HospitalInspections.org

Based on record review and interview, the facility failed to ensure the governing body appointed eligible candidates for medical staff membership as are required by the facility's Governing Board By-Laws, last reviewed 11/04/15.

Findings included:


1. Record review on 12/15/15 of physician credentialing files revealed that seven of eight (Files #1, 2, 4, 5, 6, 7, & 8 ) physician's who practiced at the facility had expired medical staff appointments to the facility medical staff ( #1, 2, 4, 5, 6, 7 had expired 07/02/15 and #8 had expired 12/04/14.)

2. Record review on 12/16/15 on of the facility's Governing Body By-Laws By-Laws revealed but was not limited to the following: " Powers of the Board: The Board of Directors have full power and authority to appoint to or dismiss from the staff such physicians as deemed necessary for the efficient operation of the hospital district; provide for temporary appointments to the staff as the Board considers necessary; and consider the recommendations of the Medical Staff, as provided by VI of these Bylaws. The Board shall be responsible for the organization, management, control, and operation of the Hospital, including appointment of the Medical Staff.

3. Interview on 12/16/15 at 11:00 AM with the facility Health Information Manager/Medical Staff Coordinator revealed she was responsible for the credentialing process including new and reappointments of physicians and mid-level practitioners. She indicated that all reappointments to the medical staff were not current due to other projects being completed at the facility. She stated that all expired physician appointments have not been reviewed by the Board of Directors as of this date.

Based on record review and interview, the facility failed to ensure the medical staff examined the credentials of eligible candidates for medical staff membership and a recommendation was made to the governing body regarding their ability to provide medical services at the facility as are required by the facility's By-Laws, Rules & Rules of the Medical Staff of the facility.

Findings included:

1. Record review on 12/15/15 of physician credentialing files revealed that seven of eight (Files #1, 2, 4, 5, 6, 7, & 8 ) physician's who practiced at the facility had expired medical staff appointments to the facility medical staff ( #1, 2, 4, 5, 6, 7 had expired 07/02/15 and #8 had expired 12/04/14.)

2. Record review on 12/16/15 on of the facility By-Laws, Rules & Regulations of the Medical Staff of the facility, not dated, revealed but was not limited to the following: " Reappointment Application: The hospital shall send the member an application for reappointment six months prior to the expiration of the term of appointment. The member shall submit the signed reappointment application. Hospital's personnel shall verify the information provided on the reappointment application and notify the member of any information inadequacies or verification problems. Hospital personnel shall collect for the Medical Staff all relevant information regarding the appointee's professional and collegial activities, performances and conduct in the hospital as detailed in the Medical Staff policy. The Credentials and Professional Standards Committee shall review and investigate the applicant's professional competence, qualifications, character, prior behavior, ethical standing, professional or other conduct inside or outside the hospital, any current or past limitations or revocations placed on the applicant's license to practice in the state or any other state, and any other evidence it deems appropriate."

3. Interview on 12/16/15 at 11:00 AM with the facility Health Information Manager/Medical Staff Coordinator revealed she was responsible for the credentialing process including new and reappointments of physicians and mid-level practitioners. She indicated that all reappointments to the medical staff were not current due to other projects being completed at the facility. She stated that all expired physician appointments have not gone to the credential committee as of this date.