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Based on review of External Peer Review documents, review of Services Meeting minutes, review of Credential Committee Meeting minutes, review of Credentialing files and interviews with key personnel, September 1-3 and 8-9, 2015, it was determined that the facility failed to ensure that the governing body and/or the individual who assumes legal responsibility was ensuring that policies were administered to assure quality health care as evidenced by:
Findings include:
1. The hospital utilizes a professional medical review company that is not part of the hospital for the purpose of conducting medical peer reviews of the care and services provided based on national accepted standards of care. This External Peer Review Company then provides the hospital with a written evaluation of the case it was requested to review for Quality Assurance purposes. The Down East Community Hospital's Quality Improvement Patient Safety Program Medical Staff Peer Review policy requires that this External Peer Review be reviewed and included in the hospital's evaluation of Quality. The Medical Staff Peer Review policy stated, " IV. EXTERNAL REVIEW: B. All written records of all External Reviews shall be presented at the Service's next meeting after the records become available ... B. When a case is identified for Peer Review, the following steps occur: 8. Service Chiefs are responsible for any issues requiring follow up ...VII. RESULTS OF PEER REVIEW: C. Results of Peer Review activities will be incorporated into organization-wide performance improvement via quarterly reports to the hospital's Medical Executive Committee on issues identified during Peer Review related to hospital systems and hospital staff performance. MEDICAL STAFF PEER REVIEW 1. A minimum of 5 charts per year will be sent for external review each year following the provisional year (for solo practitioners)."
2. The Down East Community Hospital Quality Improvement Patient Safety Program [QIPS] 2015 was reviewed on September 1 and 2, 2015. It stated, " Introduction ...The Board delegates the responsibility for implementing this plan to the Medical Staff, QIPS Committee and the Hospital's Leadership Team ...Scope of the QIPS Program ...To provide sufficient information to the Board of Trustees to enable it to meet its obligation for oversight and evaluation of the quality and safety of the services being offered. "
3. The External Peer Review spread sheet was reviewed with the Medical Staff Coordinator on September 2, 2015, and between November 12, 2014 and July 22, 2015, 35 medical records were sent for Peer Review. It was noted that 22 of the 35 medical records sent for External Peer review were determined to not be applicable for Service discussion/review by the Medical Staff. It was noted that between December 29, 2014 and July 30, 2015, the hospital had received the completed External Peer Review reports on all 13 medical records that were submitted for external review. As of September 2, 2015, there was no evidence to validate that 7 of the 13 External Peer Review reports, that had been received by the hospital were reviewed at the Medical Staff Services Meetings consistent with the hospital policy. The Medical Staff Coordinator confirmed the above findings during the review with the surveyor.
4. While determining how the Critical Access Hospital considers the findings and recommendations of the External Peer Review Reports, the surveyor was informed that a completed External Peer Review report was received by the hospital on July 10, 2015. The Vice President of Quality stated on September 1, 2015, at approximately 1:45 PM, that she had not looked at this External Review document until just before she presented it to the surveyor. She stated, " I don't review the External reviews. It goes to the physicians. " When asked if anyone had read the report she stated, " No, it was just filed." Additionally, she stated that she did not attend any of the Medical Staff Meetings where External or Internal Peer Review was discussed.
5. The Surgical Services Report for August 2015 was reviewed on September 2, 2015. It included a Peer Review Overview. The recommendations for changes and/or improvements included only 1 of the External Peer Reviewer's recommendations from the 8 cases that were reviewed.
6 The Medical Staff Coordinator stated on September 2, 2015, at 9:50 AM, that when it was time for a practitioner to be reappointed, the Credentials Committee would get the information from the Service Committee's meeting minutes and a copy of the External Peer Review documents. She stated at 10:10 AM, that around November 2013, the Credentials Committee realized that they needed to routinely see the External Peer Review reports. She also stated that the Chief Executive Officer [CEO] and at least 1 Board member are members of the Credential Committee.
7. A review of the Credentials Committee Meeting minutes of July 7, 2015, revealed the discussion of reappointment regarding a physician. It stated, " The committee reviewed [the physician's] file including compliments, complaints, variances, and quality data. One open malpractice claim was discussed, as well as 2014 random external reviews. The reappointment is due in September. No concerns were identified and the committee agreed to recommend the reappointment to the Level II Medical Staff. " It was noted that there was no documented discussion of the External Peer Reviewer's recommendations or comments regarding this physician's cases that were submitted for external review.
8. At the July 7, 2015, Credentials Committee Meeting, the Board of Trustees member was excused. The Chief Executive Officer was present. The Medical Staff Coordinator confirmed the attendance on September 3, 2015, at approximately 1:55 PM, via telephone interview.
a. A review of the Surgical Service Meeting minutes of June 18, 2015, did not provide sufficient evidence to conclude that this committee considered all findings and recommendations of the External Peer Review Report to determine if corrective action was indicated.
b. A review of the Credentials Committee meeting minutes of July 7, 2015, failed to provide sufficient evidence that the committee was made aware of the External Peer Review Reports findings for the upcoming reappointment of a provider.
c. A telephone interview was conducted with the Chief Executive Officer [CEO] on September 8, 2015, at 8:05 AM. He verified that he was present at the July 7, 2015, Credentials Committee meeting. When asked if he remembered any discussion of the External Peer Reviews for a specific physician that was due to be reappointed. The CEO stated, " I don't remember any discussion about the External Peer Reviews for that specific physician. "
d. The Credential's Committee Chair was interviewed on September 8, 2015, at 2:30 PM via telephone. He stated that the committee discussed the External Peer Reviews for the specific physician. He stated. " We were not in a position to disagree with the reviewer." Additionally, he stated, " We took 5 points off for this provider. We didn't feel we needed to do any more investigation. "
e. The Surgical Services Chief was interviewed on September 9, 2015, at 8:25 AM via telephone. He stated, " We felt the [procedures] were okay..that didn't get into the minutes...I agree that this was not followed as vigorously as it could have been." He continued, " With the electronic medical record it is more frustrating to do chart reviews...I am not sure if the hospital reviewer had the providers office notes when the case was reviewed due to the fact that the office notes are on a different electronic system." There was no evidence to determine if the hospital evaluated their External Peer Review process and procedure to determine if corrective action was indicated regarding the Surgical Services Chief's concern that the External reviewer lacked sufficient information to make a thorough review.

