The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TRI COUNTY HOSPITAL - WILLISTON 125 SW 7TH ST WILLISTON, FL March 10, 2011
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Base on record facility record review and staff interview the facility failed to ensure that 2 of 5 (PA #1 & Physician #2) medical staff members working in the emergency room had current privileges approved by the Governing Body. Failure to follow the credentialing process has the potential of the facility allowing unqualified medical staff providing care for patients.

Findings:

1. Review of the staff file for the Physician Assistant, (PA#1), on duty on 03/10/2011 revealed that PA#1signed an Allied Health Professional Application instead of completing an application for medical staff privileges. Review of the PA #1 personnel file did not reveal that the PA was granted privileges by the Governing Board as outlined in the facility ' s Bylaws.

Review of the facility Bylaws revealed that PAs are considered Allied Health Professional, (AHP). AHPs include physicians, dentists, podiatrists, physician assistants, and nurse practitioners. The bylaws reveal that AHPs are considered " Members of the Medical Staff and shall adhere to Bylaws and by the Medical staff Rules and Regulations " .

Interview on 03/10/2011 at 3:15 PM of the Human Resource Director revealed that she had not required that the PA formally apply for privileges as required by the Bylaws. When asked why, she did not state a reason for not following the Bylaws.

2. The facility bylaws state that all initial privileges were to be for a period of 1 year and after one year every two years.

Review of credential file for Physician #2 revealed that he was initially appointed to the medical staff on 01/08/2010. Review of the file for Physician #2 did not reveal that the process for reappointment as of 03/10/2011 has not been started.

Interview with the HR Director on 03/10/2011 at 3:15 PM revealed that she did remember and that she did not notify the physician or start the re-credentialing process.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview the facility failed to maintain the physical plant in a safe and sanitary manner by not properly repairing water leaks in the water system.

Findings:

During the facility tour on 2-25-11 at 3:00 PM, it was observed that there were areas where the ceiling tiles were discolored/stained. Further observation looking above the ceiling tiles, it was revealed that there was two areas that had plastic pans placed under leaking water lines in the corridor outside the patient rooms. The two areas were approximately 25 foot apart. The plastic pans had a greenish growth in the bottom of the pans along with water.

In interview with the Maintenance Director on 2-25-11 at 3:00 PM, it was stated that there had been problems in the past, but thought that they had been fixed when they had hired a roofer to seal around the exhaust fan vent at the end of the corridor. It was acknowledged that the leaks and plastic pans were there, but not who placed the pans there.