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Based on interview, record review and policy review, the facility failed to ensure that four physicians (Staff L, N, T and X) out of six physician medical staff records reviewed, had approved and current privileges to provide medical care at the facility. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 16.

Findings included:

1. Review of the facility's document titled, "Medical Staff By-Laws," dated 01/01/17, showed the following:
- The Board of Managers was also known as the Governing Body and Board of Directors of the Hospital.
- The purpose of the By-Laws was to establish accountability of the Medical Staff to the Board of Managers for appropriateness of professional performance and ethical conduct of its members, and to monitor the quality of medical care provided by all Practitioners authorized to practice in the Hospital, through the appropriate delineation of Clinical Privileges and an ongoing review and evaluation of each Practitioner's performance in the Hospital.
- Appointment to and membership on the Medical Staff shall confer on the appointee or member only such Clinical Privileges as have been granted by the Board of Managers in accordance with these By-Laws, the Medical Staff Rules and Regulations, and other Policies and Procedures.
- No Practitioner shall admit or provide services to patients in the Hospital unless she/he has been granted Clinical Privileges in accordance with the procedures set forth in these By-Laws.

Review of the facility's document titled, "Medical Staff Rules and Regulations," showed no date that it had been adopted by the Medical Staff and no signature of the President of the Medical Executive Committee. There was no date that it was approved by the Board of Managers and no signature of the Chairperson of the Board of Managers. The Medical Staff Rules and Regulations stated that patients will be treated by ethical and competent Medical Staff members who have submitted proper credentials, met standards and requirements of the Hospital By-Laws and who have been duly appointed by the Board of Managers.

Review of the facility's Board Meeting minutes on 12/06/17, 01/15/18 and 04/17/18 showed no list of physicians that the Board had approved for credentialing.

Review of the credentialing file and recent work schedule for Staff T, Physician, showed the following:
- Bureau of Narcotic and Dangerous Drugs (BNDD) license (individuals who prescribe and dispense controlled substances) expired 12/31/18.
- No documented date that his privileges were requested and approved.
- No documented date or signatures that the Medical Staff recommended, or the Governing Body approved, his appointment.
- His start date at the facility was 07/15/18.
- In the last two months he had worked in the Emergency Department on 12/10/18, 12/16/18, 12/17/18,12/21/18, 01/06/19, 01/07/19, 01/13/19 and 01/14/19.

Review of the credentialing file and recent work schedule for Staff N, Physician and Psychiatric Director, showed that her privileges at the facility expired 01/06/19 and there were no documented date or signatures that the Medical Staff recommended, or that the Governing Body approved, her reappointment. Staff N worked on 01/07/19, 01/08/19, 01/16/19 and 01/23/19 through 01/31/19 as the Psychiatric Director since her privileges had expired.

Review of the credentialing file for Staff L, Physician and Chief of Staff, showed that his professional license expired 01/31/18, BNDD license expired 02/28/18 and hospital privileges expired 01/06/19. There was no documented dates or signatures that the Medical Staff recommended, or the Governing Body approved, his reappointment.

Review of the credentialing file and recent work schedule for Staff X, Physician, showed that his professional license expired 01/31/18, Drug Enforcement Administration (DEA) license (an identifier assigned to a health care provider allowing them to write prescriptions for drugs that are addictive and at risk for abuse) expired 10/31/18, BNDD license expired 01/31/17 and hospital privileges expired 01/06/19. There was no documented dates or signatures that the Medical Staff recommended, or the Governing Body approved, his reappointment. Staff X worked in the Emergency Department on 01/21/19.

During an interview on 01/29/19 at 2:20 PM, Staff C, Chief Executive Officer (CEO), stated the following:
- He did not know if the Board of Directors were involved in Medical Staff appointments or credentialing;
- They had hired physicians in the ED through the Medical Executive Board;
- He was surprised to hear that physician privileges had expired; and
- Physicians should not have worked if their privileges were expired.

During an interview on 01/29/19 at 4:45 PM, Staff K, Medical Staff Coordinator, stated that the position was new for her and she was trying to get caught up. When a physician was appointed or reappointed to the Medical Staff, the Medical Executive Committee approved or denied the appointment. The appointment was not approved or denied by the Governing Body with a vote, it just had to be signed by a member of the Governing Body.

During an interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that he was not involved in Medical Staff appointments. Medical Staff appointments were approved through the Medical Executive Committee.

Based on interview and record review, the facility failed to follow Medical Staff Bylaws that give only the Governing Body the authority to grant medical staff privileges. This deficient practice had the potential for all patients admitted to the facility to receive substandard care. The facility census was 16.

Findings included:

1. Review of the facility's document titled, "Medical Staff By-Laws," dated 01/01/17, showed the following:
- The Board of Managers was also known as the Governing Body and/or Board of Directors of the Hospital.
- The purpose of the By-Laws was to establish accountability of the Medical Staff to the Board of Managers for appropriateness of professional performance and ethical conduct of its members, and to monitor the quality of medical care provided by all Practitioners authorized to practice in the Hospital, through the appropriate delineation of Clinical Privileges and an ongoing review and evaluation of each Practitioner's performance in the Hospital.
- Appointment to and membership on the Medical Staff shall confer on the appointee or member only such Clinical Privileges as have been granted by the Board of Managers in accordance with these By-Laws, the Medical Staff Rules and Regulations, and other Policies and Procedures.

Review of the facility's Board Meeting minutes on 12/06/17, 01/15/18 and 04/17/18 showed no list of physicians that the Board had approved for credentialing, appointment or reappointment.

During an interview on 01/30/19 at 9:00 AM, Staff L, Physician and Chief of Staff, stated that the Governing Body was not involved in the process of appointing Medical Staff.

During an interview on 01/29/19 at 2:20 PM, Staff C, Chief Executive Officer (CEO), stated that he did not know if the Board of Directors was involved in Medical Staff appointments or credentialing. They have hired physicians in the Emergency Department through the Medical Executive Committee.

During a telephone interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that he was not involved in Medical Staff appointments. Medical Staff appointments were approved through the Medical Executive Committee.

Based on interview and record review, the facility failed to ensure that the Governing Body had direct consultation with the leader of the Medical Staff, or the designee, to discuss matters related to the quality of medical care provided to patients. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 16.

Findings included:

Review of the facility's document titled, "Medical Staff By-Laws," dated 01/01/17, showed that the Chief of Staff duty was to provide day to day liaison on medical matters with the Chief Executive Officer (CEO) and the Board of Managers. He was to oversee that programs are clinically and professionally sound in accomplishing their objectives and are in compliance with regulatory requirements and report to the Board of Managers regarding such programs and activities.

Record review of the Governing Body Board Meeting Minutes did not contain any evidence that there were scheduled direct consultations between the Governing Body and the leader of the Medical Staff. The two Board meetings during 2018, 01/15/18 and 04/17/18, showed that neither the Chief of Staff nor any Medical Staff member, were present during the meetings.

During an interview on 01/30/19 at 9:00 AM, Staff L, Physician and Chief of Staff, stated that he did not meet with the Governing Body last year.

During a telephone interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that the Governing Body had not had any direct consultations with the Chief of Staff in the last year.