9. These deficient practices resulted in this Condition of Participation being out of compliance

Based on review of External Peer Review documents, review of Services Meeting minutes, review of Credential Committee Meeting minutes, review of Credentialing files and interviews with key personnel, September 1-3 and 8, 2015, it was determined that the facility failed to ensure that the governing body and/or the individual who assumes legal responsibility was ensuring that policies were administered to assure quality health care as evidenced by:
Findings include:
1. The Down East Community Hospital Quality Improvement Patient Safety Program [QIPS] 2015 was reviewed on September 1 and 2, 2015. It stated, " Introduction ...The Board delegates the responsibility for implementing this plan to the Medical Staff, QIPS Committee and the Hospital ' s Leadership Team ...Scope of the QIPS Program ...To provide sufficient information to the Board of Trustees to enable it to meet its obligation for oversight and evaluation of the quality and safety of the services being offered. "
2. The Medical Staff Coordinator stated on September 2, 2015, at 9:50 AM, that when it was time for a practitioner to be reappointed, the Credentials Committee would get the information from the Service Committee's meeting minutes and a copy of the External Peer Review documents. She stated at 10:10 AM, that around November 2013, the Credentials Committee realized that they needed to routinely see the External Peer Review reports. She also stated that the Chief Executive Officer [CEO] and at least 1 Board member are members of the Credential Committee.
3. A review of the Credentials Committee Meeting minutes of July 7, 2015, revealed the discussion of reappointment regarding a physician. It stated, " The committee reviewed [the physician's] file including compliments, complaints, variances, and quality data. One open malpractice claim was discussed, as well as 2014 random external reviews. The reappointment is due in September. No concerns were identified and the committee agreed to recommend the reappointment to the Level II Medical Staff. " It was noted that there was no documented discussion of the External Peer Reviewer's recommendations or comments regarding this physician's cases that were submitted for external review.
4. At the July 7, 2015, Credentials Committee Meeting, the Board of Trustees member was excused. The Chief Executive Officer was present. The Medical Staff Coordinator confirmed the attendance on September 3, 2015, at approximately 1:55 PM, via telephone interview.
5. The Down East Community Hospital's Quality Improvement Patient Safety Program Medical Staff Peer Review policy requires that the External Peer Reviews be reviewed and included in the hospital's evaluation of Quality. The Medical Staff Peer Review policy stated, " IV. EXTERNAL REVIEW: B. All written records of all External Reviews shall be presented at the Service's next meeting after the records become available ... B. When a case is identified for Peer Review, the following steps occur: 8. Service Chiefs are responsible for any issues requiring follow up ...VII. RESULTS OF PEER REVIEW: Results of Peer Review activities will be incorporated into organization- wide performance improvement via quarterly reports to the hospital ' s Medical Executive Committee on issues identified during Peer Review related to hospital systems and hospital staff performance. MEDICAL STAFF PEER REVIEW 1. A minimum of 5 charts per year will be sent for external review each year following the provisional year (for solo practitioners)."
a. A review of the Surgical Service Meeting minutes of June 18, 2015, did not provide sufficient evidence to conclude that this committee considered all findings and recommendations of the External Peer Review Report to determine if corrective action was indicated.
b. A review of the Credentials Committee meeting minutes of July 7, 2015, failed to provide sufficient evidence that the committee was made aware of the External Peer Review Reports findings for the upcoming reappointment of a provider.
c. A telephone interview was conducted with the Chief Executive Officer [CEO] on September 8, 2015, at 8:05 AM. He verified that he was present at the July 7, 2015, Credentials Committee meeting. When asked if he remembered any discussion of the External Peer Reviews for a specific physician that was due to be reappointed. The CEO stated, " I don't remember any discussion about the External Peer Reviews for that specific physician. "
d. The Credential's Committee Chair was interviewed on September 8, 2015, at 2:30 PM via telephone. He stated that the committee discussed the External Peer Reviews for the specific physician. He stated. " We were not in a position to disagree with the reviewer." Additionally, he stated, " We took 5 points off for this provider. We didn't feel we needed to do any more investigation. "
e. The Surgical Services Chief was interviewed on September 9, 2015, at 8:25 AM via telephone. He stated, " We felt the [procedures] were okay..that didn't get into the minutes...I agree that this was not followed as vigorously as it could have been." He continued, " With the electronic medical record it is more frustrating to do chart reviews...I am not sure if the hospital reviewer had the providers office notes when the case was reviewed due to the fact that the office notes are on a different electronic system." There was no evidence to determine if the hospital evaluated their External Peer Review process and procedure to determine if corrective action was indicated regarding the Surgical Services Chief's concern that the External reviewer lacked sufficient information to make a thorough review.
Please refer to citation C-240 for additional information regarding the Organizational Structure Condition findings.

