HospitalInspections.org

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Based on interview and document review, the Governing Board failed to adopt and implement processes for ensuring that all providers obtained clinical privileges prior to practice (Item #1) and for granting clinical privileges to providers and as required by the Governing Board Bylaws (Item #2) for 14 of 15 provider records reviewed (Staff #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #19).

Failure to grant clinical privileges and ensure that all providers obtain clinical privileges prior to treating patients according to the Governing Board Bylaws risks patient harm from substandard care and adverse outcomes.

Findings included:

Item #1 Treating Patients without Privileges

1. Review of the hospital document titled, "Amended and Restated Governing Board Bylaws of Cascade Behavioral Health Hospital, LLC," approved 08/25/21, showed that in order for any physician or Allied Health Professional to practice in the facility, the provider must first be appointed to the Medical Staff or the Allied Health Professional staff and be granted specific clinical privileges. The Medical Staff Bylaws shall include a mechanism whereby the Medical Executive Committee (MEC) makes recommendations to the Goverrning Board regarding the mechanism used to review credentials and delineate individual clinical privileges and approval or denial for Medical Staff or Allied Health Professional Staff appointment and clinical privileges.

2. On 02/09/22 at 1:22 PM, the Director of Risk (Staff #1) emailed a document to the investigators showing that 14 providers received Governing Board approval for clinical privileges as follows:

a. On 11/16/20, Staff #10, #11, and #12 were approved for clinical privileges.

b. On 05/10/21, Staff #4, #10, and #15 were approved for clinical privileges.

c. On 09/29/21, Staff #5, #6, #7, #8, #9, #13, #14, and #19 were approved for clinical privileges.

d. Staff #16 did not appear on the list.

3. Review of the year 2021 Governing Board meeting minutes showed the following:

a. On 02/25/21, the Governing Board approved clinical privileges for Staff #16.

b. On 05/10/21, the Governing Board approved clinical privileges for Staff #4, and #18.

c. On 09/29/21, the Governing Board approved clinical privileges for Staff #5, #14, #15, and #19.

d. On 11/29/21, the Governing Board approved clinical privileges for Staff #6, #7, #9, and #13.

e. There was no documentation showing that Staff #8 ever received the Governing Board's approval for clinical privileges.

4. Review of provider schedules showed the following:

a. Staff #4 was scheduled 9 shifts without approved clinical privileges between 04/10/21 and 05/09/21.

b. Staff #19 was scheduled 22 shifts without approved clinical privileges between 09/01/21 and 09/28/21.

c. Staff #13 was scheduled 52 shifts without approved clinical privileges between 09/01/21 and 11/29/21.

d. Staff #8 was scheduled 99 shifts without approved clinical privileges between 09/01/21 and 02/15/22.

5. On 02/09/22 at 9:36 AM, Investigators #12 and #15 interviewed the Corporate Director of Quality and Compliance (Staff #3). Staff #3 stated that she was a voting member of the Governing Board, and she participated in the approval process for providers' clinical privileges. Staff #3 confirmed that all provider credentialing files should include accurate documentation of when the MEC and the Governing Board approved clinical privileges. Staff #3 confirmed the investigators' findings that the approval dates in the providers' records and the actual committee approval dates were inaccurate, stating they "don't match up a lot of times."

Item #2 Clinical Privileging Approval Process

1. Review of the hospital document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective 06/07/21, showed that:

a. Applicants seeking Medical Staff membership and clinical privileges must submit a completed application prior to consideration. Completed application packets include: a signed application form with the request for specific clinical privileges desired, detailed information concerning the applicant's qualifications, education, character, experience, background, relevant training, ability, current licensure, competence, clinical activity professional ethics, physical emotional, and mental capability, valid picture identification and an agreement to follow administrative remedies if an adverse ruling occurs.

b. Medical Staff member responsibilities include the investigation and consideration of each complete application seeking initial appointment or reappointment to the Medical staff and for any Allied Health Staff seeking clinical privileges. The MEC is responsible for reviewing all completed applications and submitting recommendations for approval or denial of clinical privileges to the Governing Board. No provider shall be awarded Medical Staff membership or clinical privileges without Governing Board approval.

