§ 555.3. Requirements for membership and privileges.
(a) To receive favorable recommendation for appointment, or reappointment,
members of the medical staff shall always act in a manner consistent with the
highest ethical standards and levels of professional competence.
(b) Privileges granted shall reflect the results of peer review or utilization
review programs, or both, specific to ambulatory surgery.
(c) Privileges granted shall be commensurate with an individual ' s qualifications,
experience and present capabilities.
(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:
(1) A written record of the application, which includes the scope of privileges
sought and granted. The delineation ' ' clinical privileges ' ' shall address
the administration of anesthesia.
(2) A review, summarized on record with appropriate documentation, of
the qualifications of the applicant.
(e) Reappraisal and reappointment shall be required of every member of the
medical staff at regular intervals no longer than every 2 years.
(f) The governing body shall request and consider reports from the National
Practitioner Data Bank on each practitioner who requests privileges.
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Observations:
Based upon a review of facility documents, credential files (CF), and employee interview (EMP), it was determined that the facility failed to follow established policies and procedures as outlined in the Medical Staff Bylaws for two of ten credential files (CF1 and CF10).
Findings include:
On March 11, 2025, a review of Waterfront Surgery Center, LLC, Medical Staff Bylaws (Last Revised: October 16, 2023) was completed and revealed: " Article IV- Privileges: Section B: Temporary Privileges- 2. Re-Application: In the event of a practitioner having re-applied for staff privileges and who is in the process of being re-appointed but whose privileges will expire prior to the next meeting of the Governing Body, the Medical Director may grant the practitioner temporary privileges for up to 90 days or until the next meeting of the Governing Body. The granting of temporary privileges will be based upon receipt of a completed re-application for staff privileges, including evidence and documentation of current Commonwealth of Pennsylvania medical license, current DEA registration and proof of professional liability insurance in the amount required by Pennsylvania law. The Medical Director may also rely upon other information as to the competence and ethical standing of the practitioner. "
On March 11, 2024, a review of CF1 revealed that the practitioner was granted a two year appointment from September 19, 2022 through September 19, 2024. On September 19, 2024, CF1 was granted temporary privileges until December 19, 2024 (90 days). Again, on December 19, 2024, temporary privileges were granted until March 19, 2025 (90 additional days) despite having a completed application on file from the practitioner dated August 16, 2024 and Governing Body meetings on September 16, 2024, November 18, 2024, and January 20, 2025.
On March 11, 2024, a review of CF10 revealed that the practitioner was granted a two year appointment from September 18, 2023 through September 18, 2024. On September 18, 2024, CF10 was granted temporary privileges until December 18, 2024 (90 days). Again, on December 18, 2024, temporary privileges were granted until March 18, 2025 (90 additional days). An application for re-appointment was completed by the practitioner on January 30, 2025. Thus, temporary privileges were granted for 180 days without a completed application on file, as outlined in the Medical Staff Bylaws.
On March 11, 2025, EMP1 and EMP2 confirmed the above findings at 12:58 PM.
| | Plan of Correction - To be completed: 03/17/2025
On March 17, 2025, the Credentialing/Re-credentialing procedure for Medical Staff Privileges was revised to further define the steps necessary prior to granting "temporary privileges."
On Monday evening, March 17, 2025, the Board of Managers will meet and vote on the proposed procedure revisions.
On Tuesday, March 18, 2025, following approval by the Board of Managers, the Credentialing Committee will be informed of the revisions to the procedure regarding temporary privileges. Procedure revisions include:
A Credentialing Committee meeting will be held prior to granting "temporary privileges." At that time the applicant's documents will be reviewed. These documents must include:
(1) Completed application
(2) Completed and signed "Delineation of Privileges "
(3) A valid and current license to practice medicine issued by the Commonwealth of Pennsylvania
(4) A valid and current DEA registration
(5) Proof of professional liability insurance in the minimum amount required by the Commonwealth of Pennsylvania.
(6) Recent report from the National Practitioner Data Bank
Following review of the required documents, temporary privileges will be recommended for a period of ninety (90) days with one (1) 90-day extension if the committee determines that the applicant meets all necessary requirements. Recommendations from the Credentialing Committee will then be taken to the Board of Managers for review and final approval. Emergency meetings of the Credentialing Committee and Board of Managers will be held as deemed necessary for the expedient processing of all applications/re-applications for Medical Staff Privileges.
Beginning Tuesday, March 18, 2025, the Director of Nursing/designee will monitor for a period of 60 days all applications/re-applications for Medical Staff privileges to ensure adherence to the procedure. Compliance goal will be set at 95%. Once compliance goal is met, periodic monitoring will be conducted to confirm continued compliance.
Results of all audits will be reported to the Patient Safety Committee, Quality Assurance Committee, and Board of Managers.
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