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Based on review of credential files, review of a credentialing agreement with a teleradiology entity, review of the Telemedicine Credentialing policy and procedure, and staff interview; the Critical Access Hospital (CAH) failed to have a telemedicine credentialing agreement that included all of the specification in the regulations for 2 of 2 teleradiologists (Radiologists W and X) reviewed. The Medical Staff Roster provided by E-mail on 1/28/16 listed 20 teleradiologists. The lack of an appropriate credentialing agreement for teleradiology has the potential to affect all patients receiving radiology services at the CAH.

Findings are:

A. Review of the credential files for Radiologists W and X revealed the information provided for the credentialing process was provided by the company that Radiologists W and X worked for. The other credential files contained information provided through an agreement with a CVO (Credential Verification Organization).

B. Review of the Credentialing Acknowledgement with the teleradiology entity with an effective date of 11/19/2007 revealed reference to Joint Commission (an accrediting organization) requirements; however, only stated that "CMS (Centers for Medicare and Medicaid Services) allows hospitals to delegate their responsibility for verification of credentials similarly to what is done when employing a CVO to perform those functions." The contract failed to include the CMS requirements at 485.616(c)(1)(i) through 485.616(c)(1)(vii) in the contract, which requires the distant site entity to:
-"Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff";
-"Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff";
-"Assure that the medical staff has bylaws";
-"Approve medical staff bylaws and other medical staff rules and regulations";
-"Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients";
-"Ensure that criteria for selection are individual character, competence, training, experience, and judgement"; and,
-"Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society".

C. Interview with the Executive Assistant (responsibilities included maintaining physician credential files for appointments/reappointments) on 1/21/16 at 1:05 PM revealed that the CAH relied on the credentialing information provided by the teleradiology entity.

D. Review of the Telemedicine Credentialing policy and procedure last reviewed in June of 2015 revealed the following:
"The written agreement must contain provisions requiring the distant-site hospital or telemedicine entity to use a credentialing and privileging process that meets Medicare standards defined in 42 CFR [Code of Federal Regulations] 482.12(a) and 482.22(a)." These regulation references are for Acute Care Hospitals but are the same as listed at 485.616(c)(1)(i) through 485.616(c)(1)(vii).

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to provide preventive maintenance for 8 of 48 randomly observed pieces of medical equipment (2 defibrillators - a piece of equipment used to shock the heart to get it beating right; 2 electrical surgical units - a piece of equipment used in surgery for cutting and or cauterizing living tissue; 1 suction pump in surgery - a pump that suctions blood, tissue and body fluids away from a surgical site; 2 noninvasive ventilators - piece of equipment that helps people that can not breathe on their own; and 1 heated humidifier - a device that adds heated moisture for patients using ventilators). The CAH identified 624 pieces of medical equipment. This failed practice has the potential to affect all patients of the CAH.

Findings are:

A. During tours of the Respiratory Therapy services on 1/12/16 from 4:10 PM to 4:25 PM, Outpatient Specialty Clinic Services on 1/14/16 from 9:00 AM - 10:05 AM, and the Surgery Department on 1/13/16 from 3:45 PM to 4:35 PM revealed 48 random pieces of equipment that had Biomedical stickers with an identification number on the equipment.

B. Interview with the Biomedical Equipment Support Services (Contracted employee doing preventive maintenance on medical equipment at the hospital), Electrician (CAH employee), CEO (Chief Executive Officer), CFO (Chief Financial Officer) and Support Services Director on 1/20/16 from 1:00 PM to 2:00 PM revealed the following:
-The 2 noninvasive ventilators (identifier numbers SA01035 and SA00720) in the respiratory storeroom need preventive maintenance by the company the ventilators were purchased from and this has not been done.
-The heated respiratory humidifier (identifier number SA01369) in the respiratory storeroom only gets an electrical safety check and needs a more in depth preventive maintenance according to the technical manual for the piece of equipment.
-The defibrillator in the surgery area (identifier number SA00981) and in the Outpatient Specialty Clinic (identifier number SA00904) were only getting electrical leakage and function test and need a more extensive preventive maintenance.
-The 2 electrosurgical units (identifier numbers SA00504 and SA00957) were only getting an electrical leakage and function test and need more extensive preventive maintenance. Preventive maintenance was completed on these 2 units yesterday after identified by surveyors on 1/13/16.
-The suction pump/waste management system (identifier number SA00929) located in the surgery area was not on the of medical equipment list, so added that piece of equipment which needs preventive maintenance.

