HospitalInspections.org

Based on document review and interview, the Critical Access Hospital (CAH) failed to assure three of three active medical staff, one of one consulting medical staff and one of one allied medical staff are credentialed and certified as required the the CAH Medical Staff Bylaws for re-appointment to the staff and assure receipt and review of application to the medical staff (medical staff C, D, E, F, G and H).


Findings include:

- Active medical staff C's credentialing file, reviewed on 4/19/11 at 3:15pm, revealed the approval of qualifications and appointment to the Active Medical Staff on 3/31/08, more than three years ago. The credentialing file lacked evidence of current certification in 1.) Advance Trauma Life support, 2.) Advance Cardiac Life Support, 3.) Neonatal Advance Life Support and 4.) Pediatric Advance Life Support.

- Active medical staff E's credentialing file, reviewed on 4/19/11 at 3:15pm, revealed the approval of qualifications and appointment to the Active Medical Staff on 3/31/08, more than three years ago. The credentialing file lacked evidence of current certification in 1.) Advance Trauma Life support, 2.) Advance Cardiac Life Support, 3.) Neonatal Advance Life Support and 4.) Pediatric Advance Life Support.

- Active medical staff G's credentialing file, reviewed on 4/19/11 at 3:15pm, revealed the approval of qualifications and appointment to the Active Medical Staff on 6/10/08, more than two years ago. The credentialing file lacked evidence of current certification in 1.) Advance Trauma Life support, 2.) Advance Cardiac Life Support, 3.) Neonatal Advance Life Support and 4.) Pediatric Advance Life Support.

- Consulting medical staff D's credentialing file, reviewed on 4/19/11 at 3:15pm revealed the approval of qualifications and appointment to the consulting medical staff on 3/27/08, more than three years ago.

- Consulting medical staff F's credentialing file, reviewed on 4/19/11 at approximately 3:45pm revealed the CAH lacked evidence of an application for appointment to the medical staff. Staff E has performed consulting services for the CAH and lacked appointment to the medical staff.

- Allied medical staff H's credentialing file, reviewed on 4/19/11 at 3:15pm revealed the approval of qualifications and appointment to the consulting medical staff on 6/16/08, more than two years ago.

- The "Medical Staff Bylaws" Article III, Categories of Membership 3.2 Active Staff, 3.2-1 Qualifications (c) directs the active staff shall consist of Member who "Maintain current certification in the following: 1.) Advance Trauma Life support, 2.) Advance Cardiac Life Support, 3.) Neonatal Advance Life Support and 4.) Pediatric Advance Life Support.

- The "Amended and Restated Bylaws of Washington County Hospital Board of Trustees" Article III, Committees, b. directs the board to "i. Receive and make recommendations to the Board on all applications for appointment to the Medical Staff of the Hospital'. Article VI, Medical Staff, Section 4. Term directs "Membership on the Medical Staff she be for a period of two (2) years...".

- Staff B, interviewed on 4/19/11 at 3:35pm confirmed the CAH lacked evidence of appointment/re-appointment and the lack of required certifications for active medical staff C, D, E, F, G and H.

- Administrative staff A, interviewed on 4/20/11 at 9:15am confirmed knowledge of the requirements to the active medical staff.

The CAH's Governing Body failed to re-credential the active medical staff at least every two years, failed to assure the medical staff met the qualification of re-appointment, and failed to obtain and review applications for new medical staff appointments.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to develop and implement a plan to assure quality of patient care.

Findings include:

- Review of the Quality Assurance/Improvement Plan on 4/20/11 at 11:10am, revealed the plan was approved through "the calendar year 2010". The CAH's objectives were "to have a planned, systematic and comprehensive approach to objectively examine and assess important aspects of patient care, to identify known, suspected or potential problems, to develop and implement corrective action and to monitor and comply with policies, standards, regulations and laws.

- The Quality Assurance/Improvement Plan data collected by the CAH, reviewed on 4/20/11 at 11:00am, revealed the lack of identification of concerns, analysis of problems, corrective actions to be taken and evaluation of the the actions regarding regulatory non-compliance issues identified during a re-survey on 2/3/11. The failure to perform analysis of the identified problems, take corrective actions and evaluate the actions resulted in the non-compliance of CFR 485.627(a), C241, Governing Body.

- Staff A, B and I, interviewed on 4/20/11 at 12:00pm, confirmed the CAH failed to assure the CAH's Quality Assurance plan was approved by the Governing Body, failed to include all departments of the CAH, failed to include recent survey findings, failed to document corrective actions and failed to assure continued compliance with state and federal regulations.