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.

Based on the review of records and interview with hospital staff, it was determined that the hospital failed to perform timely and consistent reviews of CRNA competencies who are employed by the university but credentialed by the hospital.

Records indicated that administrative lead CRNA who was responsible for completing both the Ongoing Professional Practice Evaluations(OPPE) and the Focused Professional Practice Evaluations (FPPE) for the CRNAs, had failed to complete the 90 day evaluations which were required by the governing body. In addition, it was also determined that some of the 90 day evaluations that had been completed by the lead CRNA, were completed and signed but lacked evidence such as the dates, time, and signatures of the audited staff members. Therefore, these staff members had not had an opportunity to provide input into the evaluation process. These reviews were also required as part of the employees compensation package.

Further review revealed that the hospital's governing body had been made aware of these concerns and inconsistencies regarding monitoring practitioner competencies and timely completing of the required Ongoing Professional Practice Evaluations and Focused Professional Practice Evaluations (FPPE) as early as January 2012 and began to investigate. The hospital conducted initial audits of the employee files, which were completed August 3, 2012. Additional audits were finalized on September 14, 2012 and variances were identified.
The hospital also identified that the staff responsible for evaluating the practitioners was an employee of the university system, which contributed to the hospital's oversight of her performance related to the completion of the evaluations.

At the time of this survey, it was also determined that hospital had investigated; completed internal audits during the summer of 2012; had implemented personnel changes including additional staff to assist in the evaluation and review process and had made improvements to facilitate communication between the hospital and the university which had proven to be an obstacle to timely staff evaluations and had moved oversight of the process to the hospital's credentialing staff. The surveyor's were able to verify the corrective action taken. The evidence of these efforts was also noted by the ongoing collaborative meetings between the university and the hospital to monitor and improve the oversight process.