HospitalInspections.org

Based on bylaws review, agreement review, physician list document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend and the governing body failed to approve the reappointment/privileges for 1 of 1 distant-site hospitals' (Hospital #1) physicians reviewed who provided emergency services to the CAH through telemedicine. Failure of the medical staff to recommend and the governing body to approve reappointments/privileges of telemedicine medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the governing board's "CORPORATE BYLAWS Of SOUTHWEST HEALTHCARE SERVICES" occurred on the afternoon of 09/12/22. These bylaws, dated 05/04/16, stated,
". . . Article VIII - Medical Staff . . .
Section 2. a. . . . The Board of Trustees shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership as set forth in the Bylaws of the Medical Staff. . . . c. All appointments to the Medical Staff shall be for two years only, renewable by the Board of Trustees pursuant to formal application. . . .
Section 3. . . . c. The Medical Staff shall make recommendations to the Board of Trustees concerning: 1. Appointments, reappointments . . . 2. Granting of clinical privileges . . ."

Review of the "MEDICAL STAFF BYLAWS" occurred on the afternoon of 09/12/22. These bylaws, dated August 2017, stated,
". . . Article IV Medical Staff Membership . . .
Section 3. Conditions and Duration of Appointment. A. Initial and reappointments to the Medical Staff shall be made by the Governing Body. The Governing Body shall act on appointments, reappointments . . . after there has been a report from the Medical Staff . . . B. Initial appointments shall be for a period of two years. Reappointments shall be completed bi-annually
. . .
Article V . . . Categories of the Medical Staff . . .
Section 7. The Telemedicine Consulting Medical Staff . . . shall consist of practitioners who are recognized clinical specialists in the area for which the practitioner respectively proposes to be a consultant . . . In order to be a member of the telemedicine consulting medical staff, a practitioner must be on the medical staff of another hospital. . . . Telemedicine is the practice of medicine through the use of electronic communication or other communication technologies to provide or support clinical care at a distance, for example, eEmergency services and teleradiology services. . . ."
The medical staff bylaws failed to include a provision for accepting the credentialing and privileging of distant site hospitals through an agreement.

Reviewed on 09/13/22, the CAH's "Agreement for Credentialing and Privileging of [name of Hospital #1] Emergency Telemedicine Practitioners," dated 08/19/22, stated, ". . . Recitals . . . B. . . . Distant Site and Hospital agree to use the credentialing and privileging policies and protocols of Distant Site so Hospital can rely upon Distant Site's credentialing and privileging decisions to grant telemedicine privileges to Distant Site's Telemedicine Practitioners who will be providing telemedicine services to Hospital's patients. . . .

Reviewed on 09/13/22, distant site Hospital #1's list of telemedicine providers, dated 11/05/21, included nineteen physicians. Upon request on 09/14/22, the CAH failed to provide evidence the medical staff had recommended and the governing board had approved telemedicine reappointments/privileges for the providers on the list from Hospital #1 in the past two years.

During interview on 09/14/22 at 11:00 a.m., a staff member (#9) responsible for credentialing confirmed Hospital #1 provided emergency telemedicine services for the CAH, and the CAH had not reappointed the providers after their initial appointments.

Based on bylaws review, agreement review, physician list document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend and the governing body failed to approve the reappointment/privileges for 1 of 1 distant-site entities' (Telemedicine Entity #2) physicians reviewed who provided radiological interpretation services to the CAH through telemedicine. Failure of the medical staff to recommend and the governing body to approve reappointments/privileges of telemedicine medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the governing board's "CORPORATE BYLAWS Of SOUTHWEST HEALTHCARE SERVICES" occurred on the afternoon of 09/12/22. These bylaws, dated 05/04/16, stated,
". . . Article VIII - Medical Staff . . .
Section 2. a. Members of the medical staff shall organize the physicians and appropriate other persons granted practice privileges in the corporation's medical facilities into a medical staff . . . The Board of Trustees shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership as set forth in the Bylaws of the Medical Staff. . . . c. All appointments to the Medical Staff shall be for two years only, renewable by the Board of Trustees pursuant to formal application. . . .
Section 3. . . . c. The Medical Staff shall make recommendations to the Board of Trustees concerning: 1. Appointments, reappointments . . . 2. Granting of clinical privileges . . ."

