HospitalInspections.org

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Based on interview and document review, the governing body failed to ensure that the provider appointment/reappointment process and granting of clinical privileges was determined by individual character, competence, training, experience, and judgment.

Failure to ensure that the providers are appointed/reappointed and granted clinical privileges based on individual character, competence, training, experience, and judgment 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 that the Governing Board shall appoint only those providers meeting the qualifications prescribed in the Medical Staff Bylaws and other written or unwritten facility standards. The policy showed that the Medical Staff Bylaws shall include a process whereby the Medical Executive Committee (MEC) makes recommendations to the governing board regarding the mechanism used to review credentials and delineate individual clinical privileges and the individual medical staff or Allied Health Professionals appointment and clinical privileges.

The document also showed that a governing board member shall be deemed to be present at a meeting if the member participates in the meeting using a conference telephone, speaker telephone or similar communication device by means of which all persons participating in the meeting can hear each other at the same time. The act of a majority of the Governing board Members present and voting at a meeting at which a quorum is present shall be an act of the Governing Board. An action of the Governing Board may occur without a meeting if consent of the action set forth is in writing or otherwise approved by all Governing Board Members and filed in the Governing Board meeting minutes. A written record of all Governing Board proceedings, attendance, and actions shall be maintained by the Vice Chair or Vice Chair's designee.

Review of the hospital document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective 06/07/21, showed that each recommendation concerning appointment of a staff member and granting of clinical privileges shall be based upon an assessment of the applicant's individual character, judgment, training, experience, ability, and current competency by the MEC and the Governing Board. They will consider the applicant's proficiency in the following areas: patient care, medical/clinical knowledge and training, practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and professional judgment and individual character that demonstrate a commitment to continuous improvement, ethical practice, cultural diversity, and responsibility.

The document showed that when considering applicants for appointment/reappointment and clinical privileges, the MEC shall review the application, the related documentation and other relevant information, and then forward the entire credentialing file along with a report and recommendation regarding appointment/reappointment status and clinical privileges to the Governing Board.

2. Review of Governing Board and MEC meeting minutes and documents showed the following:

a. MEC meeting minutes dated 06/23/22, 07/05/22, 08/05/22, 08/10/22, 09/02/22, and 10/07/22 showed that committee members were provided with a credentialing file summary for each provider seeking initial appointment or reappointment and clinical privileges. With the exception of the 09/02/22 meeting, all meetings were conducted by email.

b. Governing Board ad hoc meetings for provider appointment/reappointment and credentialing held on 06/24/22, 07/12/22, 08/05/22, 08/10/22, and 09/03/22 showed that the meeting members were provided with an attachment of the providers' credentialing file summaries to review prior to voting.

c. Governing Board ad hoc meeting minutes dated 06/24/22 and 07/12/22 and the attached provider credentialing summaries showed that credentialing summary information was reviewed for 4 providers, and "after MEC recommendation, review of required license/education, certifications, peer references and competence data," the governing board approved all requests without changes.

d. Governing Board ad hoc meeting minutes dated 08/05/22, 08/10/22, and 09/03/22 showed all provider requests for privileges were approved after MEC recommendation and a "thorough review of application, peer references, competence data, and privilege request."

3. The investigator reviewed credentialing summaries for 4 providers. The review showed that credentialing summaries were a 1 to 2 page document that briefly outlined the applicant's specialty, appointment status (active, courtesy, consulting, Allied Health), privileges requested, professional license number and expiration, school(s) attended and graduation date(s), board certification date and expiration, if applicable, disciplinary action, malpractice insurance provider, amount, and claims history, names of 2 references and recommendation status, dates of data bank queries (Office of Inspector General and National Provider Data Bank) and status (clear), health status, and focused/ongoing professional practice evaluation status. Document review showed that 2 of 4 credentialing summaries failed to list the privileges requested (Staff #1 and Staff #2).

4. On 10/20/22 at 1:00 PM, Investigators #1 and #2 interviewed the Chief Medical Officer (Staff #9) via telephone. Staff #9 stated that when credentialing reviews were conducted via email, the MEC members receive a 1-2 page document that outlines the providers credentialing history, experience, any revocation of privileges. He stated that most of the provider credentials were approved electronically and during ad hoc meetings, and only credentialling summaries, not the entire credentialing files, were included as attachments.

5. On 10/26/22 at 6:00 PM, Investigators #1 and #2 interviewed 2 members of the Governing Board, including the Chief Executive Officer (Staff #7) and the Corporate Director of Quality and Compliance (Staff #8). During the meeting, Staff #8 confirmed that the Governing Board's ad hoc meetings for provider credentialing were occurring mostly by email and stated that the hospital was not including the entire credentialing files for the Governing Board members to review prior to voting. Staff #8 stated that she recently informed the executive administrative assistant that the entire file needed to be scanned and attached for the board members to review remotely prior to voting.
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