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Based on physician and allied health credential file review, governing body meeting minutes review, Governing Body Bylaws review and staff interview, the governing body failed to ensure full privileges were appointed (granted) to two (2) of two (2) practicing physicians (Physician #1 and #2) and for one (1) of one (1) allied health professional (Nurse Practitioner #1).

Findings Include:

Review of Physician #1's credential file revealed an "Appointment Letter", dated 09/01/13, informing him he had been granted temporary privileges to the Medical Staff of the hospital in Psychiatry and signed by the Chief Executive Office, who is not the current Administrator.

Review of Physician #2's credential file revealed a "Medical Staff Consultant Agreement" dated 09/01/13, with a one (1) year auto-renewal. There was no documented evidence Physician #2 had applied for medical staff privileges.

Review of Nurse Practitioner #1's credential file revealed an "Appointment Letter", dated 09/26/13, informing her she had been granted temporary privileges to the Medical Staff of the hospital as a Family Nurse Practitioner and signed by the Chief Executive Officer, who is now the current Administrator.

Review of the facility's "Governing Board Minutes" dated 02/17/14 revealed: "Medical Executive Committee Report" contained no documented evidence the Board addressed physician or allied health professional credentialing.

Review of the facility's "Governing Board Minutes" dated 09/15/14 revealed: "...Medical Executive Committee Report ...Also the discussion of added (Physician #2) as our new Medical Director. The contract will be drafted and presented to (Physician #2) on next week. We will proceed with granting temporary privileges in an emergency meeting ...". No further "Governing Board Minutes" were submitted for review or presented during the facility exit conference.

Review of the facility's "Governing Board Bylaws" revealed: "Article 1: Definitions ...1. Allied Health Professional Staff means that allied health professional Staff of the Hospital, all of whom have been appointed pursuant to the Medical Staff Bylaws ...4. Clinical Privileges means the permission granted to a Practitioner by the Governing Board to render specific diagnostic, therapeutic, medical ...or other professional services ...7. Medical Staff means the medical staff of the hospital, all of whom have been appointed pursuant to the Medical Staff Bylaws ...Article II: General Provisions, 2.1 Hospital Management: The Hospital is managed under the direction of the Governing Board. 2.2 Purposes: The Hospital is a primary acute-care hospital providing health care services to the community ...2.5 Medical Staff: The Medical Staff shall be established by and accountable to the Governing Board and shall operate as a part of the Hospital ...The Medical Staff bylaws shall include a mechanism whereby the Medical Executive Committee makes recommendations to the Governing Board regarding the following matters: ...(c)Individual Medical staff or AHP Staff appointed and Clinical Privileges, ...(e)The mechanisms by which Clinical Privileges to the Medical Staff may be modified or terminated ...2.6 Staff Appointment and Privileges: ...The Medical Staff Bylaws shall be set forth (a) the procedures by which, and criteria pursuant to which, such appointments are made and such Clinical Privileges granted; (b) the procedures by which, and criteria pursuant to which, appointments and Clinical Privileges may be modified or terminated; (c) the duties and responsibilities of appointees to the Medical and AHP Staffs; (d) and the procedures and systems of governance of the Medical Staff ...Article III Governance Board: ...3.2 Duties: The current duties of the Governing Board are as follows: (a) making final decisions, with a reasonable time as specified in the Medical Staff Bylaws, regarding Medical Staff appointments and re-appointments, the granting of Clinical Privileges, and the reduction, modification, suspension, or termination of Medical Staff appointments and Clinical Privileges pursuant to the provisions of the Medical staff Bylaws, which provisions shall include a mechanism for the prompt resolution of differences between the Medical Executive Committee's recommendation ...Article IV: Meetings: 4.1 Meetings: Regular meetings of the Governing Board may be held as necessary, but no less than quarterly ...Article VII: Amendments to Bylaws: At least once annually, the Governing Board shall review these Bylaws to determine whether they require amending ...Approved by the Governing Board of May 18, 2011".

During an interview on 06/17/15 at 2:40 p.m. the Administrator was asked how often reappointment occurs for physicians and allied health professionals. She stated, "I am not sure when it should occur." When asked why the Medical Director and Nurse Practitioner were only granted temporary privileges the Administrator stated, "I am not sure why the letters are for temporary privileges and I will have to look."

