HospitalInspections.org

Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure the medical staff were reappointed and privileges granted by failing to ensure there was a mechanism in place to ensure medical staff qualifications were periodically reviewed to determine suitability of continuing medical staff privileges for three of seven credential files reviewed (A0340); by failing to ensure temporary privileges were not granted as a quick fix to correct the facility's oversight for reappointment prior to the expiration of clinical privileges for three of seven credential files reviewed (A0341); and by failing to terminate the appointment and clinical privileges at the end of the current term of appointment when the appointment/clinical privileges expired for three of seven credential files reviewed (A0353).


Findings include:

Review on March 1, 2018, of the facility's "MCMC [Mercy Catholic Medical Center] Medical Staff Bylaws" last revised January 2018, revealed "... Preamble ... 3. These bylaws provide the professional structure for medical staff operations, organized medical staff relations with the Board of Directors, and medical staff relations with members, other practitioners, and applicants for medical staff membership and clinical privileges. Article 1 Definitions ... (11) "Medical Staff" means all Physicians and Dentists who are given privileges to treat patients at one or more of the system Hospitals ... "

Cross reference
482.22 (a)(1) Medical Staff Periodic Appraisals
482.22 (a)(2) Medical Staff Credentialing
482.22 (c) Medical Staff Bylaws

Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure there was a mechanism in place to ensure medical staff qualifications were periodically reviewed to determine suitability of continuing medical staff privileges for three of seven credential files reviewed (CF1, CF2 and CF3).

Findings include:

Review on March 1, 2018, of the facility's "MCMC [Mercy Catholic Medical Center] Medical Staff Bylaws" last revised January 2018, revealed "... Preamble ... 3. These bylaws provide the professional structure for medical staff operations, organized medical staff relations with the Board of Directors, and medical staff relations with members, other practitioners, and applicants for medical staff membership and clinical privileges. ... Article 6 Committees of the Medical Staff ... 6.C. Credentials Committee ... 6.C.2. Duties: The Credentials Committee shall perform the following duties: (a) review the credentials of all applicants for Medical Staff appointment, reappointment, and clinical privileges, make investigations of and interview such applicants as may be necessary and make a written report of its findings and recommendations; (b) review the credentials of all applicants who request to practice as Allied Health Professionals, make investigations of and interview such applicants as may be necessary and make a written report of its findings and recommendations; and (c) review, as questions arise, all information available regarding the clinical competence and behavior of persons currently appointed to the Medical Staff and of those practicing as Allied Health Professionals and, as a result of such review, make a written report of its findings and recommendations. ... Article 10 Appointment to the Medical Staff ... 10.F.3. Reappointment Application: (a) An application for reappointment shall be furnished to member at least 6 months prior to the expiration of their current appointment term. A completed reappointment application must be returned to the Central Medical Staff Office within the time frame established by that office. (b) In addition, failure to submit a complete application within this time frame will result in automatic expiration of appointment and clinical privileges at the end of the then current term of appointment, requiring reapplication for appointment. (c) Reappointment shall be for a period of not more than two years. ... (g) The Central Medical Staff Office shall oversee the process of gathering and verifying relevant information. The Central Medical Staff Office shall also be responsible for confirming that all relevant information has been received. ..."

Review of CF1 on March 1, 2018, revealed this physician's hospital privileges expired on August 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:00 PM confirmed CF1's hospital privileges expired on August 31, 2017. EMP3 and EMP7 revealed the facility identified this physician's expired privileges on October 30, 2017, and CF1 performed duties of a physician from September 1, 2017, to November 9, 2017, without current hospital privileges.

Review of CF2 on March 1, 2018, revealed this physician's hospital privileges expired on August 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:05 PM confirmed CF2's hospital privileges expired on August 31, 2017. EMP3 and EMP7 revealed the facility identified this physician's expired privileges on October 30, 2017, and CF2 performed duties of a physician from September 1, 2017, to November 1, 2017, without current hospital privileges.

Review of CF3 on March 1, 2018, revealed this physician's hospital privileges expired on August 17, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:10 PM confirmed CF3's hospital privileges expired on August 17, 2017. EMP3 and EMP7 revealed the facility identified this physician's expired privileges on October 31, 2017, and CF3 performed duties of a physician from August 18, 2017, to October 31, 2017, without current hospital privileges.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:15 PM confirmed the facility did not have a mechanism in place to monitor physician privileges for expiration.

