HospitalInspections.org

Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure appointment/ reappointment to medical staff and granting privileges followed the bylaws for 3 of 4 physicians' files reviewed (Physicians #1, #2, and #3). Failure to follow the bylaws when appointing/ reappointing physicians to the medical staff and granting privileges placed the CAH's patients at risk of receiving services from unqualified physicians.

Findings include:

Review of the governing board's "03/04 Amended Bylaws of Tioga Medical Center" occurred on 04/04/22 at 3:35 p.m. These bylaws, effective 10/16/17, stated,
". . . Article VI Medical Staff . . .
Section 1 - Appointment Medical Staff. The Board of Directors shall appoint for the Medical Center a medical staff which may be composed of the following:
(a) Physicians licensed in North Dakota to practice medicine . . . Privileges may be granted each physician as recommended by the credentials committee and approved by the Executive Committee and the entire staff membership of the Medical Center. . . .
Section 2 - Tenure. Such appointments to the medical staff shall be for one year only, commencing July 1, and may be renewed by the Board of Directors at their discretion from year to year. . . ."

Review of the "Tioga Medical Center Medical Staff By-Laws Rules and Regulations" occurred on 04/04/22 at 2:30 p.m. These bylaws, effective 04/19/21, stated,
". . . Article III. Medical Staff Membership
Section 1. Nature of Medical Staff Membership
Membership on the medical staff of the Tioga Medical Center is a privilege which shall be extended only to professionally competent physicians . . . who continuously meet the qualifications, standards and requirements set forth in these bylaws. . . .
Section 3. Conditions and Duration of Appointment
A. Initial appointments and reappointments to the medical staff shall be made by the governing body. The governing body shall act on appointments only after there has been a recommendation from the medical staff as provided in these bylaws . . .
B. Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing body, in accordance with these bylaws. . . .
Article IV Procedure for Appointment and Reappointment . . .
Section 2. Appointment Process . . .
B. After receipt of the application and the report and recommendation of the credentials committee, the medical staff shall determine whether to recommend to the governing body that the practitioner be provisionally appointed to the medical staff, that is [sic] be rejected for medical staff membership, or that his application be deferred for further consideration. All recommendations to appoint must also specifically recommend the clinical privileges to be granted . . .
Section 3. Reappointment Process
A. . . . the credentials committee shall review all pertinent information available on each practitioner scheduled for periodic appraisal, for the purpose of determining its recommendations for reappointments to the medical staff. . . .
B. Thereafter, the procedure provided in Section 2 of this Article IV relating to recommendations or applications for initial appointments shall be followed.
C. The reappointment process shall be completed every two years after the original appointment to the medical staff. . . ."

Review of the physicians' 2021 credentialing files occurred on April 5-6, 2022 and indicated the following:
- Provider #1: no evidence of Tioga Medical Center medical staff's recommendation and governing body's approval of initial appointment and privileges in 2021.
- Provider #2: no evidence of Tioga Medical Center medical staff's recommendation and governing body's approval of initial privileges in 2021.
- Provider #3: approval of reappointment and privileges on 04/15/19 and reapproved on 06/21/21 (two years and two months later).

Upon request on 04/06/22, the CAH failed to provide evidence Tioga Medical Center medical staff recommended and the governing body approved appointment/privileges for Physician #1 and approved initial privileges for Physician #2.

During interview on 04/06/22 at 10:25 a.m., an administrative staff member (#2) confirmed the following: Physician #1 provided surgical services to the CAH's patients, and the CAH did not have evidence the medical staff had recommended and the governing board had approved initial appointment/privileges; Physician #2 provided sleep study interpretations for the CAH's patients, and the CAH did not have evidence the medical staff had recommended and the governing board had approved initial privileges; and Physician #3's reappointment was late in 2021.

Based on document review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 1 of 1 year reviewed (April 2021 - March 2022). Failure to evaluate services furnished by contractors limited the CAH's ability to ensure the contractors provided quality services for the CAH and its patients.

Findings include:

Review of the CAH's lists of services occurred on April 4-5, 2022. These lists, dated 08/23/21, showed thirteen contracted services available at the CAH.

Reviewed on April 4-5, 2022, the medical staff and department manager's meeting minutes from April 2021-March 2022 failed to include evidence CAH staff had evaluated contracted services.

Upon request on 04/05/22, the CAH failed to provide evidence staff had evaluated contracted services in the past year to ensure the contrators provided quality services for the CAH and its patients.

During interview on 04/05/22 at 4:50 p.m., an administrative staff member (#2) confirmed CAH staff had failed to evaluate contracted services in the past year.

Based on professional reference review and staff interview, the Critical Access Hospital (CAH) failed to develop an infection prevention and control program, as documented in its policies and procedures, that employed methods for preventing and controlling the transmission of infections for 3 of 3 days of survey (April 4-6, 2022). Failure to develop and implement a water management program for Legionella, develop policies and procedures to reduce the risk of growth and spread of Legionella, and conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system placed staff and patients at risk of developing Legionella infections.

Findings include:

Information from the Centers of Disease Control, found at https://www.cdc.gov/legionella, stated, "In June 2017, the Centers for Medicare & Medicaid Services (CMS) released a survey and certification memo . . . stating that healthcare facilities should develop and adhere to ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) - compliant water management programs. These water management programs help reduce the risk for Legionella and other pathogens in their water systems. . . . Identify areas where Legionella could grow and spread. Identify where potentially hazardous conditions could occur in your building water systems, such as areas where water temperature could promote Legionella growth or where water flow might be low. Decide where you need to apply control measures and how to monitor them. Establish control measures and limits for each hazardous condition, as well as plans for where and how to monitor them. Control measures are actions you take in your building water systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning. Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for Legionella growth and spread. Control points are locations in the water systems where you can apply control measures. Establish ways to intervene when control limits are not met. Determine what corrective actions or contingency responses to take when control measures are outside of the control limits you established. Make sure the program is running as designed and is effective. Establish procedures, both initially and on an ongoing basis, to verify that your team is implementing the water management program as designed. Also, validate that the program effectively controls the hazardous conditions throughout the building water systems. Update the program when necessary. . . ."

Upon request on 04/06/22, the CAH failed to provide evidence of a risk assessment and policies/procedures for a Legionella water management program.

During interview on 04/06/22, an administrative nurse (#1) confirmed the facility failed to complete a risk assessment and develop policies/procedures for a Legionella water management program.