HospitalInspections.org

Based on interviews and document review, it was determined hospital management failed to appoint a physician (doctor of medicine or osteopathy) to supervise the respiratory service provided by the hospital staff.

The findings are:

During the entrance conference on 11/5/19, the surveyor requested the names of key personnel. Staff Member (SM) #1 provided the requested information, identifying SM #9 as the director or SM in charge of respiratory services.

Personnel records were reviewed on 11/7/19 with the assistance of SM # 13. A review of the personnel record of SM #9 found SM #9 was licensed as a Respiratory Therapist. The surveyor asked SM #1 who was the physician over the respiratory department. SM #1 stated there had not been a physician appointed to supervise the respiratory service. SM #1 stated that he/she was unaware of this requirement. SM #1 stated later that day, after talking to other management staff, that no one was aware of this requirement.

The surveyor reviewed the regulation with SM #1 and informed SM #1 how to review the regulation on the Centers for Medicare and Medicaid website. SM #1 stated his/her understanding of the regulation and that he/she was looking into how the hospital would meet the requirement.

The above findings were discussed for a final time prior to exit on 11/8/19, no further information was provided to the surveyor.