Cross reference
482.22 Medical Staff
482.22 (a)(2) Medical Staff Credentialing
482.22 (c) Medical Staff Bylaws

Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure temporary privileges were not granted as a quick fix to correct the facility's oversight for reappointment prior to the expiration of clinical privileges for three of seven credential files reviewed (CF1, CF2 and CF3).

Findings include:

Review on March 1, 2018, of the facility's "MCMC [Mercy Catholic Medical Center] Medical Staff Bylaws" last revised January 2018, revealed "... Preamble ... 3. These bylaws provide the professional structure for medical staff operations, organized medical staff relations with the Board of Directors, and medical staff relations with members, other practitioners, and applicants for medical staff membership and clinical privileges. ... Article 1 Definitions ... (11) "Medical Staff" means all Physicians and Dentists who are given privileges to treat patients at one or more of the System Hospitals ... Article 2 Categories of the Medical Staff All appointments to the Medical Staff shall be made by the Board of Directors and shall be to one of the following categories of the staff. ... 2.A. Active Staff 2.A.1. Qualifications: The Active Staff shall consist of those physicians who have demonstrated an interest in and commitment to the System Hospitals through both patient care activities and hospital and Medical Staff service ... 2.B. Consulting Staff 2.B.1. Qualifications: The Consulting Staff shall consist of those physicians or dentists who are either certified in a medical subspecialty or are affiliates of a national society representing subspecialties, which are recognized by the American Board of Medical Specialties or the American Osteopathic Association. ... 2.C. Emeritus Staff 2.C.1. Qualifications: The Emeritus Staff shall consist of those Medical Staff members who have retired from active hospital practice or other physicians and dentists who are of outstanding reputation, not necessarily residing in the community. ... 2.D. Affiliate Staff 2.D.1. Qualifications: (a) The Affiliate Staff shall consist of those physicians who desire to be associated with the System Hospitals, but who do not intend to establish a practice at any of the System Hospitals. The primary purpose of the Affiliate Staff is to promote professional and educational opportunities, including continuing medical education endeavors, and to permit such individuals to access hospital services for their patients by direct referral of patients to other members on the Medical Staff for admission, evaluation and/or care and treatment ... 2.E. Senior Active Staff 2.E.1. Qualifications: The Senior Active Staff shall consist of those members who have reached the age of sixty five (65) years or who have been a member of the Active Staff for twenty five (25) years and who apply to become a member of the Senior Active Staff by giving written notice of that election to the Board of Directors. ... 2.F. Courtesy Staff 2.F.1. Qualifications: The Courtesy Staff in any department shall consist of those physicians and dentists who have been granted privileges to admit, attend, and consult on a limited number of patients per year. ... Article 6 Committees of the Medical Staff ... 6.C. Credentials Committee ... 6.C.2. Duties: The Credentials Committee shall perform the following duties: (a) review the credentials of all applicants for Medical Staff appointment, reappointment, and clinical privileges, make investigations of and interview such applicants as may be necessary, and make a written report of its findings and recommendations ... Article 10 Appointment to the Medical Staff ... 10.E. Procedure for Temporary Clinical Privileges 10.E.1. Temporary Clinical Privileges for Applicants: Temporary privileges shall not routinely be granted to applicants. Temporary admitting and clinical privileges may only be granted by the Chief Executive Officer or designee if all of the following conditions have been met and to fulfill an important patient care need while awaiting review of the MEC [Medical Executive Committee] and approval of the Board of Directors. ... "

Review of CF1 on March 1, 2018, revealed this physician's hospital privileges expired on August 31, 2017. CF1 continued to provide patient care, services and treatment until October 30, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:00 PM confirmed CF1's hospital privileges expired on August 31, 2017. EMP3 and EMP7 revealed CF1 was granted temporary privileges on November 9, 2017. EMP3 revealed granting temporary privileges to CF1 was a quick fix to correct the facility's oversight of not completing this physician's reappointment prior to CF1's expiration of clinical privileges.

Review of CF2 on March 1, 2018, revealed this physician's hospital privileges expired on August 31, 2017. CF2 continued to provide patient care, services and treatment until October 30, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:05 PM confirmed CF2's hospital privileges expired on August 31, 2017. EMP3 and EMP7 revealed CF2 was granted temporary privileges on November 9, 2017. EMP3 revealed granting temporary privileges to CF2 was a quick fix to correct the facility's oversight of not completing this physician's reappointment prior to CF2's expiration of clinical privileges.

