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Based on medical record review, interview, policy review and review of the facility's Medical Staff Bylaws and documentation regarding license verification for referring physicians for outpatient services, the facility failed to ensure referring physicians for outpatient laboratory services have an active license. This affected two patients and has the potential to affect every patient who receives outpatient laboratory services. (Patient #11 and #12) The facility sees approximately 95 patients per day for outpatient laboratory services.

Findings include:

On 8/11/14 at 1:32 PM, the facility's Outpatient Services brochure was reviewed. The brochure stated all laboratory tests require a valid physician's order.


Review of the medical record for Patient #11 revealed the patient received treatment at the facility's outpatient laboratory on 6/20/14 and 6/24/14. The medical record contained a prescription from 6/20/14 for Laboratory tests complete blood cell count (CBC), comprehensive metabolic panel(CMP) and prostate specific antigen (PSA). The prescriptions had the words "Mail results" written at the top. The record contained a prescription from 6/24/14 for Vitamin D 25-OH level and B12 level. Both prescriptions were prescribed for Patient #11 by Patient #11. The medical record revealed the specimens were collected from Patient #11 on 6/20/14 at 10:22 AM and 6/24/14 at 10:03 AM.

Review of Patient #12's medical record revealed Patient #12 received treatment at the facility's outpatient laboratory on 6/24/14. The record contained an order for laboratory tests prescribed for Patient #12 by Patient #11. The prescription was for a cholesterol panel, thyroid stimulating hormone (TSH) level and CMP. The medical record revealed the facility collected a specimen from Patient #12 on 6/24/14 at 10:05 AM.


On 8/11/14 at 9:55 AM, Staff S was interviewed. Staff S reported the facility does not have a system in place to determine the validity of prescriptions.

On 8/11/14 at 10:27 AM, Staff T was interviewed. Staff T reported laboratory staff are able to enter physicians into the Epic (electronic medical record) system.

On 8/11/14 at 1:35 PM, Staff U was interviewed. Staff U reported a medical board license search for Patient #11 was completed on 6/25/14. Staff U reported Patient #11's license had been revoked in 1997. Staff U reported the facility filed a police report on 6/25/14 and called the State Medical Board to report Patient #11 on 6/25/14.

On 8/11/14 at 4:57 PM, Staff X reported any registrar can enter a new physician into the Epic system.


The facility's instructions on how to enter a physician into the electronic medical record were reviewed on 8/12/14 at 8:18 AM. The instructions did not include directions for verifying if a physician's license is active.

On 08/12/14 at 8:22 AM, the facility's Epic Training: Provider on the fly instructions was reviewed. The instructions stated to use Provider on the Fly when registering lab patients when the referring provider is not in the EPIC system. The instructions did not include directions to verify whether or not the physician's license was active.

On 8/12/14 at 1:08 PM, Staff V was interviewed regarding manual entry of referring physicians for outpatient services into the Epic system. Staff V reported no one verifies whether or not external providers' licenses are active.


On 8/12/14 at 1:29 PM, the facility's Outpatient Laboratory Services policy was reviewed. The policy stated outpatient laboratory services are available to any licensed practitioner with a valid national provider number (NPI), upon written receipt of tests requested and patient diagnosis.

On 08/12/14 at 1:29 PM, the facility's Department of Pathology-Performance Improvement Activity meeting minutes from 7/28/14 were reviewed. The review revealed the facility had concerns with a previously licensed physician who was able to order laboratory testing. The minutes stated the issue was being investigated and the lab office manager is participating on a committee reviewing options for validating licensure at the time of test request.

On 08/12/14 at 1:29 PM, review of the facility's Referring Physician Verification for Outpatient Services meeting minutes from 7/17/14 revealed discussions occurred with regard to the need for verifications and coordinating verification/authorization into the Epic System.

On 8/12/14 at 9:41 AM, the facility's Medical Staff Bylaws were reviewed. The bylaws did not contain information on how the facility verifies the license of the referring/ordering practitioner and scope of practice.

This deficiency substantiates Substantial Allegation OH00075343.