Review of the "MEDICAL STAFF BYLAWS" occurred on the afternoon of 09/12/22. These bylaws, dated August 2017, stated,
". . . Article IV Medical Staff Membership . . .
Section 3. Conditions and Duration of Appointment. A. Initial and reappointments to the Medical Staff shall be made by the Governing Body. The Governing Body shall act on appointments, reappointments . . . after there has been a report from the Medical Staff . . . B. . . . Reappointments shall be completed bi-annually
. . .
Article V . . . Categories of the Medical Staff . . .
Section 7. The Telemedicine Consulting Medical Staff . . . shall consist of practitioners who are recognized clinical specialists in the area for which the practitioner respectively proposes to be a consultant . . . In order to be a member of the telemedicine consulting medical staff, a practitioner must be on the medical staff of another hospital. . . . Telemedicine is the practice of medicine through the use of electronic communication or other communication technologies to provide or support clinical care at a distance, for example, eEmergency services and teleradiology services. . . ."
The medical staff bylaws failed to include a provision for accepting the credentialing and privileging of distant site telemedicine entities through an agreement.

Reviewed on 09/13/22, the CAH's "Credentialing and Privileging Agreement" with Telemedicine Entity #1, dated 05/01/18, stated, ". . . The parties agree as follows: . . .
Section 3. Decision of Facility Governing Body. 3.1 Facility represents that its Governing Body has directed Facility's medical staff to rely on the credentialing and privileging decisions made by Telemedicine Entity when making Facility privilege recommendations for the Physicians
. . ."

Reviewed on 09/13/22, distant-site Telemedicine Entity #2's list of providers, dated 01/29/20, included 37 physicians. Upon request on 09/14/22, the CAH failed to provide evidence the medical staff recommended and the governing board approved telemedicine reappointments/ privileges for the providers on the list from Telemedicine Entity #2 in the past two years.

During interview on 09/13/22 at 9:00 a.m., an administrative radiology staff member (#10) stated Telemedicine Entity #2 provided after hours radiological interpretation telemedicine services for the CAH.

During interview on 09/14/22 at 11:00 a.m., a staff member (#9) responsible for credentialing confirmed the CAH had not reappointed Telemedicine Entity's providers after their initial appointments.

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 of privileges followed the bylaws for 7 of 8 providers' files reviewed (Providers #1, #2, #3, #4, #5, #6, and #7). Failure to follow the bylaws when appointing/reappointing providers to the medical staff and granting privileges placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the "MEDICAL STAFF BYLAWS" occurred on 09/12/22 at 2:45 p.m. These bylaws, dated August 2017, stated,
". . .Article II Definitions . . . Medical Staff Year commences on the first day of January and ends on the 31st day of December. . .
Article IV Medical Staff Membership . . .
Section 3. Conditions and Duration of Appointment. A. Initial and reappointments to the Medical Staff shall be made by the Governing Body. The Governing Body shall act on appointments, reappointments . . . after there has been a report from the Medical Staff as provided in these Bylaws. . . . B. Initial appointments shall be for a period of two years. Reappointments shall be completed bi-annually and shall be valid through the end of the Medical Staff year 2 years from the time that the initial or reappointment was last approved. All reappointments shall expire at the end of the Medical Staff Year. C. Appointments 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. D. Every application for staff appointment shall be signed by the applicant . . .
Article VI Procedure For Appointment . . .
Section 2. Appointment Process A. At its next regular meeting after receipt of the completed application for membership, the Medical Staff shall make recommendation to the Governing Body that the applicant be appointed to the category of staff membership requested . . . All reports to appoint must specifically recommend the clinical privileges to be granted.
Section 3. Reappointment Process: A. . . . the Medical Staff shall review all pertinent information available . . . for the purpose of determining its report for reappointments to the Medical Staff and for granting of clinical privileges for the ensuing period and shall transmit its report to the Governing Body. . . .
Article VII Clinical Privileges . . .
Section 2. Temporary Privileges A. Upon receipt of an application for Medical Staff membership from the appropriately licensed practitioner, the Administrator may . . . with the written concurrence of the Chief of Staff, grant temporary admitting and/or clinical privileges to the applicant . . . C. The administrator may permit a practitioner serving as locum tenens for a member of the Medical Staff to attend patients without applying for membership on the Medical Staff for a period not to exceed one hundred twenty (120) days, providing his or her credentials have first been approved by the Medical Staff. . . ."

Review of the "CORPORATE BYLAWS Of SOUTHWEST HEALTHCARE SERVICES" occurred on 09/12/22 at 3:00 p.m. These bylaws, dated 05/04/16, stated,
". . . Article VIII - Medical Staff . . .
Section 2. a. . . . The Board of Trustees shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership as set forth in the Bylaws of the Medical Staff. . . . c. All appointments to the Medical Staff shall be for two years only. . .
Section 3. . . . c. The Medical Staff shall make recommendations to the Board of Trustees concerning: 1. Appointments, reappointments . . . 2. Granting of clinical privileges . . ."

