HospitalInspections.org

Based on review of Medical Staff Bylaws, review of medical staff policies and procedures, review of physician credential files, review of outpatient rehabilitation medical records, review of physician rosters and staff interview, the CAH (Critical Access Hospital) failed to: 1) Follow the medical staff bylaws for reappointment of physicians to the CAH medical staff for 2 of 2 sampled Active physician credential files reviewed (Physicians B and D) and 9 of 9 sampled Courtesy physician credential files reviewed (Physicians A, C, E, F, G, H, I, J and K). Medical staff listing showed CAH has 4 Active members and 46 Courtesy members of the medical staff; and, 2) Follow the policy and procedure for Orders from Outside Providers for 1 of 3 outpatient rehabilitation medical records reviewed. Findings are:

A. Review of the Medical Staff Bylaws with an approval date of 10/26/09 revealed the following required qualifications for exercise of privileges at the CAH:
- "Competence: Possess and maintain demonstrated clinical competence, including current knowledge, judgement, and technique, in his or her specialty area and for all privileges held or applied for;"
- "Observation: Perform a sufficient number of procedures, manage a sufficient number of cases, and have sufficient patient care contact with the hospital to permit the proctor or medical staff to assess the current competency for all requested privileges..."
- "Responsibilities: Consistently carry out assigned patient care, committee, and staff responsibilities consistent with the practitioner's membership..."
- "Records: Complete all required patient care records in a thorough, professional and timely fashion."

Further review of the Medical Staff Bylaws revealed the following concerning the Reappointment/Renewal Process:
"In reviewing applications for reappointment and renewal of privileges, the Executive Committee and Board will not be limited to review of information supplied within or in support of the applications, but may review and consider any other records and information deemed relevant to their review. Without limitation, this may include review of such items as Board, Medical Staff, or committee meeting minutes or records; utilization review, peer review, and quality assurance records and reports; patient charts; incident reports; records of civil malpractice proceedings; insurance documents; records of the Board of Medical Examiners or other governmental agencies; personal medical records of the applicant; complaints or comments from other members of the public; and any other relevant documents or information. The Executive Committee and Board may also consider whether the practitioner has actually exercised all of the requested privileges with sufficient frequency since the time of last appointment or reappointment, to indicate current proficiency."

Review of on-line physician credential files with the QRM (Quality Risk Management) Clerk on 3/16/10 starting at 1:10 PM revealed the following information was available for review: verification of current Nebraska physician's license; application; current DEA (Drug Enforcement Administration) License; Query of the National Practitioner Data Bank; Certificate of Insurance; Privilege listing; 2 - 3 Peer References; Office of Inspector General Sanctions (query to find out if practitioner has been excluded or sanctioned from participating in Medicare, Medicaid or other Federally funded health care programs); some files included evaluations from other hospitals where the physician held privileges; and, multiple acknowledgement statements signed by the practitioner. This information was reviewed for Physicians A, B, C, D, E, F, G, H, I, J and K. However, no information was available concerning: clinical competence including knowledge, judgement and techniques; information on number of procedures, cases and patient care contacts; and completion of medical records .

Interview with Director of QRM, Quality Project Coordinator and QRM Clerk on 3/16/10 from 1:10 PM to 2:45 PM, while reviewing the credential files, revealed the following:
- The Network Hospital is responsible for sending out all documents to the physician when it is time to start the renewal process;
- The Network Hospital verifies and collects all of the documents;
- When an application is complete the packet is sent to the CAH by the Network Hospital;
- Just recently the Network Hospital has started scanning all of the documents into the computer;
- This packet of information is given to the Chief of Staff for review;
- Then the packet goes to the Medical Executive Committee for review;
- Last step is to take the packet of information to the Governing Board for final approval.
The CAH provides no other information concerning peer review, medical record completion, number of patients admitted/seen in the hospital for consideration in the reappointment process.

Review of the CAH Annual Program Evaluation 2008-2009 revealed an Action Plan to "Develop provider profiles using data from peer review". Interview with the Director of QRM and Quality Project Coordinator on 3/16/10 from 3:00 PM to 4:15 PM revealed that the intent of this profile was for use in credentialing and confirmed that this had not been done yet.

B. Review of the policy and procedure for Orders from Outside Providers which was last reviewed and revised by the Medical Staff Executive Committee on 12/15/09 revealed the following policy "Orders for testing and services will be accepted under certain conditions from providers who are not members of the Pender Community Hospital medical staff or who have not had privileges approved". The policy and procedure listed the providers that were allowed as "...physicians, podiatrists, dentists and other licensed practitioners who reside in Nebraska or who reside and are licensed in a state bordering Nebraska". Testing and services allowed included "procedures performed by laboratory, radiology, physical therapy, occupational therapy, speech therapy, and cardiac rehabilitation". The policy and procedure required verification of the following information prior to the testing or provision of services:
- Provider's state licensure or license from another;
- Check OIG Sanctions for exclusion from federal programs;
- Verify the provider's demographic information, at a minimum verification of address, phone number, and UPIN (Unique Physician Identification Number).

The CAH provided a Roster of Outside Providers (listing 18 current providers) that had all the above verifications completed and were approved for ordering tests or services.

Review of Medical Record 36 revealed a Rehab Services order sheet dated 2/9/09 with the only instructions of "See Discharge Orders" and Physician Q's signature. Physician Q is on the Active member list of the medical staff. Interview with the CAH's only Occupational Therapist on 3/16/10 at 11:50 AM revealed a call was placed to the office of Physician R who wrote the discharge instructions for clarifications of the discharge orders (this physician was not a member of the CAH medical staff). Further review of the medical record revealed orders dated 2/12/09, 2/19/09 and 3/19/09 with all orders originating from Physician R. Review of the Outside Provider Roster revealed this physician was not on the Roster. Further interview with the Occupational Therapist on 3/16/10 from 11:50 AM to 12:00 Noon revealed the Occupational Therapist was unaware of the policy for Orders from Outside Providers.

Based on review of personnel files, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to check the State Nurse Aide Registry prior to hiring 2 of 2 NAs (Nursing Assistants) reviewed. The CAH had hired 3 NAs in the last year and had a total of 16 NAs on staff. Census on the first day of the survey was 6 acute patients and 5 swingbed patients. Findings are:

A. Review of the personnel file for NA-S with a hire date of 2/23/09 revealed a form titled Pender Community Hospital New Employee Checklist. One item on this list was "Verify Licensure and Certification: Check under the Department of Regulation and Licensure for all nurse aides and other licensed staff". NA was written in front of this statement indicating this section was "not applicable" for this individual.

Review of the personnel file for NA-U with a hire date of 3/21/09 revealed a form titled Pender Community Hospital New Employee Checklist with a section that says "Verify and obtain copy of license and /or certification". Again NA was written in front of this section for "not applicable".

Interview with the Human Resource Manager on 3/17/10 from 1:15 PM to 1:30 PM and again at 2:00 PM confirmed that they could find no evidence that the NA Registry had been checked for NA-S and NA-U.

B. Review of the policy and procedure titled Background Investigations with a date of 8/1/08 revealed the following instructions "In conjunction with the background check, the State Nurse Aide Registry will also be checked for nurse aides at www.hhs.state.ne.us under the Department of Regulation and Licensure".