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Based on review of facility documents, medical records, (MR) and staff interview (EMP), it was determined that the facility failed to follow their established Medical Staff Bylaws and Rules and Regulations relating to the requirement of medication and treatment orders being signed by a practitioner. (MR7, MR8, MR9, and MR10).

Findings Include:

Review of "Medical Staff Bylaws of Kane Community Hospital Kane, Pennsylvania," dated August 2012, revealed, "Article I. Definitions ... 4. 'Medical Staff' means all physicians and dentists who are given privileges to treat patients in the hospital. 5. 'Physicians' shall be interpreted to include both doctors of medicine and doctors of osteopathy; ... Article III Allied Health Professionals. Article III, Part A: Independent Allied Health Professionals Section 1. General: a) Podiatrists, Chiropractors, Optometrists, CRNAs [Certified Registered Nurse Anesthetist] and other classes of health care professionals approved by the Board, who have been licensed or certified by their respective licensing or certifying Agencies and who desire to provide professional services in the hospital, are eligible to be appointed as Independent Allied Health Professionals. Section 2 Appointment Procedure: ... b) At the same time the Credentials Committee submits a delineation of the scope of activities to the Board, it shall furnish a copy of the delineation to the Executive Committee, which may issue a recommendation to the Board, agreeing or disagreeing in whole or in part, with the delineation. ... Section 3 ... Conditions of Appointment: (b) Independent Allied Health Professionals shall not be entitled to the rights, privileges, and responsibilities of appointment to the Medical Staff, and may only engage in acts within the scope of practice or clinical privileges specifically granted by the Board. ... ."

Review of "Kane Community Hospital Medical Staff Rules and Regulations," dated August 2012, revealed, " ... 5. All orders for treatment shall be in writing. ... An order shall be considered to be in writing, if transcribed by a Registered Nurse or other authorized person, and signed by the attending physician. ... 30. ... The history, physical examination, consultation, progress notes, required physician anesthetic documentation, operative record, pathology report, x-ray report, nuclear medicine, respiratory report, informed consent, doctor's orders ... shall be dated and authenticated by the responsible practitioner. ... ."

1) Review of Credential File (CF8) was conducted on July 24, 2013. There was no documented evidence of privileges requested and/or granted to write orders for medication or treatment unrelated to Anesthesia.

2) Review of "KCH An Affiliate of UPMC Hamot Job Title: Certified Registered Nurse Anesthetist ... Job Summary: Administers anesthesia and anesthesia-related care under the orders of a physician. ... ."

3) Review of "KCH Post Anesthesia Care Unit Admission Orders ... Post Anesthesia Care Unit Discharge Orders" was conducted with EMP2 and revealed that medications and treatments, unrelated to Anesthesia were ordered and authenticated by the CRNA in four of four medical records (MR7, MR8, MR9 and MR10).

Interview with EMP2 on July 24, 2013, at approximately 2:00 PM confirmed the above findings..

Based on a review of facility documents and staff interview [EMP], it was determined that the facility failed to follow their established Utilization Review Plan regarding the determination of admissions or continued stays that were not medically necessary.

Findings include:

A review of Kane Community Hospital Case Management Utilization Review Plan, revised June 2013, revealed, " The Kane Community Hospital (KCH), its governing board and medical staff, in conformity with the requirements of the Department of Health, Medicare, Medicaid and other payer does hereby define and describe its concurrent and continuous plan for the utilization of its facilities and services by those availing themselves of the hospital's services regardless of the source of payment. Purpose of the Plan: The general aim of this plan is to assure maintenance of high-quality patient care and effective and efficient use of the hospital; facilities and services through an educational approach to the study of patterns of care. The specific aim is to assure that no influence other than medical need is identified, analyzed and minimized toward the encouragement of appropriate utilization. Responsibility: Ultimate responsibility for optimum care for all patients who are treated in this hospital rests with the governing board. The specific responsibility for utilization review is delegated to the entire active medical staff with the assistance of other designated personnel as listed under the Organization and Composition of the Committee. ... Organization and Composition of the Committee: The Utilization Review Committee is composed of all members of the Medical Executive Committee, one whom is designated Chair, with non-physician members to represent Utilization Review (Care Manager), the DON, Social Services, Quality/Risk Manager, Laboratory, Diagnostic Imaging, Respiratory, Finance and CEO. ... No person on the Committee or on a committee performing functions delegated by the Utilization Review Committee may have a financial interest in KCH. No person may participate in the review of any care in which he or she was professionally involved in providing care. Authority: The Utilization Review Committee has the authority to perform concurrent review of the chart of any patient admitted to KCH or treated on an outpatient basis, and to discuss it with the physician or physicians concerned, but does not have the authority to take disciplinary action. Findings and recommendations of the Utilization Review Committee are reported to the medical staff, which has the authority and responsibility for considering and acting on them. ... Functions: ... B. Meetings: held once monthly for the flowing (sic) purposes: 1. Address all reports and correspondences with Care Management. 2. Keeps abreast of and implements changes which affect needs for acute care, length of stay or consideration for disposition on patients as required by Medicare, Medicaid and/or commercial insurance. 3. Makes recommendations concerning documentation on medical records. 4. Reviews individual cases as necessary when Care Management concerns exist. Physician Advisor: A. Confers at least twice weekly and as needed with Care Manager ... B. Reviews charts of patients referred by Care Management as "problem" cases; renders decision ... C. Handles inquires physician to physician ... ."

1) The Kane Community Hospital Case Management Utilization Review Plan failed to establish procedures for the review of the medical necessity of admissions, the appropriateness of the setting, the medical necessity of extended stays, and the medical necessity of professional services. The Plan failed to include the requirement for written notification of final determination to the facility Administrator, the attending physician, the patient, no later than two days after such final determination.

2) A review of the "Utilization Review Committee Meeting Minutes," dated October 17, 2012 through June 19, 2013, failed to contain documented evidence of review of admissions or continued stays that were not medically necessary.

3) An interview was conducted with EMP3 on July 22, 2013, at 3:00 PM. EMP3 confirmed the above and revealed, "We do not dispute the medical staff. We don't do it that often, our docs are pretty good. You won't find that in my policy."

Based on a review of facility documents and staff interview [EMP3], it was determined that the facility failed to follow their established Utilization Review Plan regarding review of the professional services provided to determine medical necessity and promote efficient use of services.

Findings include:

A review of Kane Community Hospital Case Management Utilization Review Plan, revised June 2013, revealed, " The Kane Community Hospital (KCH), its governing board and medical staff, in conformity with the requirements of the Department of Health, Medicare, Medicaid and other payer does hereby define and describe its concurrent and continuous plan for the utilization of its facilities and services by those availing themselves of the hospital's services regardless of the source of payment. Purpose of the Plan: The general aim of this plan is to assure maintenance of high-quality patient care and effective and efficient use of the hospital; facilities and services through an educational approach to the study of patterns of care. ... ."

1) A review of the "Utilization Review Committee Meeting Minutes," dated October 17, 2012 through June 19, 2013, failed to contain documented evidence of the review of the professional services provided. Documentation of the Committee meeting minutes revealed statistical based information only.


2) An interview was conducted with EMP3 on July 22, 2013, at 3:00 PM. EMP3 confirmed the above and revealed, "We do not review a lot of records, because we do not have a lot of problems. So we never had a review for example, on professional services including drugs and biologicals."