Based on review of credential files, review of Medical Staff Bylaws on Appointment, Reappointment and Clinical Privileges Part II, review of medical records data on procedures performed by Physician - S and staff interview; the Critical Access Hospital (CAH) failed to follow the Medical Staff Bylaws in appointment/reappointment for 8 of 18 physicians/practitioners reviewed (Physicians N, O, Q and V; Nurse Practitioner Y; and Dentist T). The Medical Staff Roster listed 133 physician/practitioners. This failed practice has the potential to affect all patients receiving services at the hospital.

Findings are:

A. Review of the Medical Staff Bylaws on Appointment, Reappointment and Clinical Privileges Part II, (approved by the Board of Directors on 11/19/14) revealed the following under Article IV Clinical Privileges:
"Every practitioner practicing at this hospital by virtue of Medical Staff membership or otherwise shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to [Sic] by the Hospital Board of Directors except as provided in Section 3 and 4 of this Article IV. Review of Sections 3 and 4 revealed information about who could have admitting and co-admitting privileges.

Review of the credential file for Physician - S on 1/21/16, revealed the physician was recommended by the Medical Staff for appointment on 11/10/15. The section where the Board of Directors sign and date was dated 1/26/16 but contained no Board Member signature. Interview with the Executive Assistant on 1/21/16 at 9:50 AM revealed the following:
-Physician - S's credential file was to go to the Board of Director's meeting in November.
-The November meeting was canceled because there were not enough action items on the agenda.
-The Board of Directors do not have meetings in December.
-The January Board of Directors meeting is scheduled for 1/26/16.
-Physician S's credential file will go to the Board of Directors meeting at the 1/26/16 for granting of privileges.

Review of a document with Physician S's name at the top and a listing of procedures performed provided by the Medical Records Director on 1/21/16 at 10:20 AM revealed Physician S had performed 16 procedures between 12/17/15 and 1/13/16 without being granted those privileges by the Board of Directors.

Review of the credential files for Physicians U and W revealed there were no privilege listings in the credential files. Interview with the Executive Assistant on 1/21/16 at 1:05 PM confirmed these 2 credential files lacked a listing of privileges.

C. Review of the Medical Staff Bylaws on Appointment, Reappointment and Clinical Privileges Part II, approved by the Board of Directors on 11/19/14 revealed the following under Article III Clinical Privileges Section 2 Appointment Process "Verification includes, but may not be limited to verification of...Query of the National Practitioners Data Bank." Review of credential files for Physicians N, O, Q, Dentist - T and Nurse Practitioner Y revealed no copies of querying the National Practitioners Data Bank.

Interview with the Executive Assistant on 1/21/16 at 9:50 AM and again at 1:05 PM confirmed the credential files lacked the query of the National Practitioner Data Bank for Physicians N, O and Q, Dentist T and Nurse Practitioner Y.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to:
Part I: Ensure that 2 of 2 patient medical records (Patients 19 and 20) of patients identified as had died had a discharge order /release the body order.
Part II: Ensure that 1 of 5 swing bed records (Patient 33) contained documentation of the Speech Therapist visit following a physician order.
The failed practice of incomplete medical records, has the potential to affect all patients that were provided services at the CAH.

Findings are:

Part I
A. A review of Patient 19's medical record revealed that Patient 19 was admitted to the hospital on 5/2/15 and passed away on 5/7/15. A review of Patient 19's physician orders showed the lack of a discharge order/release of body order at the time of death. The body was released to the mortuary per the family request.

