HospitalInspections.org

Based on review of facility documents, credential files (CF) and interview with facility staff (EMP) it was determined that the facility failed to follow adopted bylaws by failing to ensure that medical staff and allied health professionals were credentialed/privileged to practice in five of 10 credential files (CF1, CF2, CF3, CF4 and CF5).

Findings include:

Review of "Bylaws of the Medical Staff of Windber Medical Center" dated October 4, 2023, revealed, "... Definitions ... 6) Clinical Privileges or Privileges-Duty or permission to independently provide medical or other patient care services in the Medical Center. When an individual has clinical privileges, that individual shall have full and unrestricted access to those hospital resources which are reasonably necessary to the full exercise of the privileges, including but not limited to, all necessary hospital equipment, facilities, and personnel, except to the extent such access is limited by a restriction on the privileges imposed in accordance with these Bylaws. ... Part B. Section 1. Duration of Initial Provisional Appointment ... All initial appointments to the Medical Staff, regardless of the staff category and all initial clinical privileges are provisional from the date of the appointment until the board has acted upon a recommendation to grant or not to grant a regular appointment. At the end of the initial six-month provisional period, the practitioner's activity will be assessed. If the practitioner's clinical activity has not been sufficient upon which to make a determination, the provisional period may be extended to a total of 24 months (to allow for the aggregation of sufficient data on clinical activity). The appointment is then provisional up to 24 months from the initial date of appointment until the board has acted upon a recommendation to grant or not to grant a regular appointment. ... ."

Review of credential file (CF1) Board of Directors most current reappointment letter dated July 7, 2022, revealed, "... You have been granted Allied Health Professionals Staff, Category I A (Independent Practitioner) privileges from 7/6/2022-6/30/2024. ... ."

Review of credential file (CF2) Board of Directors most current reappointment letter dated July 7, 2022, revealed, "... You have been granted Active Medical Staff privileges in the Department of Surgery-Anesthesia, from 7/6/2022 thru 6/30/2024. ... ."

Review of credential file (CF3) Board of Directors most current reappointment letter dated January 10, 2023, revealed, "... Provisional privileges are granted from 1/4/2023 to 1/4/2024 (always 12 months. ... ."

Review of credential file (CF4) Board of Directors most current reappointment letter dated October 7, 2022, revealed, "... You have been granted Allied Health Professionals Staff, Category II A privileges as a Certified Physician Assistant from 10/5/2022 to 9/30/2024. ... ."

Review of credential file (CF5) Board of Directors most current reappointment letter dated September 8, 2023, revealed, "... You have been granted provisional active privileges in the Department of Surgery. Your provisional privileges are granted from 9/6/2023 to 9/6/2024, (always 12 months). ... ."

Interview with EMP3 and EMP4 on October 3, 2024, confirmed the above medical staff and allied health professionals lapsed in their stated appointment/reappointment and continued to attend patients.

Based on review of facitlty documents and interview with facility staff (EMP) it was determined that the facility failed to ensure safe practices by failing conduct quarterly fire drills at its provider-based satellite clinics in three of eight clinics.

Findings include:

Request was made by surveyor to review the last four quarterly fire drills for the facility's provider-based satellite clinics on October 1, 2024.

Review of facility documentation entitled, "Educational Inservice Sign-In Sheets ... Program Title: Fire Drill off Site Draw Stations ... Fire drill performed by: ..." failed to reveal documention that a fire drill was conducted quarterly in three of eight locations.

Interview with EMP1 on October 3, 2024, confirmed the above finding.