HospitalInspections.org

Based on a review of the hospital Ongoing Professional Practice Evaluation (OPPE) policy (revised 1/2017); credentialing files for 4 physicians and one Certified Registered Nurse Practitioner (CRNP), and interview with the Chief Medical Officer (CMO), it was not possible to determine if effective OPPE and Focused Professional Practice Evaluations (FPPE) were being conducted.

Review of the hospital OPPE policy revealed that on a semi-annual basis, the hospital tracks a number of data points related to physician documentation and timeliness. Review of 4 physician and 1 CRNP credentialing files revealed that credentialing and re-credentialing activities were active and ongoing. However, no OPPE, and no FPPE documentation was found related to those files.

Interview with the new Medical Director on December 18, 2017 at approximately 1 pm revealed that a contracted outside provider conducts patient chart reviews for OPPE. The Medical Director also indicated that if a physician was identified as requiring a focused review, FPPE would be completed. At the time of survey, no physician OPPE and FPPE documentation was found. Therefore, the hospital failed to meet requirements for conducting OPPE and FPPE of physicians.