B. A review of Patient 20's medical record revealed that Patient 20 was admitted and passed away in the Emergency Room at the hospital on 9/29/15. A review of Patient 20's physician orders showed the lack of a discharge order/release of body order. The body was released to the mortuary at this time per the family request.

Interview with the Informatics Nurse on 1/20/16 at 12:15 PM, verified that there was not a discharge order/release of body order on Patient 19 or 20's record, and there is not a hospital policy to address it. The Informatics Nurse did convey that before Electronic Records were initiated that they obtained that order.
Part II
C. A review of Patient 33's medical record revealed a Physician order for Speech Therapyon 7/16/15 at 15:04 PM (3:04 PM) when admitted from acute level of care to swing bed (skilled level of care). Review of the medical record lacked any documentation of Speech Therapy provided to Patient 33 during the swing bed stay. Patient 33 was discharged on 7/22/15.

An interview on 1/20/16 at 2:30 PM with the Director of Therapy related to the missing documentation for the 7/16/15-7/22/15 Speech Therapy order revealed, that the Director of Therapy phoned the Speech Therapist on 1/19/16. The Speech Therapist could not recall the order or any circumstances in which the patient would not have been seen. The Director of Therapy reported that upon looking, there were no charges for Speech Therapy and no Speech Therapy notes in the swing bed stay medical record.

Based on record review, staff interview and policy review, the Critical Access Hospital (CAH) failed to ensure that 2 of 5 (Patients 33 and 34) patients medical record's included an updated History and Physical (H&P) or a progress note with the updated physical information at the time of the patients Swing bed admission. This failed practice has the potential to affect all patients that were admitted to Swing bed at the CAH.

Findings are:

A. A review of Patient 33's medical record revealed that the patient was admitted to Swing bed status on 7/16/15. The History and Physical for Patient 33 which was located on the Swing bed record was dated 7/13/15.

B. A review of Patient 34's medical record revealed that the patient was admitted to Swing bed status on 12/27/15. The History and Physical for Patient 34 which was located on the Swing bed record was dated 12/22/15.

Both Patient 33 and 34's medical record lacked a progress note with the updated physical information at the time of the Swing bed admission.

An interview with the Informatics Nurse on 1/20/16 at 12:15 PM verified that there was not a History and Physical or a progress not with the updated physical information present on the date of admission to Swing bed status for Patients 33 or 34.

Review of the Medical Record Documentation Requirements Policy (with the last date revised of 3/15) revealed: "...If a complete history has been recorded and a physical examination performed within thirty days prior to the patient's admission to the hospital, a reasonable durable, legible copy of these reports may be used in the patient's hospital medical record in lieu of a new H&P, provided these reports were recorded by a member of the medical staff. It is strongly suggested that a note be made on the progress notes, which includes the reason for hospitalization, the admitting diagnosis and the general plan of treatment, if established..."

Based on record review, staff interview and review of policy and procedures, the Critical Access Hospital (CAH) failed to ensure that 2 of 5 swing bed patients (Patients 32 and 33) records included documentation of activities offered or provided to the swing bed patients. This had the potential to affect all swing bed patients.

Findings are:

A. A review of Patient 32's medical record revealed that the patient was admitted to Swing bed status on 9/23/15 and discharged on 9/28/15. Patient 32's medical record lacked documentation of activities offered or provided to the patient while in swing bed.

B. A review of Patient 33's medical record revealed that the patient was admitted to Swing bed status on 7/16/15 and discharged on 7/22/15. Patient 33's medical record lacked documentation of activities offered or provided to the patient while in swing bed.

C. An interview with the Informatics Nurse on 1/20/16 at 12:15 PM verified that Patient's 32 and 33's medical record lacked documentation of activities offered or provided to the patients.

D. Review of the Skilled Care Activity Program Policy with a date revised of 5/09 revealed, "...Activities will be provided on a group or individual basis, to allow the patient the opportunity to engage in continuing life experience..."