Based on review of the 2015 Down East Community Hospital Quality Improvement Patient Safety Program, review of External Peer Review reports, review of Medical Staff Services Meetings, review of the Medical Staff Peer Review policy, review of an External Peer Review spread sheet, review of Credentials Committee meeting minutes and interviews with key personnel on September 1-3 and 8-9, 2015, it was determined that the facility failed to evaluate all patient External Peer Review reports consistent with its policies and procedures for quality and physician credentialing.
Findings include:
1. The hospital utilizes a professional medical review company that is not part of the hospital for the purpose of conducting medical peer reviews of the care and services provided based on national accepted standards of care. This External Peer Review Company then provides the hospital with a written evaluation of the case it was requested to review for Quality Assurance purposes. The Down East Community Hospital's Quality Improvement Patient Safety Program Medical Staff Peer Review policy requires that this External Peer Review be reviewed and included in the hospital's evaluation of Quality. The Medical Staff Peer Review policy stated, " IV. EXTERNAL REVIEW: B. All written records of all External Reviews shall be presented at the Service's next meeting after the records become available ... B. When a case is identified for Peer Review, the following steps occur: 8. Service Chiefs are responsible for any issues requiring follow up ...VII. RESULTS OF PEER REVIEW: C. Results of Peer Review activities will be incorporated into organization-wide performance improvement via quarterly reports to the hospital's Medical Executive Committee on issues identified during Peer Review related to hospital systems and hospital staff performance. MEDICAL STAFF PEER REVIEW 1. A minimum of 5 charts per year will be sent for external review each year following the provisional year (for solo practitioners). "
2. The External Peer Review spread sheet was reviewed with the Medical Staff Coordinator on September 2, 2015, and between December 29, 2014 and July 30, 2015, the hospital had received the completed External Peer Review reports on 9 of 13 medical records that were found to be applicable for Service Committee Meeting reviews. As of September 2, 2015, there was no evidence that 7 of the 9 received External Peer Review Reports were reviewed at a Medical Staff Services Meeting as required by the hospital's policy. The Medical Staff Coordinator confirmed the above findings, while reviewing the information with the surveyor.
3. While determining how the Critical Access Hospital considers the findings and recommendations of the External Peer Review Reports, the surveyor was informed that a completed External Peer Review report was received by the hospital on July 10, 2015. The Vice President of Quality stated on September 1, 2015, at approximately 1:45 PM, that she had not looked at this External Review document until just before she presented it to the surveyor. She stated, " I don't review the External reviews. It goes to the physicians. " When asked if anyone had read the report she stated, " No, it was just filed. " Additionally, she stated that she did not attend any of the Medical Staff Meetings where External or Internal Peer Review was discussed.
4. The surveyor noted that as of September 2, 2015, the hospital had not followed its Medical Staff Peer Review policy, as Patients A, B, C, D, E, F and G had External Peer Review reports that had not been reviewed at a Medical Staff Services Meeting.
5. The Medical Staff Coordinator stated on September 2, 2015, at 9:50 AM, that the Credentials Committee would get the information from the Service Committee's Meeting and a copy of the External Peer Review documents would be attached. At 10:10 AM, she stated that around November 2013, the Credentials Committee realized that they routinely needed to see the External Peer Review reports. She also stated that the Chief Executive Officer [CEO] and at least 1 Board member are members of the Credential Committee.
a. A review of the Surgical Service Meeting minutes of June 18, 2015, did not provide sufficient evidence to conclude that this committee considered all findings and recommendations of the External Peer Review Report to determine if corrective action was indicated.
b. A review of the Credentials Committee meeting minutes of July 7, 2015, failed to provide sufficient evidence that the committee was made aware of the External Peer Review Reports findings for the upcoming reappointment of a provider.
c. A telephone interview was conducted with the Chief Executive Officer [CEO] on September 8, 2015, at 8:05 AM. He verified that he was present at the July 7, 2015, Credentials Committee meeting. When asked if he remembered any discussion of the External Peer Reviews for a specific physician that was due to be reappointed. The CEO stated, " I don't remember any discussion about the External Peer Reviews for the specific provider. "
d. . The Surgical Services Chief was interviewed on September 9, 2015, at 8:25 AM via telephone. He stated, " We felt the [procedures] were okay..that didn't get into the minutes...I agree that this was not followed as vigorously as it could have been." He continued, " With the electronic medical record it is more frustrating to do chart reviews...I am not sure if the hospital reviewer had the providers office notes when the case was reviewed due to the fact that the office notes are on a different electronic system." There was no evidence to determine if the hospital evaluated their External Peer Review process and procedure to determine if corrective action was indicated regarding the Surgical Services Chief's concern that the External reviewer lacked sufficient information to make a thorough review.
6. These deficient practices resulted in this Condition of Participation being out of compliance.

