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 document review and staff interview it was determined the governing body failed to ensure State law was followed and medical staff requirements were met in one (1) of three (3) Ancillary Medical Staff hired (Staff #1). This failure can result in patients not receiving the correct medical treatment, resulting in worse behavior and need for extended medical treatment.

Findings include:

1. A review of the facility document entitled, "Action Plan 8/4/16 Licensing and Board Requirements and Regulations for ... psychology", revealed the facility failed to follow State regulation when the only psychologist they had ever hired (Staff #1) was not hired under a correct job description nor credentialed per facility policy for 'Ancillary Medical Staff'.

2. On 8/16/16 at about 2:30 p.m. a review of the West Virginia Board of Examiners of Psychologists' (WVBEP) statement for the procedure of a graduate psychologist to obtain licensure revealed a graduate psychologist must go through a period of working under a board-approved licensed supervisor for a certain length of time, then apply and pass the WVBEP test to receive a license to practice psychology in the State of WV. It further states this procedure has been in effect since at least 2010, and in the State of WV a psychologist must be licensed by the WVBEP.

3. On 8/15/16 at about 2:00 p.m. a review of the facility's Medical Staff By-laws, last reviewed 5/26/16, revealed the credentialing process for all medical staff at the facility. It further defines the levels of staff. Section 8-Ancillary Staff is defined as: "...consists of professionals who are not physicians. They are required to hold a license to provide direct patient care services...Ancillary staff criteria for appointment...current and valid license where appropriate...permission to make whatever inquiries necessary to validate information provided in the application...from...appropriate licensing, certification or registry where applicant holds or has held such credentials..."

4. In an interview with the Director of Quality Management and the Chief Exective Officer on 8/15/16 at about 11:00 a.m. the above findings were discussed and they both agreed the facility failed to follow the WV State law concerning the practice of psychology in WV when Staff #1 was hired. They also agreed the facility failed to ensure Staff #1 completed the required test to practice as a licensed psychologist in WV. Lastly, they agreed the facility failed to classify Staff #1's job description correctly. He was allowed to practice as a 'non-licensed psychologist' when there is no such title in the State of WV.