasive cardiac laboratories."

1) Review of PF1 on July 13, 2010, revealed a letter from the "Cardiovascular Credentialing International" dated May 21, 2001, stated "you passed the Invasive Registry" valid January 1, 2002 through December 31, 2004.

During an interview July 21, 2010, with EMP1 revealed another letter from CCI dated July 13, 2010, that stated "The credential(s) held by ... [PF1] is/are currently active and in good standing with CCI. Their credential(s) is /are valid until 03/31/2011. EMP1 confirmed that the employee's (PF1) CCI certification was not valid from December 31, 2004, to receipt of the CCI credential confirmation notice (mentioned previously).