555.3 Requirements for membership and privileges.
(d) Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(2) A review, summarized on record with appropriate documentation of the qualifications of the applicant.
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Observations:
Based on a review of facility documents, credential files (CF), and employee interview (EMP), it was determined that the facility failed to adequately review appointments to the medical staff as defined in the medical staff bylaws for appointment and reappointment in six of ten credential files. (CF1, CF4, CF7, CF8, CF9 and CF10).
Findings include:
On May 7, 2024, a review of the Medical Staff Bylaws (Last Revised: July 2022; Last Approved: December 2023) was completed and revealed the following: "Due Process Procedures- Article IV- Part A: Qualifications for Appointment: 1. Appointment to the medical staff ... which shall be extended only to professionally competent physicians, dentists, podiatrist, chiropractors, certified registered nurse anesthetists, and physician assistants who continuously meet the qualifications, standards set forth in these bylaws. 2 ...offices located within a sufficiently close distance to the Surgery Center in order to provide continuous care to their patients if needed, who can document their background experience, training, demonstrated competence, adherence to the ethics of their profession, their good reputation and character .... 5 ... must have in effect currently valid professional liability insurance in the amounts required by the state ... Section 3: Reappointment to the Active Medical Staff: All credential files of active medical staff members shall be reviewed every two years by the Credentialing Committee and National Practitioners Data Bank Query. The following areas will be reviewed for completeness prior to recommend [sic] for initial approval and as appropriate for renewal of privileges: licensure verification ..., DEA valid registration, valid professional liability insurance, updated delineation of privileges, verification of completion of continuing medical education, and competency in specialty, ...and peer review for reappointment and review of any pending malpractice proceedings. The Board shall approve all reappointments at its next meeting. Section 4: Peer Review- Peer review will be conducted on all credentialed files."
On May 6, 2024, a review of CF1 (Reappointment Term: 07/29/2023 to 07/29/2025) revealed a letter to the practitioner from the Credentialling Committee, granting privileges was signed on June 6, 2023; however, the delineation of privileges was not signed until June 29, 2023. There was no documented meeting of the Credentialling Committee in June 2023. Additionally, per the minutes of the Credentialling Committee, CF1was not presented to the Committee on July 25, 2023, for review of qualifications or peer review, but was granted reappointment effective July 29, 2023.
On May 6, 2024, a review of CF4 (Reappointment Term: 05/01/2024 to 05/01/2026) revealed a letter to the practitioner from the Credentialling Committee, granting reappointment was signed on April 30, 2024; however, the delineation of privileges was not signed until May 1, 2024. Additionally, per the minutes of the Credentialling Committee, CF4 was not presented to the Committee on April 23, 2024, for review of qualifications or peer review, but was granted reappointment effective May 1, 2024.
On May 6, 2024, a review of CF7 (Initial Appointment Term: 10/16/2023 to 10/16/2024) revealed a the letter to the practitioner from the Credentialling Committee, granting initial appointment was signed on October 10, 2023; however, the delineation of privileges was not signed until October 12, 2023. Additionally, per the minutes of the Credentialling Committee, CF7 was not presented to the Committee on September 21, 2023, for review of qualifications or references, but was granted an initial one tear appointment effective October 16, 2023.
On May 6, 2024, a review of CF8 (Reappointment Term: 02/07/2023 to 02/07/2025) revealed a letter to the practitioner from the Credentialling Committee, granting reappointment was signed on January 31, 2023; however, the delineation of privileges was not signed until January 31, 2022. Additionally, per the minutes of the Credentialling Committee, CF8 was not presented to the Committee on January 19, 2023, for review of qualifications or peer review, but was granted reappointment effective February 1, 2024.
On May 6, 2024, a review of CF9 (Reappointment Term: 02/01/2024 to 02/01/2026) revealed a reappointment letter from the Credentialing Committee was dated February 1, 2024. Per the minutes of the Credentialing Committee, CF9 was not presented to the committee on January 25, 2024 for review of qualifications or peer review but was granted reappointment effective February 1, 2024. In addition, there is not an updated delineation of privileges for the current reappointment. This file was presented to the Credentialing Committee on April 23, 2024, 83 days after commencement of reappointment without committee approval.
On May 6, 2024, a review of CF10 (Initial Appointment Term: 08/07/2023 to 08/07/2024) revealed an appointment letter from the Credentialing Committee was dated July 31, 2023. Per the minutes of the Credentialing Committee, CF9 was not presented to the committee on July 25, 2023, for review of qualifications or written references but was granted an initial appointment effective August 7, 2023.
On May 6, 2024, at 12:46 PM, EMP1 confirmed the above.
| | Plan of Correction - To be completed: 05/28/2024
Credentialing files were reviewed by the Administrator and reviewed at re-credentialing and at initial appointment to ensure that all files have been reviewed and signed by the medical director and approved by the credentialing committee prior to re-appointment and/or initial letter being sent to the provider.
QAPI will be conducted monthly on all files that are up for reappointment and all privileges in that month. QAPI will be done monthly until 100% compliance is attained for 90 consecutive days and quarterly thereafter.
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