Initial Comments:
This report is the result of a full Medicare recertification survey conducted on August 18-19, 2023, at Warren State Hospital. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.22(a)(2) STANDARD
MEDICAL STAFF CREDENTIALING
Name - Component - 00
The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section.
Observations:
Based on review of facility documentation, credential file review (CF), as well as employee interviews (EMP), it was determined the facility failed to ensure that the medical staff examined the credentials of all eligible candidates for medical staff membership to make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and medical staff bylaws, rules, and regulations for one of 10 credential files [CF1].
Findings Include:
Review, at approximately 10:34 AM on September 20, 2023, of "Clinical Privileging Criteria Warren State Hospital Medical Staff," dated September 2023, revealed, "... Properly privileged physicians, CRNPs, dentists, podiatrists, and licensed independent practitioners under contract may or may not be members of the Medical Staff. The individual's qualifications shall be evaluated against established criteria. This shall include a review of the individual's professional competence, training, and ethical practices, and querying the National Practitioner Data Bank to comply with Title IV of the Health Care Quality Improvement Act of 1986. ... Appointments and reappointments shall be made by the Governing Body for Warren State Hospital on the recommendations of the Credentials Committee and the Medical Staff Executive Committee. All initial appointments shall be for a maximum period of two years of until the next reappointment process for the entire Medical Staff. ..."
Review, at approximately 10:40 AM on September 20, 2023, of "Credentialing Procedure Warren State Hospital Medical Staff," no date, revealed, "... Interested applicants receive the following packet of material to be completed and returned to the Medical Staff Secretary. ... Upon receipt of the above items, the Medical Staff Secretary requests the following information: ... Completed application is forwarded to Chairman of Department in which privileges are sought. Application with recommendation of Department Chairman, is forwarded to the Credentialing, Clinical Privileging, and By-Laws Committee. Credentialing, Clinical Privileging and By-Laws Committee schedules a meeting to review credentials of interested applicant. An interview with applicant may be requested at this time. Details will be handled by the Medical Staff Office. Application is reviewed, signed by committee chairperson, and presented with recommendations, to the Medical Staff Executive Committee. Upon approval by the Medical Staff Executive Committee, application is signed by the Chief Medical Officer and President of Medical Staff, then forwarded, with recommendations to the Governing Body for final approval. Applicant is notified of approval or disapproval, usually by telephone call. Applications shall be acted upon by the Credentialing, Clinical Privileging, and By-Laws Committee and the Medical Staff Executive Committee within a period of sixty (60) days. ..."
1. Review, at approximately 11:00 AM on September 19, 2023, of "Pennsylvania Department of Public Welfare," dated June 30, 2021, revealed that CF1 was reappointed for a two-year period commencing on July 1, 2021.
EMP3 confirmed the above findings at the time of observation.
2. Review, at approximately 10:51 AM on September 20, 2023, of "Warren State Hospital Psychiatry Services," dated July 2023, revealed that CF1 was providing patient care for 18 days between July 5, 2023, and July 31, 2023.
3. Review, at approximately 10:55 AM on September 20, 2023, of "Warren State Hospital Psychiatry Services," dated August 2023, revealed that CF1 was providing patient care for 21 days between August 1, 2023, and August 31, 2023.
4. Review, at approximately 10:57 AM on September 20, 2023, of "Warren State Hospital Psychiatry Services," dated September 2023, revealed that CF1 was providing patient care for 12 days between September 1, 2023, and September 19, 2023.
5. EMP1 and EMP2 confirmed that CF1 has been providing care to patient's after privileges expired on July 1, 2023.
Plan of Correction:POC
The medical staff will examine all credentials for all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of candidates. Staff who are determined to be eligible for clinical privileging will be appointed for a maximum period of two years or until the next reappointment process.
All medical staff privileges will be reviewed by the Credentialing Committee and the Credentialing Committee will provide a report on current privilege status of all medical staff monthly to be presented at the monthly medical staff meeting conducted by the CMO.
The CMO will provide the Risk Management Committee a report on current privilege status of all medical staff twice yearly.
All requests for reappointment must be completed a minimum of 90 days prior to the expiration of existing appointment and submitted to the governing body for signature within 60 days of the expiration of existing appointment.
All renewals must be signed and returned no later than 30 days before appointment lapses.
A tickler file will be created within 45 days utilizing these time parameters to ensure that reappointments are received/ signed and completed by no later than 30 days prior to the date current appointments are scheduled to expire.
Monitoring will occur monthly by CMO to ensure compliance.
Target date for completion: 1/31/2024
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