Observations:
Based on a review of facility documents, credential files (CF) and staff interview (EMP), it was determined that the facility failed to complete a query of the National Practitioner Data Bank (NPDB) prior to approval of the delineation of privileges by the Credentialing Committee for one of ten credential files (CF6).
Findings include:
On May 5, 2025, a review the Allegheny Health Network Surgery Center Medical Staff Bylaws (Last Revised: May 27, 2021) was completed and revealed: "4.A.4. Steps to Be Followed for Initial Applicants: (c) The Credentialing and Privileging Office will also query the National Practitioner Data Bank and obtain privileged peer review evaluations from professional health care providers, both individual peers and other hospitals, regarding the quality and efficiency of services provided by the applicant."
On May 5, 2025, a review of the initial appointment file of CF6 (Initial Appointment: 10/01/2024 through September 30, 2025) was completed and revealed that CF6 submitted and signed the completed application for initial appointment to the Medical Staff on April 2, 2024. The delineation of privileges were approved on August 12, 2024; prior to query of the NPDB on August 30, 2024 and prior to receipt of written references on August 26, 2024 and August 27, 2024.
On May 5, 2025 at approximately 12:30PM, EMP7 confirmed the above.
| | Plan of Correction - To be completed: 06/30/2025
1. Specific Corrective Action for CF6: o Immediately initiate and complete an NPDB query for CF6. o Review the NPDB report for any reportable actions or information. o If any adverse information is revealed, the Credentialing Specialists and Committee will immediately evaluate the information to determine if the privileges granted should be modified or rescinded. 2. Systemic Corrective Actions (Already Implemented & Ongoing): o Counseling and Education: On May 11, 2025, the Credentialing Verification Services (CVS) team addressed clerical errors with the specialist responsible for the error. The specialist was coached on ASC-specific requirements and the importance of attention to detail. o Team Education: On May 12, 2025, a comprehensive education session was held with all CVS specialists to reinforce their understanding of ASC-specific credentialing requirements and address deficient areas. o Enhanced Auditing Process: The CVS manager or delegate is currently auditing 46% of every specialist's completed files for errors. Once a specialist achieves a 96% accuracy rate, the audit frequency will be reduced to 15% of their files. A minimum of 15% of each specialist's files will be audited monthly to ensure ongoing compliance. 3. Preventative Measures: o Policy Reinforcement: The Allegheny Health Network Surgery Center Medical Staff Bylaws, specifically section 4.A.4(c) regarding NPDB queries, will be reviewed with all relevant personnel (Credentialing Committee members, CVS staff, Medical Staff Leadership). o Process Improvement: Explore the feasibility of assigning permanent CVS staff to ASC files to ensure consistent application of ASC-specific requirements. 4. Monitoring and Evaluation: o Credentialing Leadership will track all NPDB query dates to ensure compliance with the policy. o The results of the enhanced auditing process will be reviewed monthly by Credentialing Leadership to identify any trends or areas needing further improvement. o The Credentialing Committee will receive regular reports on credentialing activities, including NPDB query compliance. 5. Date of Completion: o Corrective action for CF6: Immediately upon submission of this plan: 5/31/2025 o Systemic corrective actions and preventative measures: Ongoing.
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