Based on review of the 2015 Down East Community Hospital Quality Improvement Patient Safety Program, review of External Peer Review reports, review of Medical Staff Services Meetings, review of the Medical Staff Peer Review policy, review of an External Peer Review spread sheet, review of Credentials Committee meeting minutes and interviews with key personnel on September 1-3 and 8-9, 2015, it was determined that the facility failed to evaluate the quality and appropriateness of the treatment furnished by physicians for consistency with the facility's Quality Assurance Program.

Findings include:

1. The hospital has an arrangement with an outside entity (as part of the Quality Assurance Program) to review the appropriateness of the diagnosis and treatment of physician's providing services to patients of the hospital. The Down East Community Hospital's Quality Improvement Patient Safety Program Medical Staff Peer Review policy requires that this External Peer Review be reviewed and included in the hospital's evaluation of Quality. Please refer to citation C-330 for additional information regarding the Quality Assurance Condition findings.
2. The hospital was unable to provide sufficient evidence to demonstrate that the findings of the External Peer Review's that were completed by the outside entity were incorporated and evaluated as part of the hospital wide quality assurance program.

a. A telephone interview was conducted with the Chief Executive Officer [CEO] on September 8, 2015, at 8:05 AM. He verified that he was present at the July 7, 2015, Credentials Committee meeting. When asked if he remembered any discussion of the External Peer Reviews for a specific physician who was due to be reappointed. The CEO stated, " I don't remember any discussion about the External Peer Reviews for that physician."

b. The Credential's Committee Chair was interviewed on September 8, 2015, at 2:30 PM via telephone. He stated that the committee discussed the External Peer Reviews for the specific physician. He stated. " We were not in a position to disagree with the reviewer." Additionally, he stated, " We took 5 points off for this provider. We didn't feel we needed to do any more investigation."

c. The Surgical Services Chief was interviewed on September 9, 2015, at 8:25 AM, via telephone. He stated, " We felt the [procedures] were okay..that didn't get into the minutes...I agree that this was not followed as vigorously as it could have been." He continued, " With the electronic medical record it is more frustrating to do chart reviews...I am not sure if the hospital reviewer had the providers office notes when the case was reviewed internally due to the fact that the office notes are on a different electronic system." There was no evidence to determine if the hospital evaluated their External Peer Review process and procedure to determine if corrective action was indicated regarding the Surgical Services Chief's concern that the External reviewer lacked sufficient information to make a thorough review.

