HospitalInspections.org

Based on interviews and document review, the facility's governing body failed to appoint medical staff in accordance with the facility's Medical Staff By-laws and Rules and Regulations in 8 of 8 provider records reviewed (Providers #1, #2, #3, #4, #5, #6, #7 and #8).

The failure to adequately check the qualifications of providers, and to appoint and specifically delineate privileges for each provider, created the potential for unqualified providers to treat patients in the facility.

Findings:

1. Review of the Medical Staff By-laws and Rules and Regulations for the facility, last revised July, 2013, revealed patients were to be admitted to a practitioner with "Active Medical Staff " level of membership in the medical staff. The medical staff also had additional levels of membership, including "Consulting Medical Staff," Temporary Privileges," Courtesy Medical Staff" and "Allied Health Professionals."

The By-laws required that all medical staff membership was to be initiated by a written application for medical staff appointment and a request for specific privileges, which included evidence of professional training, valid/current professional license and Drug Enforcement Administration (DEA) registration. The written application also required evidence of adequate malpractice insurance, specialty board certification, information related to professional practice experiences and hospital affiliations. The document additionally indicated that the facility would review background checks, history of Medicare/Medicaid sanctions, evidence of review by the National Practitioners Data Base (DPDB) and 3 professional peer references. The document also stated that the term of appointment was 2 years with a reappointment application to be submitted to renew membership. The document also referred to delineation of privileges request that was a part of the applications forms to be completed and submitted to the Administrator to begin the appointment process.

a) Review of provider files provided by the facility revealed that 7 of 8 files (Providers #1, #2, #4, #5, #6, #7 and #8) did not contain evidence of appointment by the governing body. A signature sheet for Provider #1, dated 10/21/09 and signed by the governing board chairman on 10/27/09 simply carried the heading "Medical Staff" with the provider's name written in below it. It contained no language indicating medical staff appointment or the membership level.

There was no evidence any of the above listed providers had been appointed to the medical staff by the Governing Body.

b) 8 of 8 files (Providers #1 through #8) did not contain appointment applications, delineation of privileges, evidence of insurance, evidence of background checks, third-party verification of the supplied information, review for any history of Medicare/Medicaid sanctions, evidence of review by the National Practitioners Data Base (DPDB) or a check of 3 professional peer references.

c) Although Provider #1 had evidence through the signature sheet of an affiliation with the hospital since October, 2009, there was no evidence of re-applications or re-appointments, which would have been due in 2011 and 2013.

d) During an interview with the Administrator on 04/08/14 at 1:15 p.m., s/he stated the facility was not generating appointment or delineation of privileges documents.

On 04/09/14 at 9:20 a.m., the Administrator stated the appointment and credentialing paperwork was the responsibility of the Director of Medical Records. The Administrator stated s/he had spoken with the Director of Medical Records and confirmed s/he had never done a delineation of privileges and the two cardiology consultants and chiropractor were not appointed or privileged, since they did not admit patients.

On 04/09/14 at 1:50 p.m., the Administrator confirmed Provider # 8, had never been appointed to the medical staff of the hospital. The Administrator stated s/he was unaware the provider should have been appointed to the hospital staff when the transition from the nursing home to Swing Beds occurred. S/he acknowledged the process they were following and the provider files were not in compliance with the requirements and the process outlined in the Medical Staff By-laws, Rules and Regulations.

e) During an interview with the Chief of Staff (Provider #1) on 04/09/14 at 1:30 p.m., the process for credentialing, appointing medical staff and delineating privileges was reviewed. S/he acknowledged that all providers seeing patients in the facility would need a thorough credential review, be appointed and have their specific privileges delineated as a part of the process. S/he stated this would happen going forward and that they had been mistakenly relying on a parallel process conducted by the facility's insurance company, rather than following the process outlined in the Medical Staff By-laws, Rules and Regulations.

f) On 04/09/14 at 2:00 p.m. the Director of Medical Records, who also acted as the support to the Medical Staff regarding applications, credentialing and appointments, was interviewed. S/he acknowledged the facility was not currently doing appointment letters and following the application process outlined in the Medical Staff By-laws, Rules and Regulations.

The Director of Medical Records stated s/he had previously kept better provider records, but had stop in the last several years when the process was taken over by the previous administrator. S/he stated they had believed there was no need to do delineation of privileges because the providers did not do surgery at the hospital. The by-law requirements and the intent of delineation of privileges and examples of other kinds of non-surgical privileges were discussed and s/he stated s/he would work to be more compliant with the by-laws for all providers, regardless of their membership level.