Review of providers' credentialing files occurred on September 13-14, 2022, and identified the following:
- Provider #1: Application Date - 10/08/20 (not signed by provider). The administrator failed to sign and date temporary privileges granted by the medical staff on 11/24/20. Provider #1 began providing services to the CAH's patients on 01/01/21. Medical staff recommended approval on 07/09/21 and the governing body approved appointment on 09/01/21. The file lacked evidence of Provider #1's delineation and approval of privileges. The facility provided delineation of privileges on 09/13/22, which the governing body signed on 09/13/22. Provider #1 provided services to patients from 01/01/21 to 09/13/22 without approved privileges.
- Provider #2: Application Date - 06/24/21. The administrator failed to sign and date temporary privileges granted by the medical staff on 01/07/22. Provider #2 began providing services to the CAH's patients on 01/14/22. Medical staff recommended and governing body approved appointment in February 2022 (date unspecified). The file lacked evidence of Provider #2's delineation and approval of privileges. The facility provided delineation of privileges on 09/13/22, which the governing body approved on 09/13/22. Provider #2 provided services to inpatients and emergency department outpatients on 11 days in August 2022 and five days in September 2022 without approved privileges.
- Provider #3: Previous appointment 12/30/19 - 12/29/21. The medical staff recommended re-appointment on 03/08/22 and the governing body approved it on 04/07/22. Provider #3 provided surgical services to patients on 01/13/22, 02/03/22, and 03/03/22 without governing body approval of reappointment and privileges.
- Provider #4: Previous appointment 08/29/19 - 08/28/21. The administrator approved temporary privileges on 10/20/21 and the medical staff approved it on 02/07/22. The medical staff recommended and the governing body approved reappointment February 2022 (unspecified date). The file lacked evidence of Provider #4's delineation and approval of privileges. Provider #4 provided telemedicine psychiatric care to patients without approved privileges.
- Provider #5: Previous reappointment 06/24/20 - 06/23/22. The administrator approved temporary privileges on 08/24/22 and medical staff approved them on 09/12/22. Provider #5 provided treatment for inpatients and emergency department outpatients June 24 - September 11, 2022 without approved reappointment/privileges.
- Provider #6: Previous reappointment 01/29/20 - 01/28/22. Medical staff and the governing body signed the reappointment form on 01/29/20. The form failed to include whether the medical staff recommended or the governing body approved reappointment. The file lacked evidence of reappointment after 01/28/22. Provider #6 provided anesthesia services for the CAH's surgical patients on eight days in 2022 without approved reappointment/privileges.
- Provider #7: Previous reappointment 10/30/19 - 10/29/21. Medical staff did not recommend and the governing body did not approve privileges for this reappointment. The medical staff did not approve temporary privileges signed by the administrator on 10/20/21. The file lacked evidence of reappointment from October 30, 2019 - September 14, 2022. Provider #7 provided sleep study interpretations for forty-eight patients during this timeframe without approved reappointment/privileges.

During interview on 09/14/22 at 11:00 a.m., a staff member (#9) responsible for credentialing confirmed the above findings for Providers #1-#7.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure a medical doctor (MD) or doctor osteopathy (DO) periodically reviewed and signed the records of all inpatients cared for by a nurse practitioner (NP) for 5 of 5 closed records (Patients #7, #8, #9, #17, and #19) reviewed who were admitted and cared for by an NP. Failure to periodically review and sign records of inpatients cared for by a nurse practitioner limited the CAH's ability to ensure the quality and appropriateness of patient care provided.

Findings include:

Review of patient closed medical records occurred on 09/14/22 and identified a physician failed to sign the following records of inpatients admitted and cared for by an NP:
- Patient #7 admitted on 04/13/22.
- Patient #8 admitted on 06/28/22.
- Patient #9 admitted on 07/05/22.
- Patient #17 admitted on 04/16/22.
- Patient #19 admitted on 06/01/22.

During interview on 09/14/22 at 1:27 p.m., an administrative staff member #3 confirmed physician signatures were missing on the above records.

Upon request, the facility failed to provide a policy regarding the requirement for a physician to sign the records of all inpatients cared for by nurse practitioners.

Based on record review, medical staff rules and regulations review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff notified a medical doctor (MD) or doctor of osteopathy (DO) of a patient's admission to the CAH by a nurse practitioner (NP) for 2 of 6 patients (Patient #3 and #19) admitted by an NP. Failure of staff to notify the MD/DO of patients admitted by an NP limited the MD/DO's ability to ensure the appropriateness of the admission and to monitor the care provided to the patients by the NP.

