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Based upon reviews of 8 of 16 credentialing files for Medical Staff and Allied Health Personnel, Medical Staff Bylaws, Governing Body/Board of Managers/Medical Executive Committee meeting minutes and Administrative interviews; the Governing Body/Board of Managers failed to ensure all providers were currently appointed to the hospital's Medical Staff prior to provision of patient care as per the Medical Staff Bylaws. This was evidenced by Nurse Practitioner S10; Physician Assistant S11; Certified Registered Nurse Anesthetists S18, S19, S20; and Physicians S12, S13 and S17, none held current appointments/re-appointments to the Medical Staff and continued to provide patient services. Findings:

Review of the Medical Staff Bylaws, Article VIII titled "Reappointment To Medical Staff and Allied Health Care Staff" Section 8.3 "Reappointment Applicant's Responsibilities" "The reappointment application shall be submitted to the Administrator or designee at least four (4) months prior to the expiration of the Reappointment Applicant's current appointment term. Failure to submit an application by that time will result in automatic expiration of the Reappointment Applicant's appointment and Clinical Privileges at the end of the appointment term. The Reappointment Applicant has the responsibility to provide the required information and documentation for the evaluation and resolution of concerns regarding clinical competence, character, fitness, education, training, cooperation, behavior and other pertinent qualifications. If complete information has not be received by the Hospital within thirty (30) days of the provision of a reappointment application form, the reappointment application shall be considered abandoned by the Reappointment Applicant and the Reappointment Applicant's membership on the Medical Staff or Allied Health Care Staff and Clinical Privileges shall be considered to be voluntarily relinquished at the end of the appointment term without the right to a hearing under these Bylaws."

1) Family Practice Nurse Practitioner S10 (Allied Health Care Staff): Reappointment application dated 05/10/11; failed to have evidence the clinical privileges from other hospitals was verified, a query from the National Practitioner Data Bank failed to be conducted. Interview with Nurse Practitioner S10 on 10/05/11 at 11:05 AM, revealed he took after hours call for physicians S15, S16, and S17; however, review of the Collaborative Agreement revealed these physicians failed to be identified. Review of the form titled "Employing/Sponsoring Physician Agreement" revealed the form was to be signed and dated by the sponsoring physician, however, the form was blank.

2) Physician Assistant S11 (Allied Health Care Staff): No signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee approving medical staff reappointment. Missing from the credentialing file was the Tuberculin skin testing; verification of clinical privileges from other hospitals where S11 is on the medical staff; a National Practitioner Data Bank Query; professional letters of references.

3) Certified Registered Nurse Anesthetist (CRNA) S18: No signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee approving medical staff re-appointment. Continued review of S18's credentialing file revealed his appointment expired 08/13/2011 and was performing anesthesia services.

4) CRNA S19: Missing from S19's credentialing file was verification of Tuberculin skin testing (TB) and no signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee. Continued review of the credentialing file revealed S19's initial appointment expired 09/28/2011 and was performing anesthesia services.

5) CRNA S20: Review of the credentialing file revealed there failed to be documentation of a TB test; nor were there delineation of privileges with signatures from the approving bodies as noted above as he continued to provide anesthesia services.

6) Physician S12: Tuberculin skin test not competed; delineation of privileges failed to be approved/denied by a member of the medical staff; there were no signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee.

7) Physician S13: Last medical staff re-appointment dated 08/13/09. A post-it-note was attached to the form titled "Physician Re-Credentialing Checklist" stating "Waiting on reappointment packet". There failed to be any further documentation of the re-appointment related to physician S13.

8) Physician S17: Last medical staff appointment had expired on 08/12/2011. Continued review of S17's credentialing file revealed there failed to be documented evidence S17's request for privileges had been approved nor was there documentation relative to S17's re-appointment. S17 Physician has been admitting patients and performing surgical procedures.

Review of the Medical Executive Committee Meeting Minutes for the past 12 months revealed there failed to be documented evidence there were any approvals for medical staff re-appointments.

Interview, on 10/06/2011 at 10:40AM, with S1 Administrator confirmed the 8 individuals listed above had not been re-appointed to the hospital's medical staff and they had continued to provide services to the hospital's patients.

Based upon review of the list of contracted services and interview, the hospital failed to ensure the scope and nature of all contracted services were identified. Findings:

Review of the list of contracted services revealed 57 contracted services were listed; however, the nature and scope of the contracted service was not identified. Interview on 10/06/11 at 10:45 AM, with the Director of Nursing RN S2 confirmed the list of contracted services did not identify the nature of the service and the contractor's scope of responsibilities.