Based on review of the 2015 Down East Community Hospital Quality Improvement Patient Safety Program, review of External Peer Review reports, review of Medical Staff Services Meetings, review of the Medical Staff Peer Review policy, review of an External Peer Review spread sheet, review of Credentials Committee meeting minutes and interviews with key personnel on September 1-3 and 8-9, 2015, it was determined that the facility failed to consider the findings and recommendations of the External Peer Review reports for 7 of 9 received reports.

Findings include:

1. The Down East Community Hospital's Quality Improvement Patient Safety Program Medical Staff Peer Review policy requires that this External Peer Review be reviewed and included in the hospital's evaluation of Quality. The Medical Staff Peer Review policy stated, " IV. EXTERNAL REVIEW: B. All written records of all External Reviews shall be presented at the Service's next meeting after the records become available ... VII. RESULTS OF PEER REVIEW: C. Results of Peer Review activities will be incorporated into organization-wide performance improvement via quarterly reports to the hospital's Medical Executive Committee on issues identified during Peer Review related to hospital systems and hospital staff performance."
2. The External Peer Review spread sheet was reviewed with the Medical Staff Coordinator on September 2, 2015, and between December 29, 2014 and July 30, 2015, the hospital had received the completed External Peer Review reports on 9 of 13 medical records that were found to be applicable for Service Committee Meeting reviews. As of September 2, 2015, there was no evidence that 7 of the 9 received External Peer Review Reports were reviewed at a Medical Staff Services Meeting as required by the hospital's policy. The Medical Staff Coordinator confirmed the above findings, while reviewing the information with the surveyor.
3. While determining how the Critical Access Hospital considers the findings and recommendations of the External Peer Review Reports, the surveyor was informed that a completed External Peer Review report was received by the hospital on July 10, 2015. The Vice President of Quality stated on September 1, 2015, at approximately 1:45 PM, that she had not looked at this External Review document until just before she presented it to the surveyor. She stated, " I don't review the External reviews. It goes to the physicians." When asked if anyone had read the report she stated, " No, it was just filed." Additionally, she stated that she did not attend any of the Medical Staff Meetings where External or Internal Peer Review was discussed.
4. The surveyor noted that as of September 2, 2015, the hospital had not followed its Medical Staff Peer Review policy, as Patients A, B, C, D, E, F and G had External Peer Review reports that had not been reviewed at a Medical Staff Services Meeting.
5. The Medical Staff Coordinator stated in an interview on September 2, 2015, at approximately 10:10 AM, "I file them [External Peer Reviews] when they are returned from the External Peer Reviewer. She stated that around November 2013, the Credentials Committee realized that they routinely needed to see the External Peer Review reports. It is up to the Service Chief to take them to the Service Meeting for discussion." She further stated that the External Review Spread Sheet was up to date regarding discussion of the External Peer Review reports at the Service Meetings."

Based on review of the 2015 Down East Community Hospital Quality Improvement Patient Safety Program, review of External Peer Review reports, review of Medical Staff Services Meetings, review of the Medical Staff Peer Review policy, review of an External Peer Review spread sheet, review of Credentials Committee meeting minutes and interviews with key personnel on September 1-3 and 8-9, 2015, it was determined that the facility failed to take appropriate remedial action to address recommendations of the External Peer Review reports for 7 of 9 received reports.

Findings include:

1. The Down East Community Hospital's Quality Improvement Patient Safety Program Medical Staff Peer Review policy requires that this External Peer Review be reviewed and included in the hospital's evaluation of Quality. The Medical Staff Peer Review policy stated, " IV. EXTERNAL REVIEW: B. All written records of all External Reviews shall be presented at the Service's next meeting after the records become available ... VII. RESULTS OF PEER REVIEW: C. Results of Peer Review activities will be incorporated into organization-wide performance improvement via quarterly reports to the hospital's Medical Executive Committee on issues identified during Peer Review related to hospital systems and hospital staff performance."

2. The External Peer Review spread sheet was reviewed with the Medical Staff Coordinator on September 2, 2015, and between December 29, 2014 and July 30, 2015, the hospital had received the completed External Peer Review reports on 9 of 13 medical records that were found to be applicable for Service Committee Meeting reviews. As of September 2, 2015, there was no evidence that 7 of the 9 received External Peer Review Reports were reviewed at a Medical Staff Services Meeting as required by the hospital's policy. Therefore, since the findings of the report were not reviewed, there is no evidence that the hospital took appropriate action to address the recommendations and findings of the External Peer Review Reports. The Medical Staff Coordinator confirmed the above findings, while reviewing the information with the surveyor.