HospitalInspections.org

Based on document review and interview, the facility failed ensure that all medical staff members maintain current hospital required competencies for 1 of 4 medical staff member files (staff # T) reviewed during the survey.

Based on document review and interview, the facility failed to ensure that all personnel are licensed in accordance with job descriptions developed by the facility. This was identified in 1 of 20 personnel files (staff # G) reviewed during the survey.

Findings:

-Review of staff # T"s personnel file completed on 4/16/2024 noted his ATLS expired on 2/12/2023.

-Document "UHS Rules & Regulations Emergency Department Delaware Valley Hospital" approved in January 2023 was reviewed on 4/16/2024. This document specifies all emergency department (ED) providers shall be ACLS, ATLS and PALS certified.

-Additionally, New York State regulations governing the operation of Primary Care Hospitals require that emergency services attending physicians be currently certified in advanced trauma life support (ATLS) or have current training and experience equivalent to ATLS.

-Interview with Director of Primary Care and Health Information Management on 4/16/2024 at 10:15 am confirmed this and stated there was a 6 month grace period given and noted difficulty in finding a class.

-Review of the job description in the personnel file for Director Primary Care Centers (staff # G) identified the hospital requires a NYS RN license for this position. Staff # G does not have a NYS RN license.

-This was confirmed by the Director of Human Resources on 4/16/2024 at 10:30 am..