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Based on bylaws review, agreement review, document review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure medical staff reappointment followed the bylaws for 1 of 1 distant-site telemedicine entity physician (Physician #2) reviewed who provided emergency care services to the CAH's patients through telemedicine. Failure to follow the bylaws for reappointment of telemedicine providers placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the governing board's "Bylaws of Mountrail County Medical Center, Inc. [incorporated]" occurred on 11/20/23 at 3:30 p.m. These undated bylaws, stated,
". . . Article 6 - Medical Staff . . .
6.2) Medical Staff Applications. . . . the Board shall act on Medical Staff applications that have been approved by the Executive Committee. . . ."

Review of the "Bylaws Medical Staff Mountrail County Medical Center, Inc. Stanley, North Dakota" occurred on 11/20/23 at 12:35 p.m. These bylaws, effective 04/21/23, stated,
". . . Article IV Membership . . .
Section 5. Term of Appointment
a. Appointments to the Medical Staff shall be made by the Governing Board and shall be for a period of two years. . . .
Section 7. Credentialing from outside hospital or entity
The medical staff . . . will also accept credentialing and privileging of telemedicine practitioners thru [sic] [name of telemedicine entity] . . ."

Reviewed on 11/21/23, the CAH's "Agreement for Credentialing and Privileging of [name of entity]," dated 02/26/20, stated, ". . . Now, therefore, the parties do hereby agree as follows: . . .
6. Hospital's Responsibilities. Hospital agrees to perform the following:
A. Rely upon the credentialing and privileging decisions and protocols as established by Distant Site to grant telemedicine privileges to Distant Site's Telemedicine Practitioners who will be providing telemedicine services to Hospital's patients. . . ."

Review of providers' 2021-2023 credentialing files occurred on 11/21/23 and indicated the following:
- Physician #2: lacked evidence of reappointment since 07/23/20.

Upon request on 11/21/23, the CAH failed to provide evidence of Physician #2's reappointment since 2020.

During interview in the afternoon of 11/21/23, two administrative staff members (#2 and #3) responsible for medical staff credentialing confirmed the CAH had not reappointed emergency telemedicine Physician #2 since 2020.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure medical staff reappointment followed the bylaws for 1 of 4 consulting physician's file reviewed (Provider #1). Failure to follow the bylaws for reappointment of medical staff members placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the governing board's "Bylaws of Mountrail County Medical Center, Inc. [incorporated]" occurred on 11/20/23 at 3:30 p.m. These undated bylaws, stated,
". . . Article 6 - Medical Staff . . .
6.2) Medical Staff Applications. . . . the Board shall act on Medical Staff applications that have been approved by the Executive Committee. . . ."

Review of the "Bylaws Medical Staff Mountrail County Medical Center, Inc. Stanley, North Dakota" occurred on 11/20/23 at 12:35 p.m. These bylaws, effective 04/21/23, stated,
". . . Article IV Membership . . .
Section 5. Term of Appointment
a. Appointments to the Medical Staff shall be made by the Governing Board and shall be for a period of two years. . . ."

Review of providers' 2021-2023 credentialing files occurred on 11/21/23 and indicated the following:
- Physician #1: lacked evidence of reappointment since 06/22/11.

Upon request on 11/21/23, the CAH failed to provide evidence of Physician #1's reappointment since 2011.

During interview on 11/21/23 at 10:15 a.m., an administrative staff member (#4) confirmed Physician #1 provided laboratory directorship for the CAH.

During interview in the afternoon of 11/21/23, two administrative staff members (#2 and #3) responsible for medical staff credentialing confirmed the CAH had not reappointed Physician #1 since 2011.

Based on policy review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the services furnished by the CAH for 1 of 1 year reviewed (October 2022 - September 2023). Failure to evaluate the services furnished by the CAH limited the CAH's ability to ensure the provision of quality services to meet the needs of the CAH's patients.

Findings include:

Review of the policy "Quality Assurance Program" occurred on 11/21/23. This policy, revised in 2016, stated, ". . . Annual Assessment: This plan shall be evaluated on an ongoing basis to assure that it meets the quality review needs of the institution. . . . Documentation will include a summary of relevant findings and actions required assuring or improving the coordination of quality assurance and evidence or the program impact on improving clinical performance and patient/resident care. . . ."

Review of the Quality Assurance Quarterly Meeting Minutes from October 2022 through September 2023 occurred on 11/21/23. The minutes failed to include a review and evaluation of the services directly provided by the CAH to ensure the services met the needs of the CAH's patients.

Upon request on 11/22/23, the CAH failed to provide evidence of review and evaluation of the services directly provided by the CAH.

During interview on 11/22/23 at 10:10 a.m., an administrative staff member (#1) confirmed the CAH had not documented an evaluation of the services directly provided by the CAH.

Based on policy review, meeting minutes review, document review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 1 of 1 year reviewed (October 2022 - September 2023). Failure to evaluate services furnished by contractors limited the CAH's ability to ensure the contractors provided quality services for the CAH and its patients.

Findings include:

Review of the policy "Quality Assurance Program" occurred on 11/21/23. This policy, revised in 2016, stated, "Purpose: To implement a quality assurance program designed to monitor, evaluate, maintain and/or improve the quality and appropriateness of patient/resident care within available resources. . . . Scope: The Quality Assurance Program shall be facility wide, apply to all departments, services and practitioners whose activities within the facility have direct influence on the quality of patient/resident care. . . ."

Review of the Quality Assurance Quarterly Meeting Minutes from October 2022 through September 2023 occurred on 11/21/23. The minutes included evaluations of three nursing and eight plant operations contracted services. The minutes failed to include evaluations to ensure the contracted services met the needs of the CAH and its patients for approximately 22 contracted services.

Review of the CAH's list of contracted services occurred on 11/22/23. This undated list showed approximately thirty contractors provided direct and indirect patient care services at the CAH.

Upon request on 11/22/23, the CAH failed to provide evidence of evaluation of approximately 22 contracted services used by the CAH to ensure the contractors provided quality services for the CAH.

During interview on 11/22/23 at 10:10 a.m., two administrative staff members (#1 and #2) confirmed the CAH had not documented an evaluation of all the contracted services used by the CAH in the past year.