HospitalInspections.org

Based on policy review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure reappointment to medical staff followed their policy for 2 of 5 providers' (Providers #1 and #2) credentialing files reviewed. Failure to follow the policy for reappointing providers to the medical staff placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the policy "Northwood Deaconess Health Center Procedures of the Medical Staff Credentialing" occurred on 01/24/2023 at 4:00 p.m. This policy, dated May 2012, stated,
". . . Appointment to the Medical Staff . . .
Duration of Initial Appointment: All initial appointments to the Medical Staff shall be for a period not to exceed two years, regardless of the category of the staff to which appointment is made . . ."

Review of providers' 2018-2022 credentialing files occurred on January 24-25, 2023, and identified the following:
- Provider #1: Initial appointment approved on 08/28/18. The CAH failed to reappoint Provider #1 after initial appointment ended on 08/27/20.
- Provider #2: Initial appointment approved on 08/28/18. The CAH failed to reappoint Provider #2 after initial appointment ended on 08/27/20.

During interview on 01/24/23 at 09:15 a.m., a staff member (#2) responsible for coordinating surgical procedures stated Provider #1 performed colonoscopies and endoscopies on the second Wednesdays of the month and Provider #2 provided anesthesia services for those procedures.

During interview on 01/25/23 at 8:25 a.m., a staff member (#1) responsible for credentialing confirmed the CAH had not reappointed Providers #1 and #2 after their initial appointments ended in 2020.