HospitalInspections.org

APPOINTMENT OF TELEMEDICINE PROVIDERS

1. Based on bylaws review, agreement review, and staff interview, the Critical Access Hospital (CAH) failed to ensure credentialing occurred for practitioners providing services for 1 of 3 current telemedicine/contracted entities (Entity #1). Failure to appoint/credential the practitioners providing telemedicine services and/or develop an agreement for appointment/credentialing practitioners providing telemedicine services placed the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "MEDICAL STAFF BY-LAWS" occurred on 06/19/17. These bylaws, adopted 09/15, identified, "Medical Staff Categories" as "The Medical Staff shall be divided into Honorary, Active, and Courtesy categories. . . .
SECTION 5. The Courtesy Staff . . . shall consist of those members of the medical . . . profession, eligible as herein provided for staff membership . . . Their privileges shall be determined by the Medical Staff and shall be restricted to those they are professionally qualified to exercise. . . .
SECTION 6. The Telemedicine Consulting Medical Staff. The telemedicine consulting medical staff shall consist of practitioners who are recognized clinical specialists in the area for which the practitioner respectively proposes to be a consultant, and who has signified the practitioner's willingness to accept such appointments and act as consultants to the medical staff. . . . In order to be a member of the telemedicine consulting medical staff, a practitioner must be on the medical staff of another hospital. . . . Telemedicine is the practice of medicine through the use of electronic communication or other communication technologies to provide or support clinical care at a distance, for example, eEmergency services and teleradiology services."

Review of the CAH's agreement with a sleep laboratory services contractor occurred on 06/21/17. The agreement, dated 03/07, stated,
". . . STATEMENT OF BACKGROUND INFORMATION . . . B. Hospital desires that [Entity #1], as an independent contractor, provide certain sleep testing services to address the Hospital's needs with respect to sleep study services. . . . represents that it is qualified to provide the services . . . ARTICLE 3 . . . Hospital shall be responsible for monitoring the credentialing and licensing . . ."

On the morning of 06/21/17, a staff member (#4) stated she did not know the names of the physicians who interpreted the sleep studies.

On 06/21/17 at 10:15 a.m., a staff member (#1) stated the CAH had not appointed the physicians providing services through the agreement/contract with [Entity #1], and did not know the name of the physicians who interpreted the sleep studies.

LOCATION OF SLEEP STUDIES

2. Based on agreement review and staff interview, the governing body failed to ensure the Critical Access Hospital (CAH) kept the area used to provide CAH services separate from space leased for 1 of 1 sleep laboratory service [Entity #1], a contracted service. Failure to keep CAH space separate from leased space limited the CAH's ability to provide services to the CAH's patients.

Findings include:

Review of the CAH's agreement with a sleep laboratory services contractor occurred on 06/21/17. The agreement, dated 03/07, stated: ". . . Hospital desires that [Entity #1], as an independent contractor, provide certain sleep testing services to address the Hospital's needs with respect to sleep laboratory services. . . . all sleep studies scheduled during the Sleep Lab's normal operating hours of 7:30 P.M. to 7:30 A.M. Monday through Friday. . . . Facilities. Hospital shall provide [Entity #1] with adequate physical space for use in performing the Services. The size and location of such space shall be determined by Hospital in consultation with [Entity #1]. At a minimum the space shall contain a private room with a bed and a bathroom and an administrative area for technicians to monitor the sleep testing. Hospital facilities shall be used only in connection with performance of the duties hereunder involving Hospital operations and Hospital patients."

On the morning of 06/21/17, a staff member (#4) stated the CAH utilized licensed and certified inpatient rooms/beds to provide the sleep study services.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to obtain a contract for 2 of 2 services (dietary and laundry) not identified by the CAH as direct services, but rather as services obtained from an outside entity. Failure to contract services obtained indirectly by the CAH limited the CAH's ability to ensure compliance with the conditions of participation and standards for contracted services.

Findings include:

On the morning of 06/19/17, a support staff member (#5) identified the CAH obtained housekeeping and dietary meal service from the Skilled Nursing Facility located adjacent to the CAH.

Review of the current "Southwest Healthcare Services Contracts" occurred on 06/20/17. The list did not include dietary meal service and laundry services.

During an interview on 06/21/17 at 9:30 a.m., a staff member (#5) confirmed the CAH lacked a contract for dietary and laundry services.

Based on policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Improvement (QI) program evaluated all patient care services and other services affecting patient health and safety for 3 of 3 quarters reviewed (August 2016, November 2016, and March 2017). Failure to ensure departments perform QI monitoring limited the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the policy titled "Quality/Performance Improvement Plan" occurred on 06/20/17. This policy, revised 04/16, stated,
". . . Scope
The Quality Improvement/Risk Management program shall apply to all departments, services, and practitioners whose activities within the institution have a direct or indirect influence on the quality of patient care/resident care. . . . B. The following services will participate in performance improvement activities: . . . Purchasing/Central Supply . . . Respiratory Care . . ."

Reviewed on 06/21/17, the CAH's 2016 and 2017 quarterly QI reporting schedule and QI monitors failed to include the Central Supply Reprocessing (CSR) department.

Reviewed on 06/21/17, the August 2016-March 2017 QI Committee's quarterly meeting minutes lacked evidence CSR submitted reports, and identified the monitoring submitted by the respiratory therapy (RT) department failed to include the quality of patient care.

During interview on the morning of 06/21/17, a quality improvement staff member (#2) confirmed RT failed to submit QI monitoring reports regarding patient care to the QI committee, and stated the monitoring for infection control may include the CSR department.

On this morning of 06/21/17, the information submitted by a CSR staff member (#3) lacked evidence of QI monitoring and subsequent reporting to the QI committee.