Based upon review of 8 of 16 physician and allied health care staff credential files, Medical Staff Bylaws, Medical Executive Committee Meeting Minutes, and staff interview, the Medical Staff failed to ensure Medical Staff Members were re-appointed in accordance with the bylaws. This was evidenced by failure of the Medical Staff Members who were requesting re-appointment to the Medical Staff to complete the re-appointment application four months prior to the expiration of the appointment term (Nurse Practitioner S10; Physician Assistant S11; Certified Registered Nurse Anesthetists S18, S19,and S20; and Physicians S12, S13 and S17). Findings:

Review of the Medical Staff Bylaws, Article VIII titled "Reappointment To Medical Staff and Allied Health Care Staff" Section 8.3 "Reappointment Applicant's Responsibilities" "The reappointment application shall be submitted to the Administrator or designee at least four (4) months prior to the expiration of the Reappointment Applicant's current appointment term. Failure to submit an application by that time will result in automatic expiration of the Reappointment Applicant's appointment and Clinical Privileges at the end of the appointment term. The Reappointment Applicant has the responsibility to provide the required information and documentation for the evaluation and resolution of concerns regarding clinical competence, character, fitness, education, training, cooperation, behavior and other pertinent qualifications. If complete information has not be received by the Hospital within thirty (30) days of the provision of a reappointment application form, the reappointment application shall be considered abandoned by the Reappointment Applicant and the Reappointment Applicant's membership on the Medical Staff or Allied Health Care Staff and Clinical Privileges shall be considered to be voluntarily relinquished at the end of the appointment term without the right to a hearing under these Bylaws."

Review of the Physician/Allied Health Care Staff credential files revealed the following:

1) Family Practice Nurse Practitioner S10 (Allied Health Care Staff): Reappointment application dated 05/10/11; failed to have evidence the clinical privileges from other hospitals was verified, a query from the National Practitioner Data Bank failed to be conducted. Interview with Nurse Practitioner S10 on 10/05/11 at 11:05 AM, revealed he took after hours call for physicians S15, S16, and S17; however, review of the Collaborative Agreement revealed these physicians failed to be identified. Review of the form titled "Employing/Sponsoring Physician Agreement" revealed the form was to be signed and dated by the sponsoring physician, however, the form was blank.

2) Physician Assistant S11 (Allied Health Care Staff): No signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee approving medical staff reappointment. Missing from the credentialing file was the Tuberculin skin testing; verification of clinical privileges from other hospitals where S11 is on the medical staff; a National Practitioner Data Bank Query; professional letters of references.

3) Certified Registered Nurse Anesthetist (CRNA) S18: No signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee approving medical staff re-appointment. Continued review of S18's credentialing file revealed his appointment expired 08/13/2011 and was performing anesthesia services.

4) CRNA S19: Missing from S19's credentialing file was verification of Tuberculin skin testing (TB) and no signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee. Continued review of the credentialing file revealed S19's initial appointment expired 09/28/2011 and was performing anesthesia services.

5) CRNA S20: Review of the credentialing file revealed there failed to be documentation of a TB test; nor were there delineation of privileges with signatures from the approving bodies as noted above as he continued to provide anesthesia services.

6) Physician S12: Tuberculin skin test not competed; delineation of privileges failed to be approved/denied by a member of the medical staff; there were no signatures for re-appointment approval from the Board of Managers, Medical Director, or Medical Executive Committee.

7) Physician S13: Last medical staff re-appointment dated 08/13/09. A post-it-note was attached to the form titled "Physician Re-Credentialing Checklist" stating "Waiting on reappointment packet". There failed to be any further documentation of the re-appointment related to physician S13.

8) Physician S17: Last medical staff appointment had expired on 08/12/2011. Continued review of S17's credentialing file revealed there failed to be documented evidence S17's request for privileges had been approved nor was there documentation relative to S17's re-appointment. S17 Physician has been admitting patients and performing surgical procedures.

Interview with S8 on 10/04/11 at 1:20 PM, revealed she was responsible for medical staff credentialing. When asked about the expiration of the medical staff re-appointments for Nurse Practitioner S10, Physician Assistant S11, CRNAs S18, S19, S20, Physicians S12, S13, and S17; S8 responded she was still waiting on the allied health care staff and physicians to complete the re-appointment application (Physician S13) and furnished the missing credentialing information (NP S10, PA S11, CRNAs S18, S19, S20, Physicians S12 and S17).

Interview, on 10/06/2011 at 10:40AM, with S1 Administrator confirmed the 8 individuals listed above had not been re-appointed to the hospital's medical staff and they had continued to provide services to the hospital's patients.

Review of the Medical Executive Committee Meeting Minutes for the past 12 months revealed there failed to be documented evidence there were any approvals for medical staff re-appointments.