Review of CF3 on March 1, 2018, revealed this physician's hospital privileges expired on August 17, 2017. CF3 continued to provide patient care, services and treatment until October 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:10 PM confirmed CF3's hospital privileges expired on August 17, 2017. EMP3 and EMP7 revealed CF3 was granted temporary privileges on October 31, 2017. EMP3 revealed granting temporary privileges for CF3 was a quick fix to correct the facility's oversight of not completing this physician's reappointment prior to CF3's expiration of clinical privileges.

482.22 Medical Staff
482.22 (a)(1) Medical Staff Periodic Appraisals
482.22 (c) Medical Staff Bylaws

Based on review of facility documents, credential files and staff interview (EMP), it was determined the facility failed to terminate the appointment and clinical privileges at the end of the current term of appointment when the appointment/clinical privileges expired for three of seven credential files reviewed (CF1, CF2 and CF3).

Findings include:

Review on March 1, 2018, of the facility's "MCMC [Mercy Catholic Medical Center] Medical Staff Bylaws," last revised January 2018, revealed "... Preamble ... 3. These bylaws provide the professional structure for medical staff operations, organized medical staff relations with the Board of Directors, and medical staff relations with members, other practitioners, and applicants for medical staff membership and clinical privileges. ... Article 6 Committees of the Medical Staff ... Article 10 Appointment to the Medical Staff ... 10.F.3. Reappointment Application: (a) An application for reappointment shall be furnished to members at least 6 months prior to the expiration of their current appointment term. A completed reappointment application must be returned to the Central Medical Staff Office within the time frame established by that office. (b) In addition, failure to submit a complete application within this time frame will result in automatic expiration of appointment and clinical privileges at the end of the then current term of appointment, requiring reapplication for appointment. (c) Reappointment shall be for a period of not more than two years. ... (g) The Central Medical Staff Office shall oversee the process of gathering and verifying relevant information. The Central Medical Staff Office shall also be responsible for confirming that all relevant information has been received. ..."

Review of CF1 on March 1, 2018, revealed this physician's hospital privileges expired on August 31, 2017. CF1 continued to provide patient care, services and treatment until October 30, 2017.

There was no documentation the facility terminated CF1's clinical privileges at the end of this physician's appointment term on August 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:00 PM confirmed CF1's hospital privileges expired on August 31, 2017, and there was no documentation the facility terminated CF1's clinical privileges at the end of this physician's appointment term on August 31, 2017, and CF1 continued to provide patient care, services and treatment until October 30, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:00 PM revealed CF1 was granted temporary privileges on November 9, 2017, and the facility backdated CF1's privileges to September 1, 2017, to correct the oversight of not re-credentialing this physician before the end of CF1's appointment term on August 31, 2017.

Review of CF2 on March 1, 2018, revealed this physician's hospital privileges expired on August 31, 2017. CF2 continued to provide patient care, services and treatment until October 30, 2017.

There was no documentation the facility terminated CF2's clinical privileges at the end of this physician's appointment term on August 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:05 PM confirmed CF2's hospital privileges expired on August 31, 2017, and there was no documentation the facility terminated CF2's privileges at the end of this physician's appointment term on August 31, 2017, and CF2 continued to provide patient care, services and treatment until October 30, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:05 PM revealed CF2 was granted temporary privileges on October 30, 2017, and the facility backdated CF2's privileges to September 1, 2017, to correct the oversight of not re-credentialing this physician before the end of CF2's appointment term on August 31, 2017.

Review of CF3 on March 1, 2018, revealed this physician's hospital privileges expired on August 17, 2017. CF3 continued to provide patient care, services and treatment until October 31, 2017.

There was no documentation the facility terminated CF3's privileges at the end of this physician's appointment term on August 17, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:10 PM confirmed CF3's hospital privileges expired on August 17, 2017, and there was no documentation the facility terminated CF3's privileges at the end of this physician's appointment term on August 17, 2017, and CF3 continued to provide patient care, services and treatment until October 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:15 PM revealed CF3 was granted temporary privileges on October 31, 2017, and the facility backdated CF3's privileges to October 31, 2017, to correct the oversight of not re-credentialing this physician before the end of CF3's appointment term on August 31, 2017.

Interview with EMP3 and EMP7 on March 1, 2018, at approximately 2:20 PM confirmed there was no documentation in the facility's approved Medical Staff Bylaws regarding the backdating physician privileges.

Cross reference
482.22 Medical Staff
482.22 (a)(1) Medical Staff Periodic Appraisals
482.22 (a)(2) Medical Staff Credentialing