HospitalInspections.org

Based on interview and documentation review the hospital faild to ensure that each Medicare certified hospital had its own separate Governing Body.

Interviews and policy review established that the SMDC Health System Governing Body is the corporate board for all governing responsibilities for St Marys Medical Center and each of its entities, which includes: St Mary's Medical Center, St Mary's Duluth Clinic, Pine Medical Center, and St Mary's of Superior. The Governing Body will take action for credentialing, privileging, officers, bylaws, and rules and regulations for each facility.


Employees (C)/Senior Officer and Employee (A)/Vice President of Medical Affairs verifed that there is one governing body for all of the hospitals, and that is the SMDC Board. The Board is responsible for approving medical staff, credentialing, hiring of the CEO, and the budgets. They stated that each hospital has an advisory board or an operational board in place. Each facility has a Medical Staff Executive Committee which will approve the medical staff, and the final approval will be made by the SMDC board.