HospitalInspections.org

Based on interview, record review, and policy review, the provider failed to ensure six of eight (E, F, H, I, J, and K) medical provider's request for additional privileges beyond the core privileges had been reviewed and approved by the medical staff and advisory board during the credentialing privileging process. Findings include:

1. Credentialing and privileging are formal, documented procedures that require specific rules and regulations for granting patient admission and provider clinical privileges to a hospital. They are an essential part of providing patients with the highest possible standards and levels of care

Review of the provider's undated Application Approval signature sheet included the following to have been checked:
*Appointment recommended, admitting privileges, and co-admitting privileges.
*Signatures of the chief of medical staff, administrator, and the advisory board chairman.

Review of the provider's undated Core Privileges, Duties, and Functions Request Form for Practice Area for the core areas included:
*Family practice, administration of anesthesia, certified nurse practitioner (CNP), physician assistant, general surgery procedures, and ophthalmology/optometry.
*Any other special request practice areas were also to have been marked on the form. Those special request areas could include additional:
-Diagnostic procedures.
-Treatment procedures.
-Surgical procedures.
*The special requests required documentation of additional training and/or experience in the credentialing file.

Interviews on 8/10/22 at 11:55 a.m. and 3:00 p.m. with director of administrative services B and business office representative C revealed:
*The credentialing and privileging process started approximately three to four months before having the medical staff or advisory board approve or reapprove the candidate.
*They were responsible for ensuring all the credentialing and privileging document requirements had been completed by the medical staff who had applied for credentialing and privileging.
*They had a checklist to ensure all the documents had been completed.
*They provided those completed checklists to the medical staff and advisory board.
*The checklist had all the requirements to have been completed and the dates they had been completed.
*Confirmed the privileging document had not been given to the medical staff or advisory board to review and sign.

Interview on 8/10/22 at 4:45 p.m. with administrator A revealed:
*He had just recently been appointed as the administrator.
*An interim administrator had attended the medical staff and advisory board meetings.
*No medical staff or advisory board meetings had been held in July 2022.
*He thought the entire credentialing file was taken to those meetings and all parts reviewed.
-He would have expected the entire credentialing file to have been taken to those meetings.

Review of the credentialing and privileging files for:
a. Medical doctor (MD) E:
*Had requested core privileges on 9/21/20 for family practice.
*Had requested additional privileges for cardioversion, pediatric electrocardiography interpretation, thoracentesis, chest tubes, and ultrasound to determine fetal position.
*He had requested those privileges to have been reviewed with his reapproval application.
*There were no signatures on the privilege request form from the medical staff or advisory board to indicate the requested privileges had been reviewed or approved.
*His credentialing application had been accepted on 1/8/21 by the medical staff and 1/25/21 by the governing body.

b. Certified registered nurse anesthetist (CRNA) F:
*Had requested privileges on 11/2/21 for the administration of anesthesia to have been reviewed with his reapproval application.
*There were no signatures on the privilege request form from the medical staff or advisory board to indicate the requested privileges had been reviewed or approved.
*His credentialing application had been accepted on 4/1/22 by the medical staff and 4/25/22 by the governing body.

c. Physician assistant - certified (PA-C) H:
*Had requested privileges on 2/21/22 for the core privileges of a PA-C to have been reviewed with her reapproval application.
*Had requested additional privileges that included intubation, simple suture of lacerations, vaginal exam/pap/smear, and clean and debride wounds
*There were no signatures on the privilege request form from the medical staff or advisory board to indicate the requested privileges had been reviewed or approved.
*Her credentialing application had been accepted on 3/4/22 by the medical staff and 3/28/22 by the governing body.

d. MD I:
*Had requested privileges on 1/8/21 for general surgery to have been reviewed with his reapproval application.
*Had requested additional privileges that included laparoscopic surgery, advanced.
*There were no signatures on the privilege request form from the medical staff or advisory board to indicate the requested privileges had been reviewed or approved.
*His credentialing application had been accepted on 6/4/21 by the medical staff and 6/7/21 by the governing body.

e. MD J:
*Had requested privileges on 5/5/21 for ophthalmology to have been reviewed with his reapproval application.
*Had requested additional privileges that included ophthalmologic surgery.
*There were no signatures on the privilege request form from the medical staff or advisory board to indicate the requested privileges had been reviewed or approved.
*His credentialing application had been accepted on 10/8/21 by the medical staff and 10/25/21 by the governing body.

f. CRNA K:
*He had requested privileges on 3/10/21 for the administration of anesthesia to have been reviewed with his reapproval application.
*There were no signatures on the privilege request form from the medical staff or advisory board to indicate the requested privileges had been reviewed or approved.
*His credentialing application had been accepted on 8/6/21 by the medical staff and 8/30/21 by the governing body.

Review of the 1/7/22, 2/4/22, 3/4/22, 4/1/22, 5/6/22, and 6/10/22 medical staff meeting minutes revealed the following statement before the initial appointments, reappointments, and resignations. "The applications for privileges were reviewed by the Medical Staff as they relate to appointments, reappointments, and resignations from Avera Dells Area Hospital (ADAH) Medical Staff. [physician name] made a motion to approve the below slate of appointments, reappointments, and resignations of privileges to ADAH. The applications will further be reviewed by [interim administrator] and then the Hospital Board for the recommendation for final approval by the Avera McKennan Board."

Review of the 1/31/22, 2/28/22, 3/28/22, 4/25/22, 5/23/22, and 6/27/22 advisory board meeting minutes revealed the following statement before the initial appointments, reappointments, and resignations. "Applications for credentialing and privileges to Avera Dells Area Hospital were reviewed by the Advisory Board. [Board member] motioned to recommend to the Avera McKennan Board of Directors the above slate of Medical Staff member appointments, reappointments, and resignations to ADAH. [Board member] seconded the motion. Motion carried unanimously by the Advisory Board. The Medical staff member appointments, reappointments, and resignations were further reviewed and approved by the Medical Staff, signed by [name] Chief of Medical Staff, as well as the Interim Administrator [name]."

Review of the provider's last revised August 2011 Medical Staff Credentialing policy revealed:
*"The assure that the appointment and reappointment process and the granting of clinical privileges will be accomplished in a uniform manner which ensures that only individuals who have gone through the credentialing process with final approval from the Avera Dells Area Hospital Board of Directors provide services within the scope of their granted individual clinical privileges."
*"When completed credentialing files are returned from Avera Credentialing Verification Services, the file will be submitted to the Medical Staff for their review and approval. If the Medical Staff approves of the file, the file will then be forwarded to the Avera Dells Area Hospital Board of Directors for their review by the CEO [chief executive officer] requesting approval of the file."