2. On 02/10/22, Investigators #12 and #15 reviewed the hospital's credentialing and privileging records of 14 hospital providers. The record review showed that:

a. 3 of 14 provider records showed no documentation of MEC and Governing Board approval for clinical privileges (Staff #5, #6, and #7).

b. 2 of 14 providers showed documentation that the temporary privileges granted had expired after 120 days (Staff #8 and #9). The clinical privileges for Staff #8 expired on 12/22/21, and Staff #9's clinical privileges expired on 02/10/22.

c. 3 of 14 providers showed applications for clinical privileges were expired or missing documentation of Governing Board approval (Staff #13, #14, #15).

d. 3 of 14 providers worked 10 months with expired clinical privileges (Staff #10, #11, and #12). The requests for clinical privileges were approved by the MEC on 01/06/20, but they were not approved by the Governing Board until 11/16/20.

e. 6 of 14 provider records did not contain documentation from 2 references (Staff #4, #8, #10, #11, #12, and # 16).

3. On 02/14/22 at 4:46 PM, Investigators #12 and #15 interviewed the Administrative Assistant responsible for provider credentialing (Staff #17). The interview showed that the facility terminated the credentialing specialist in 09/21, the duties were reassigned to Staff #17, and she was trained to process applications for initial and renewal of clinical privileges by the Corporate Director of Quality (Staff #3). Staff #17 stated that when applying for clinical privileges, the applicants must submit the names of three references, and at least two references must be returned in order for the applicant to advance. Staff #17 stated that once the application packet was complete, she would type up a credentialing summary for the Chief Executive Officer (CEO) to review, and the CEO would forward the information to "anyone who needed it."

4. On 02/15/22 at 9:36 AM, Investigators #12 and #15 interviewed the Corporate Director of Quality and Compliance (Staff #3). Staff #3 stated that she was a voting member of the Governing Board, and she participated in the approval process for providers' clinical privileges. Staff #3 confirmed that all application packets must be complete before they were sent to the MEC and Governing Board for review, and the hospital required that all providers obtain at least two references to complete the application packet. Staff #3 stated that applications should not move forward with one or fewer references, but "I'm not going say it's never happened."
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Based on interview and document review, the hospital failed to ensure that any revisions or modifications to the medical staff bylaws and medical staff rules and regulations were approved by the medical staff and the governing body.

Failure to ensure that the governing body and medical staff review and approve any revisions or modifications to the medical staff bylaws and medical staff rules and regulations risks patient harm from substandard performance and unsafe care.

Findings included:

1. Review of the document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective 06/07/21, showed that the Medical Staff shall have the initial responsibility and authority to formulate, adopt and recommend Medical Staff Bylaws and amendments for approval by the Governing Board. Neither the Medical Staff nor the Governing Board may unilaterally amend the Medical Staff Bylaws. Bylaws shall be adopted, amended, or repealed by an affirmative vote of a majority of Medical Staff members eligible to vote, present, and voting at a meeting where a quorum is present, followed by a the affirmative vote of a majority of the Governing Board after receiving the recommendation of the Medical Staff.

2. Review of the document titled, "Rules and Regulations of the Medical Staff of Cascade Behavioral Health," effective 11/21, showed that changes in the Rules and Regulations may be initiated by any committee of the Medical Staff and subject to the approval process set forth in the Medical Staff Bylaws. The document contained no dates or signatures from the Chief Medical Officer (CMO) or the Governing Board.

3. Document review of Medical Executive Committee (MEC) meeting minutes, dated 11/17/21, showed no evidence that the MEC recommended Governing Board approval for amendments to the Medical Staff Rules and Regulations as required by the Medical Staff Bylaws.

4. Document review of the Governing Board meeting minutes showed that on 11/29/21, the Governing Board held an ad hoc meeting to discuss provider credentialing. The investigator found no evidence that amendments to the Medical Staff Rules and Regulations made on 11/18/21 were recommended by the MEC and approved by the Governing Board as required by the Medical Staff Bylaws.

5. On 02/15/22 at 4:30 PM, the Director of Risk Management (Staff #1) confirmed the investigator's findings that on 11/18/21, the Governing Board made changes to the Medical Staff Rules and Regulations without recommendation from the MEC, and the signature sheet for the amended document did not contain dates or signatures from the CMO and the Governing Board.
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Based on interview and document review, the governing body failed to have direct consultation with Medical Staff Leadership about the quality of medical care provided to patients.

Failure to review and discuss quality of medical care provided to patients with the Medical Staff Leadership places patients at risk for harm from substandard care.

