HospitalInspections.org

Based on review of records and interview, the facility failed to ensure that procedures for Medical Staff Credentialing as set in the Medical Staff Bylaws were followed for 3 (Staff #9, Staff #10, and Staff #11) out of 3 Advanced Healthcare Practitioners (AHP) credential file reviewed.

Findings included:

Review of Staff #9's credential file showed that Staff #9 was recommended and accepted for re-appointment by the Medical Staff in December 2019 without having the required peer references checked.

Review of Staff #10's credential file showed that Staff #10 was recommended and accepted for re-appointment by the Medical Staff in August 2018 without a prior review of requested privileges by the Chief Nursing Officer.

Review of Staff #11's credential file showed that Staff #11 was recommended and accepted for re-appointment by the Medical Staff in January 2019 without a prior review of requested privileges by the Chief Nursing Officer or having the required peer references checked.

Staff #3 and Staff #4 verified that peer references were missing from Staff #9's and Staff #11's credential files.

An interview was conducted with Staff #2 on the afternoon of 1-3-2020. Staff #3 confirmed that she had not reviewed and signed the requested delineation of privileges form for Staff #10's and Staff #11's reappointments.

Review of the Medical Staff Bylaws, last revised June 2018, Article 16.0 Advanced Healthcare Practitioners, Page 84 showed:
"16.6 PROCEDURES FOR APPOINTMENT OF PRIVILEGES, REAPPOINTMENT, SUSPENSION, TERMINATION
(a) AHPs shall be credentialed in the same manner as outlined in the Medical Staff Bylaws and Credential Manual for credentialing of Practitioners except that all nurse advanced healthcare practitioner's credentials and privilege lists will also include review by the Chief Nursing Officer prior to application being forwarded to the Credentials Committee to verify that scope of practice is appropriate. The Board in consultation with the MEC shall determine the scope of the activities, which each AHP may undertake. Such determinations shall be furnished in writing to the AHP and shall be final and not eligible for appeal except as specifically and expressly provided in these Bylaws."



Review of the Medical Staff Credentialing Manual, Section II Application Process showed:
"Each application for appointment or reappointment to the Medical Staff and each application for delineation of Clinical Privileges shall be submitted electronically or submitted in writing on the prescribed form, ...

II. APPLICATION PROCESS
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1. APPLICATION CONTENTS
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(g) Peer References: The names of at least three (3) peers, (excluding partners, associates in practice, employers, employees or relatives), who have worked with the applicant within the past two (2) years and personally observed his/her professional performance and who are able to provide knowledgeable peer recommendations as to applicant's relevant training and experience, current clinical competence, education, experience, ethical character, ability to perform privileges requested, and ability to work with others. Peer References will include these elements: medical/clinical knowledge; technical and clinical skills; clinical judgement; interpersonal skills; communication skills; professionalism; and applicant's health status as related to ability to perform privileges requested.
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III. VERIFICATION OF INFORMATION PROCESS
Following receipt of all information required on the application, the PSO [Provider Services Office] will begin the processing the application. All information on the application will be verified.
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Letters of inquiry will be sent to all current and previous affiliations/employers and references.

The Provider Services Office will make an appropriate, reasonable effort to obtain verification from the appropriate entities. If a response has not been received by the end of 30 days following initial request, the PSO will send a second request and notify the applicant and request his assistance. The applicant will be notified that information must be received with 30 days of notification or the application will not be processed. If a response still has not been received by the end of this second 30 day period, processing of the application will be discontinued and the applicant will be notified that the application will not be processed further due to failure to receive requested information.

The PSO will query the National Practitioner Data bank at initial appointment, reappointment, and other times as indicated including when adding or expanding privileges and at least every two years.

Applications for appointment and clinical privileges will not be presented to the Credentials Committee for review until all required information is complete and verification has occurred."