Based on documentation review, policy and procedure review and staff interview, the governing body failed to assume full legal responsibility for the conduct of the hospital and medical staff and failed to ensure the medical staff operated under current bylaws.

Findings Include:

Cross Refer to A046 for the Governing Body's failure to ensure the
Medical Staff was credentialed and/or granted physician privileges according to the Governing Board Bylaws and the Medical Staff Bylaws.

Based on physician and allied health credential file review, Governing Board Bylaws review, Governing Board Minutes review, medical staff meeting minutes review, Medical Staff Bylaws review and staff interview, the facility failed to ensure the medical staff operated under the bylaws approved by the governing body for the appointment and/or reappointment activities for two (2) of two (2) physicians (Physician #1 and #2), and for one (1) of one (1) allied health professionals (Nurse Practitioner #1).

Findings Include:

Review of Physician #1's credential file revealed an "Appointment Letter", dated 09/01/13 informing him he had been granted temporary privileges to the Medical Staff of the hospital in Psychiatry and signed by the Chief Executive Officer who is now the current Administrator.

Review of Physician #2's credential file revealed a "Medical Staff Consultant Agreement" dated 09/01/13 with a one (1) year auto-renewal. There was no documented evidence Physician #2 had applied for medical staff privileges.

Review of Nurse Practitioner #1's credential file revealed an "Appointment Letter", dated 09/26/13 informing her she had been granted temporary privileges to the Medical Staff of the hospital as a Family Nurse Practitioner and signed by the Chief Executive Officer who is now the current Administrator.

Review of the facility's medical staff meeting documentation revealed the facility submitted minutes dated 05/29/15, 07/03/13 and 09/19/11 for review. No further medical staff meeting documentation was provided or submitted during exit conference.

Review of the facility's "Medical Staff " minutes dated 05/29/15 revealed: "...Topic: ...Credentialing/Privileges: No discussion ...".

Review of the facility's "Medical Staff " minutes dated 07/03/13 revealed: "Topic: ...Credentialing/Privileges: Nurse Practitioner (no name was referenced) for (Physician #1) to be granted temporary privileges ...(Physician #1) has been granted full privileges. Contact Nurse Practitioner to obtain needed documents ...".

Review of the facility's "Medical Executive Committee Meeting" minutes dated 09/19/11 revealed: "Topic: ...Credentials/Discussion: (Nurse Practitioner #2) - Approved. (Physician #3) - Approved for temporary privileges ...".

