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Based on review of facility documents and staff interviews (EMP), it was determined that the Governing Body failed to ensure that the necessity of procedures were assessed or reviewed prior to the procedures being performed.

Findings include:

1) During interviews with EMP2 on March 9 and May 25, 2011, and interviews with EMP3 on March 9 and June 1, 2011, and interviews with EMP6 on May 31 and June 1, 2011, it was determined that the facility initiated an external "Medical Necessity Review Audit" for the purpose of randomly reviewing interventional cardiology and radiology procedures performed by physicians at the facility, from June 1, 2009, to May 31, 2010. During these interviews an exact date of when the review were commissioned or started could not be determined but an approximate date of June 2010 was determined.

2) Review of a preliminary report for the external "Medical Necessity Review Audit" for EMP7, dated December 6, 2010, and for EMP8, dated December 2, 2010, revealed that the authors of the audit cited concerns with EMP7 and EMP8's judgement in performing unnecessary Percutaneous Coronary Interventional (PCI) procedures. During the above multiple interviews with EMP2, EMP3 and EMP6, it could not be determined the exact date that the facility received or reviewed these preliminary external "Medical Necessity Review Audits".

3) Interview with EMP3 on June 1, 2011, at approximately 1:05 PM revealed that on December 19, 2010, EMP3 and members of the Governing Board and the Medical Staff met to discuss the findings of the preliminary external "Medical Necessity Review Audits" for EMP7 and EMP8.

4) Further interview with EMP3 revealed "[EMP2] was reviewing every [PCI] case that was on the schedule in the cath lab [to assess the necessity of the procedure] ... I am not sure of the exact date of when [EMP2] starting reviewing those cases."

Interview with EMP2 on June 1, 2011, at approximately 1:35 PM revealed "I began reviewing [PCI] cases starting on January 3 [2011] ... That was my first day on the job."

During interview with EMP2, EMP3 stated "There was a gap of time there [when PCI procedure were not being reviewed for necessity]."

5) Review of a list of PCI procedures performed by EMP7 from December 2, 2010, to January 3, 2011, revealed that EMP7 performed 54 procedures that were not reviewed for necessity of the procedure.

Review of a list of PCI procedures performed by EMP8 from December 6, 2010, to January 3, 2011, revealed that EMP8 performed 69 procedures that were not reviewed for necessity of the procedure.

Based on review of facility documents and staff interviews (EMP), it was determined that the Governing Body failed to ensure that the necessity of procedures were assessed or reviewed prior to the procedures being performed.

Findings include:

1) During interviews with EMP2 on March 9 and May 25, 2011, and interviews with EMP3 on March 9 and June 1, 2011, and interviews with EMP6 on May 31 and June 1, 2011, it was determined that the facility initiated an external "Medical Necessity Review Audit" for the purpose of randomly reviewing interventional cardiology and radiology procedures performed by physicians at the facility, from June 1, 2009, to May 31, 2010. During these interviews an exact date of when the review were commissioned or started could not be determined but an approximate date of June 2010 was determined.

2) Review of a preliminary report for the external "Medical Necessity Review Audit" for EMP7, dated December 6, 2010, and for EMP8, dated December 2, 2010, revealed that the authors of the audit cited concerns with EMP7 and EMP8's judgement in performing unnecessary Percutaneous Coronary Interventional (PCI) procedures. During the above multiple interviews with EMP2, EMP3 and EMP6, it could not be determined the exact date that the facility received or reviewed these preliminary external "Medical Necessity Review Audits".

3) Interview with EMP3 on June 1, 2011, at approximately 1:05 PM revealed that on December 19, 2010, EMP3 and members of the Governing Board and the Medical Staff met to discuss the findings of the preliminary external "Medical Necessity Review Audits" for EMP7 and EMP8.

4) Further interview with EMP3 revealed "[EMP2] was reviewing every [PCI] case that was on the schedule in the cath lab [to assess the necessity of the procedure] ... I am not sure of the exact date of when [EMP2] starting reviewing those cases."

Interview with EMP2 on June 1, 2011, at approximately 1:35 PM revealed "I began reviewing [PCI] cases starting on January 3 [2011] ... That was my first day on the job."

During interview with EMP2, EMP3 stated "There was a gap of time there [when PCI procedure were not being reviewed for necessity]."

5) Review of a list of PCI procedures performed by EMP7 from December 2, 2010, to January 3, 2011, revealed that EMP7 performed 54 procedures that were not reviewed for necessity of the procedure.

Review of a list of PCI procedures performed by EMP8 from December 6, 2010, to January 3, 2011, revealed that EMP8 performed 69 procedures that were not reviewed for necessity of the procedure.