Findings include:

Review of the "Medical Staff Rules and Regulations" occurred on 09/14/22. These rules, updated June 2017, stated, ". . . Whenever a patient is admitted to the hospital by an allied health professional staff member [practitioners other than physicians], the allied health professional staff member's sponsoring physician will be notified of that fact, . . . . "

Review of patient medical records occurred on 09/14/22. The following records of patients admitted by an NP lacked evidence the CAH staff notified an MD of the admissions:
- Patient #3 admitted on 09/02/22.
- Patient #19 admitted on 06/01/22.

During interview on 09/14/22 at 1:27 p.m., an administrative staff member #3 confirmed mid-level practitioners (nurse practitioners and physician's assistants) are required to notify the MD/DO of a patient's admission.

Based on document review, meeting minutes review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 4 of 4 quarters reviewed (3rd Quarter 2021, 4th Quarter 2021, 1st Quarter 2022, and 2nd Quarter 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 policy "Quality Assurance and Performance Improvement" occurred at 4:40 p.m. on 09/13/22. This policy, dated January 2022, stated, ". . . It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven program that focuses on indicators of the outcome of care and quality of life. . . . Policy Explanations and Compliance Guidelines . . . 3. The QAPI [quality assurance and performance improvement] plan will address the following elements: . . . f. Process to ensure care and services delivered meet acceptable standards of quality. . . Program Development Guidelines 1. Program design and Scope. a. The QAPI program will be ongoing, comprehensive and will address the full range of care and services provided by the facility. b. At a minimum, the QAPI program will: Address all systems of care and management practices . . . 2. Program Feedback, Data Systems and Monitoring . . . c. Data collected from all departments is used to develop and monitor performance indicators. . . . 5. Governance and Leadership a. The governing body and/or executive leadership are responsible and accountable for the QAPI program. . . ."

Review of the "Southwest Healthcare Services Critical Access Hospital Administrative Evaluation," dated April 15, 2021, occurred on the morning of 09/14/22. This document stated, "This report provides an administrative summary and evaluation of the services provided . . . Quality Improvement: . . . Below are important pieces of Southwest Healthcare Services QI plan: 1. Clinical Services - clinical services provided by outside venders are reviewed at least annually by administration and department managers and submitted to the QI committee for review. . . ."

Review of the CAH's list of contracted services occurred on September 13-14, 2022. This undated list showed ninety-one contracted services available at the CAH.

Reviewed on September 13-14, 2022, quality assurance meeting minutes from the last four quarters (3rd Quarter 2021, 4th Quarter 2021, 1st Quarter 2022, and 2nd Quarter 2022) failed to include evidence the CAH staff had evaluated eighty-six of the contracted services.

Upon request on 09/14/22, the CAH failed to provide evidence staff had evaluated eighty-six of the ninety-one contracted services in the past year to ensure the contractors provided quality services for the CAH and its patients.

During interview on 09/14/22 at 9:48 a.m., a quality assurance staff member (#8) confirmed CAH staff had failed to evaluate all of the contracted services in the past year.

Based on meeting minutes review, policy review, document review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance and Performance Improvement (QAPI) program evaluated all patient care services/departments affecting patient health and safety for 4 of 4 quarters reviewed (3rd Quarter 2021, 4th Quarter 2021, 1st Quarter 2022 and 2nd Quarter 2022). Failure to ensure all departments report monitoring to the QAPI committee limited the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the CAH policy, "Quality Assurance and Performance Improvement," dated January 2022, stated, ". . . It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven program that focuses on indicators of the outcome of care and quality of life. . . . Policy Explanations and Compliance Guidelines . . . 3. The QAPI plan will address the following elements: . . . f. Process to ensure care and services delivered meet acceptable standards of quality. . . Program Development Guidelines 1. Program design and Scope. a. The QAPI program will be ongoing, comprehensive and will address the full range of care and services provided by the facility. b. At a minimum, the QAPI program will: *Address all systems of care and management practices . . . 2. Program Feedback, Data Systems and Monitoring . . . c. Data collected from all departments is used to develop and monitor performance indicators. . . . 5. Governance and Leadership a. The governing body and/or executive leadership are responsible and accountable for the QAPI program. . . ."

Reviewed on September 13-14, 2022, the CAH's 2021 Strategic Priorities document failed to include laundry services or sterilization/ reprocessing services. The CAH's 2022 Strategic Priorities document included laundry services but failed to include sterilization/reprocessing services.

Reviewed on September 13-14, 2022, the CAH's QAPI committee meeting minutes (3rd and 4th Quarters 2021 and 1st and 2nd Quarters 2022) lacked evidence the departments providing laundry and sterilization/reprocessing services submitted QI monitoring reports for all four quarters.

During interview on 09/14/22 at 9:48 a.m., a quality improvement staff member (#8) confirmed the departments providing laundry and sterilization/reprocessing services failed to submit QI monitoring reports regarding patient care to the QAPI committee.