HospitalInspections.org

Based on Bylaws, Rules and Regulations of The Professional Staff Organization of Northeast Florida State Hospital review and staff interview, the facility failed to credential and reappoint candidates for 5 of 35 Employees (#s H, I, O, P, & Q).

The findings include:


The Bylaws, Rules and Regulations of The Professional Staff Organization of Northeast Florida State Hospital (May 2016) was reviewed. For Credentialing and Recredentialing, "Appointment to Professional Staff Organization is fully documented in the Bylaws of the Professional Organization. This documentation is reviewed biannually and is revised as necessary."

Review conducted of the Employee record (H), a Psychologist, was appointed to the hospital on 8/4/2011. Employee H was reappointed on 11/7/2013. There was no other reappointment in the Employee record.


Review conducted of the Employee record (I), a Physician; was hired on 7/1/2017. Employee H was not reviewed by the Credentials Committee.


Review conducted of the Employee record (O), a Psychologist; was appointed to the hospital on 11/7/2013. Employee O has not been reappointed to date.


Review conducted of Employee record (P), an Area of Critical Need Doctor; was appointed to the hospital on 8/6/2015. Employee P has not reappointed to date.


Review conducted of Employee record (Q), a Psychiatrist; was appointed to the hospital on 11/5/2015. Employee Q has not been reappointed to date.


The Associate Medical Director (AMD) was interviewed on 6/13/2018 at 2:35 PM. She stated there had not been a Medical Director there for about 2 years. The Medical Director is the one responsible for the credentialing process. She confirmed that professional staff should be reappointed every 2-3 years. She stated there was a turnover of support staff (Employee G), who was in charge of organizing the credentialing process.



Employee G, an Administrative Assistant, was interviewed on 6/14/2018 at 10:05 AM. He stated he was responsible for coordinating the credentialing process for professional staff. He stated this was a new role for him. For the first 4 months as Administrative Assistant, he was not aware he was supposed to be doing the coordination of the credentialing process for professional staff. He stated the Credentials/Executive Committee met on 4/4/2018 and previously on November 1, 2017. He confirmed that they were behind on appointments and reappointments for Employee #s H, I, O, P & Q.