HospitalInspections.org

15990


Based on a revisit to the Critical Access Hospital (CAH) on 4/24/12 at 10:30 AM revealed the CAH failed to ensure a Plan of Correction (POC) was met in a timely manner as identified on the POC for the deficiency cited at C241. Findings include:

A. A recertification survey was conducted on 2/14-23/12 and at that time a deficiency was cited at C-241 identifying issues pertaining to the CAH's By-Laws in the reappointment process of the medical staff and failed to assure that the clinical privileges reflected the actual medical practices in the CAH.

B. The faciliy submitted a POC which reads on page 5 of 5 #2: Delineation of physician privileges is currently under review and will under go final review and approval on April 11, 2012 at the medical staff meeting.

C. Telephone interviews with the Administrator and Director of Nurses (DON) on 4/24/12 revealed the medical staff meeting was held on 4/11/12, but there were disagreements with the physicians as to what privileges the physicians would change or if any changes would be made, and the revised list of the physicians' privileges that was initially submitted for review is now in a state of revision as of 4/24/12. Review of the Medical Staff Subcommittee meeting minutes dated 4/9/12 revealed the next scheduled Medical Staff Subcommittee meeting is 5/7/12. The CAH was not in compliance on 4/11/12 as identified on the POC and did not notify of change to POC date.