Findings included:

1. Review of the hospital document titled, "Amended and Restated Governing Board Bylaws of Cascade Behavioral Health Hospital, LLC," approved 08/25/21, showed the following:

a. The Governing Board is accountable for the safety and quality of care, treatment, and services provided by the facility.

b. The document showed that the Acadia Health Board of Directors authorized the Governing Board to receive and evaluate periodic reports from the Medical Staff and its officers, to oversee quality assessment and improvement, risk management, and similar matters regarding the provision of quality patient care at the facility, and to establish policies regarding these matters.

2. Review of the hospital document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective 06/07/21, showed that:

a. The MEC shall account to the Governing Board and to the Medical Staff for the overall quality, uniformity, and efficiency of medical care rendered to patients.

b. MEC shall meet at least four times during the year and maintain minutes as is appropriate for the meeting.

c. The CEO, or his designee, shall attend every MEC meeting.

3. Review of the hospital's MEC Meeting Minutes showed the following:

a. The hospital's MEC held three regular MEC meetings in 2021 including 01/29/21, 04/30/21, and 11/17/21.

b. On 04/30/21, the MEC meeting lasted 7 minutes, and a "credentialing vote" was the only agenda item listed. There was no documentation that the meeting included a discussion related to the quality, uniformity, and/or efficiency of medical care rendered to patients.

4. On 02/11/22 at 1:30 PM, Investigators #12 and #15 interviewed the Chief Medical Officer (Staff #4). During the interview, Staff #4 was unable to describe a formal process where he met with the CEO or Governing Board to discuss routine or urgent quality of medical care events in the hospital.

5. On 02/11/22 at 2:45 PM, Investigators #12 and #15 interviewed the Director of Risk Management (Staff #1). During the interview, Staff #1 confirmed the investigator's finding that the Governing Board and MEC did not meet 4 times during the 2021 calendar year.
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Based on interview and document review, the hospital failed to develop and implement policies and procedures for exemption requests and accommodations approvals (Item #1) and education to mitigate the transmission of COVID-19 for unvaccinated staff (Item #2).

Failure to develop and implement policies and procedures for accommodation contingencies, exemption requests and accommodations approvals places patients, visitors, staff, and the
community at risk for illness, disability, and death.

Findings included:

ITEM #1 Exemption Requests and Accommodation Approvals

1. Review of the hospital policy titled. "HR. CVS.101 Covid Vaccination for staff DRAFT," dated 01/01/22 , showed that:

a. Staff may be exempt from the vaccination requirements under section one (1) only upon providing their site Human Resources an exemption form, signed by the individual stating either of the following:

i. The staff is declining vaccination based on sincerely held Religious Beliefs.

ii. The staff is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reasons.

iii. To be eligible for a Qualified Medical Reasons exemption the staff must provide a written statement signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician stating that the individual qualifies for the exemption for which vaccine and clinical reason for the exemption. The statement should not describe the underlying medical condition or disability. It may indicate the probable duration of the staff's inability to receive the vaccine, if unknown or permanent, should indicate.

2. Review of 6 documents titled, "Request for Accommodation: Religious Exemption from Mandatory Covid-19 Vaccination" and signed by Staff #1601, #1602, #1603, #1604, #1605, and #1606, stated "I have read and understand Cascade's policy on religious accommodation."

3. Review of a document titled, "Request for Accommodation: Medical Exemption from Mandatory Covid -19 Vaccination," signed by Staff #1606, showed a provider statement stating that Staff #1606 should not receive a flu shot. No references to Covid-19 specific vaccinations were found.

4. On 02/08/22 at 12:09 PM, and interview with the Human Resources Manager (Staff # 1607) showed that the facility has no policy titled, "Request for Accommodation: Religious Exemption from Mandatory Covid-19 Vaccination," the criteria for exemption was to file an exemption request, and there was no process other than approval for the evaluation of either Religious or Medical accommodation requests.


Item #2 Education to Mitigate the Transmission of COVID-19 for Unvaccinated Staff

1, Document review of 7 exemption requests and approvals showed no evidence that staff requesting exemptions were provided education to mitigate the transmission of COVID-19.

2. On 02/08/22 at 12:09 PM, an interview with the Human Resources Manager (Staff #1608) showed that the facility had not provided education to mitigate the transmission of COVID-19 to staff who had requested exemption.

3. On 02/08/22 at 2:00 PM, individual interviews with Staff #1601, #1602, #1603, #1604, #1605, and #1606 showed that each staff member stated that they had not received education to mitigate the transmission of COVID-19.