Review of the facility's "Medical Staff Bylaws" adopted May, 2011 revealed: "...Article I: 1.1 Definitions ...(A) Allied Health Professional Staff ...means the allied health professional staff of the Hospital, all of whom have been appointed pursuant by the Bylaws. (B) Bylaws means these Medical Staff Bylaws ...(F) Clinical Privileges means the permission granted to a Practitioner by the Governing Board to render specific diagnostic, therapeutic, medical ...or other professional services ...(J) Medical Executive Committee (MEC) means the MEC of the Medical Staff. (K) Medical Staff means the organizational component of the Hospital consisting of all Practitioners who have been appointed to the Medical Staff pursuant to these Bylaws ...(M) Practitioner means a health care professional licensed in the State of Mississippi, including but not limited to a doctor of medicine, doctor of osteopathy ...psychologist ...Article III ...(E) Duties (1) Chief of Staff - the Chief of Staff shall serve as the principal elected officer of the Medical staff, and he shall have the following duties: ...develop and implement methods for credentials review and for delineation of Privileges ...be responsible to the Governing Board for Medical staff compliance with these Bylaws, the rules and regulations, policies, procedures ...3.3 Medical Executive Committee: (A) Composition - The MEC shall consist of the Chief of Staff, Medical staff, and all other physicians on staff ...(3) monitor on an ongoing bases compliance with these Bylaws ...(9) make recommendations to the Governing Board regarding Medical Staff structure, privileges process, recommending individuals for medical staff membership, recommending privileges for individuals ...(C) Meetings - The MEC will meet quarterly. (1) Medical Staff/Medical Executive Committee Functions (a) Credentials Review - review and evaluate the qualifications, competence and performance of each applicant or re-applicant for Medical Staff appointment, AHP appointment, and/or Clinical Privileges or modification thereof ...(k) Bylaws - Shall review these Bylaws at least annually and recommend to the Medical Staff any revisions ...Article IV/Medical Staff Qualifications, Responsibilities, and Privileges: 4.1 Credentialing Process: 1. Completion of application for appointment to the medical staff ...4.4 Categories of the Medical Staff: The Medical staff shall be composed of the categories set forth below, ...(C)Consulting Staff (1) Qualifications - In order to qualify for appointment to the Consulting Staff of the Medical Staff, a Practitioner shall: meet those qualifications identified in Section 4.1 of these Bylaws ...4.8 Temporary Privileges (A) Eligibility - Temporary Clinical Privileges may be granted to a Practitioner during the time his application is pending approval for appointment or reappointment to the Medical Staff or AHP; or any instances deemed appropriate by the Chief of Medical staff and the CEO or their Designees. (B) Prerequisites - Temporary Clinical Privileges may be granted only when: (1) the Practitioner has submitted a completed application form and the initial verification process is substantially complete, ...(C) Procedure - A request for temporary Clinical Privileges may be granted only upon the written concurrence of the Chief of staff and the CEO, ...(D) Duration - Temporary Clinical Privileges may be granted for periods of 30 days or less. A Practitioner may have Temporary Clinical Privileges renewed upon the expiration of his/her Temporary Clinical Privileges, but such renewals shall not be granted for more than 30 days at a time. Temporary Privileges should not exceed more than 120 days ...Article VIII/Allied Health Professionals ...8.4 Appointment and Privileges (A) Application - A Practitioner applying for appointment or reappointment to the AHP Staff or for additional Clinical Privileges shall submit to the Governing Board an application ...(B) CEO Action - The granting or renewal of privileges for AHP ' s will be treated in the same manner as the process for appointment to the Medical staff, ...(D) MEC Action - Following receipt of the file from the CEO, the MEC shall review the file and shall submit a report and recommendation to the Governing Board regarding the application. The report and recommendations shall specify the scope of Clinical Privileges which it recommends to be granted ...(E) Governing Board Action - Following receipt of the file from the MEC, the Governing Board shall review the file and shall make a decision whether to grant the application in whole or in part ...(H) Termination of Appointment or Privileges - The CEO may limit or terminate the AHP Staff appointment and/or Clinical Privileges of an appointee to the AHP at any time with or without cause ...Approved by the Medical Staff on May 19, 2011".

Review of the facility's "Governing Board Minutes" dated 02/17/14 revealed: "Medical Executive Committee Report" contained no documented evidence the Board addressed physician or allied health professional credentialing.

Review of the facility's "Governing Board Minutes" dated 09/15/14 revealed: "...Medical Executive Committee Report ...Also the discussion of added (Physician #2) as our new Medical Director. The contract will be drafted and presented to (Physician #2) on next week. We will proceed with granting temporary privileges in an emergency meeting ...". No further "Governing Board Minutes" were submitted for review or presented during the facility exit conference.

Review of the facility's "Governing Board Bylaws" revealed: "Article 1: Definitions ...1. Allied Health Professional Staff means that allied health professional Staff of the Hospital, all of whom have been appointed pursuant to the Medical Staff Bylaws ...4. Clinical Privileges means the permission granted to a Practitioner by the Governing Board to render specific diagnostic, therapeutic, medical ...or other professional services ...7. Medical Staff means the medical staff of the hospital, all of whom have been appointed pursuant to the Medical Staff Bylaws ...Article II: General Provisions, 2.1 Hospital Management: The Hospital is managed under the direction of the Governing Board. 2.2 Purposes: The Hospital is a primary acute-care hospital providing health care services to the community ...2.5 Medical Staff: The Medical Staff shall be established by and accountable to the Governing Board and shall operate as a part of the Hospital ...The Medical Staff bylaws shall include a mechanism whereby the Medical Executive Committee makes recommendations to the Governing Board regarding the following matters: ...(c)Individual Medical staff or AHP Staff appointed and Clinical Privileges, ...(e)The mechanisms by which Clinical Privileges to the Medical Staff may be modified or terminated ...2.6 Staff Appointment and Privileges: ...The Medical Staff Bylaws shall be set forth (a) the procedures by which, and criteria pursuant to which, such appointments are made and such Clinical Privileges granted; (b) the procedures by which, and criteria pursuant to which, appointments and Clinical Privileges may be modified or terminated; (c) the duties and responsibilities of appointees to the Medical and AHP Staffs; (d) and the procedures and systems of governance of the Medical Staff ...Article III Governance Board: ...3.2 Duties: The current duties of the Governing Board are as follows: (a) making final decisions, with a reasonable time as specified in the Medical Staff Bylaws, regarding Medical Staff appointments and re-appointments, the granting of Clinical Privileges, and the reduction, modification, suspension, or termination of Medical Staff appointments and Clinical Privileges pursuant to the provisions of the Medical staff Bylaws, which provisions shall include a mechanism for the prompt resolution of differences between the Medical Executive Committee's recommendation ...Article IV: Meetings: 4.1 Meetings: Regular meetings of the Governing Board may be held as necessary, but no less than quarterly ...Article VII: Amendments to Bylaws: At least once annually, the Governing Board shall review these Bylaws to determine whether they require amending ...Approved by the Governing Board of May 18, 2011".

