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) 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.
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Observations:
Based on a review of facility documents, credential files (CF) and staff interview (EMP), it was determined that the facility failed to follow established policies and procedures for re-appointment as outlined in the Medical Staff Bylaws in eight of ten credential files reviewed(CF2, CF3, CF4, CF6, CF7, CF8, CF9, and CF10).
Findings include:
On October 2, 2023, a review of the Medical Staff Bylaws (Last Revised: 09/23/2019) "Section E- Reappointment Process: 3. At appropriate intervals, the Governing Board shall review all pertinent information required of or available on each Practitioner for the purpose of determining recommendations for reappointment to the staff and/or renewal or change of privileges for the ensuring reappointment. When non-reappointment or a change in privileges is recommended, the reason for such recommendation shall be stated and documented."
On October 2, 2023, a review of CF2 revealed that the clinician received a letter of reappointment signed by the Medical Director on Behalf of the Governing Body on May 31, 2023, and without formal approval by the Governing Board.
On October 2, 2023, a review of CF3 revealed that the clinician received a letter of reappointment signed by the Medical Director on Behalf of the Governing Body on December 1, 2022, without formal approval by the Governing Board.
On October 2, 2023, a review of CF4 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on July 11, 2023, without formal approval by the Governing Board.
On October 2, 2023, a review of CF6 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on November 28, 2022, without formal approval by the Governing Board.
On October 2, 2023, a review of CF7 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on October 13, 2022, without formal approval by the Governing Board.
On October 2, 2023, a review of CF8 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on May 26, 2023, without formal approval by the Governing Board.
On October 2, 2023, a review of CF9 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on November 30, 2021, without formal approval by the Governing Board.
On October 2, 2023, a review of CF10 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on September 22, 2022, without formal approval by the Governing Board.
On October 2, 2023 at 12:00pm, EMP1confirmed the above findings.
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| | Plan of Correction - To be completed: 12/31/2023
The Policies: "Credentialing of Medical Staff" and "Credentialing of Allied Health Professionals" have been changed to be consistent with the Medical Staff Bylaws. Policies will be presented to Patient Care Committee, Medical Executive Committee and Board of Managers for approval at the next regularly scheduled meetings. All reappointments will be audited by the Executive Director until 100% compliance is achieved for 2 consecutive months. Results will be reported up through the Board of Managers.
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