During an interview on 06/17/15 at 2:40 p.m. the Administrator was asked how often reappointment occurs for physicians and allied health professionals. She stated, "I am not sure when it should occur." When asked why the Medical Director and Nurse Practitioner were granted temporary privileges the Administrator stated, "I am not sure why the letters are for temporary privileges and I will have to look."

Based on record review, policy review and staff interview, the facility failed to have adequate staff to perform the scope and complexity of maintaining their medical record department.

Findings Include:

On 06/16/15 at 11:00 a.m. the medical records person confirmed there were 112 incomplete medical records and that they were delinquent over 30 days. He also stated that it was mainly the physician who had not completed his records, but they do not send the physician's letters regarding the delinquencies. He was aware the letters should be sent. He confirmed an average daily census of 5.23.

Review of the facility's "Incomplete Medical Records" policy, approved on 09-12-11, revealed: "When a discharged patient's chart is analyzed, it will be considered delinquent 30 days after it is properly processed by the Medical Record Department."

The Medical Record employee had a RHIA (record health information associate) contracted to assist him. Review of the RHIA's license revealed that it had expired. The current license was requested at 10:00 a.m. and at 1:30 p.m. on 06/17/15. No current license was provided.

During Exit Conference on 06/17/15 at 4:30 p.m. these findings were discussed. No further information was provided.

Based on record review, the facility failed to have complete records for five (5) of 12 records reviewed, Patient #1, #2, #3, #4 and #5.

Findings Include:

Record review revealed that Patient #1, #2, #3, #4 and #5 had no documented evidence of discharge plans. The form was there, but was blank.

During Exit Conference on 6/17/15 at 4:30 p.m. the Acting Administrator stated that the facility was working on getting stickers on each page. She presented a report where this practice was being monitored by their Record Health Information Associate (RHIA).

Based on record review and policy and procedure review, the facility failed to arrange for the initial implementation of the patient's discharge plan for Patient's #1, #2, #3, #4 and #5, five (5) of 12 patients reviewed.

Findings Include:

Policy review revealed that the facility did not have any policies and procedures on discharge planning.

Record review for Patients #1, #2, #3, #4 and #5 revealed no documented evidence of a discharge plan started upon admission.

During Exit Conference at 4:30 p.m. on 06/17/15 these findings were discussed. No further documentation was provided for review.

Based on review of the facility's medical staffing document, physician credential files and staff interview, the facility failed to ensure a director of respiratory services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly is employed either full-time or part-time on two (2) of two (2) days of survey.

Findings Include:

Review of the facility's contracts revealed a contract with a respiratory service dated 06/07/07, with a one (1) year auto-renewal.

Review of the facility's "Medical Staffing" list revealed a contract agreement for Physician #1 and consultant contract for Physician #2.

Review of Physician #1's credential file revealed "Medical Directors and Professional Services Agreement ...entered into ...09/01/13 ...Whereas, Provider desires to contract with Physician for professional physician services and as Medical Director for Psychiatric Services, ... 8. Term and Termination: a) This agreement shall commence on September 1, 2013, and shall terminate one (1) year thereafter ...This Agreement shall automatically renew for additional one (1) year terms ...".

During an interview on 06/16/15 at 10:15 a.m. the Director of Nursing (DON) confirmed the facility provides oxygen and/or breathing treatments according to physician orders. She stated, "Respiratory Services are contracted."

During an interview on 06/17/15 at 8:45 a.m., the DON stated that the facility had two (2) physicians under contract.