Initial Comments:
This report is the result of a full Medicare initial certification survey conducted on November 7 and 8, 2022, at Berwick Hospital Center. 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.
It was determined that the facility was in compliance with the requirements of 482.60 Condition of Participation: Special Provisions Applying to Psychiatric Hospitals.
It was also determined the facility was in compliance with 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals at 482.42(g)(1)-(3)(i)-(x) COVID-19 Vaccination of Facility Staff.
Plan of Correction:
482.12(a)(3) STANDARD
MEDICAL STAFF - BYLAWS
Name - Component - 00
[The governing body must] assure that the medical staff has bylaws.
Observations:
Based on review of facility documents, credential files, and staff interview (EMP) it was determined the facility failed to develop an organized medical staff, failed to appoint a leader for the medical staff and failed to develop Medical Staff Bylaws specific to a psychiatric hospital.
Findings:
Review on November 8, 2022, of the facility document, "Berwick Hospital Center Medical Staff Bylaws," last reviewed April 2021 revealed "...Whereas, the purpose of this Hospital is to serve as a general short-term, acute care hospital, providing patient care and education; and ... Now, Therefore, the practitioners practicing in Berwick Hospital Center hereby organize themselves into a Medical Staff conforming to these bylaws. ... 5. "Chief of Staff" means the member of the Active Medical Staff who is duly elected in accordance with these bylaws to serve as chief officer of the Medical Staff of this Hospital or his/her designee. ... 15. "Medical Staff" means the formal organization of practitioners who have been granted privileges by the Board to attend patients in the Hospital. ... Article II Purposes & Responsibilities 2.1 Purpose The purposes of the Medical Staff are: ... 2.1(d) To serve as the primary means for accountability to the Board to ensure high quality professional performance of all practitioners and AHPs authorized to practice in the Hospital through delineation of clinical privileges, on-going review and evaluation of each practitioner's performance in the Hospital, and supervision, review, evaluation and delineation of duties and prerogative of AHPs; ... 8.4(h) Chief of Staff It shall be the duty of the Chief of Staff to cooperate with the CEO in enforcing all automatic suspensions and expulsions and in making necessary reports of same. The CEO or his/her designee shall periodically keep the Chief of Staff informed of the names of staff members who have been suspended or expelled under Section 8.4. ... Article X - Officers 10.1 Officers Of The Staff 10.1(a) Identification The officers of the staff shall be: (1) Chief of Staff; (2) Vice-Chief of Staff; (3) Secretary/Treasurer; and (4) Immediate Past Chief of Staff. ... 10.1(h) Duties of Elected Officers (1) Chief of Staff. The Chief of Staff shall serve as the Chief Medical Officer and principal official of the staff. As such he/she will: (i) appoint multi-disciplinary Medical Staff committees; (ii) aid in coordinating the activities of the hospital administration and of nursing and other non-physician patient care services with those of the Medical Staff; (iii) be responsible to the Board, in conjunction with the MEC, for the quality and efficiency of clinical services and professional performance within the hospital and for the effectiveness of patient care evaluations and maintenance functions delegated to the staff; work with the Board in implementation of the Board's quality, performance efficiency and other standards; (iv) in concert with the MEC and Credentials Committee, develop and implement methods for credentials review and for delineation of privileges; along with continuing medical education programs, utilization review, monitoring functions and patient care evaluation studies; (v) participate in the selection (or appointment) of Medical Staff representatives to Medical Staff and hospital management committees; (vi) report to the Board and the CEO concerning the opinions, policies, needs and grievances of the Medical Staff; (vii) be responsible for enforcement and clarification of Medical Staff Bylaws and Rules & Regulations, for the implementation of sanctions where indicated, and for the Medical Staff's compliance with procedural safeguards in all instances where corrective action has been requested against a practitioner; (viii) call, preside and be responsible for the agenda of all general meetings of the Medical Staff; (ix) serve as a voting member of the MEC and an ex-officio member of all other staff committees or functions; (x) assist in coordinating the educational activities of the Medical Staff; (xi) serve as liaison for the Medical Staff in its external professional and public relations. (xii) confer with the CEO, CFO, CNO and Service Chief on at least a quarterly basis as to whether there exists sufficient space, equipment, staffing, and financial resources or that the same will be available within a reasonable time to support each privilege requested by applicants to the Medical Staff; and report on the same to the MEC and to the Board; and (xiii) assist the Service Chief as to the types and amounts of data to be collected and compared in determining and informing the Medical Staff of the professional practice of its members. ..."
As noted above, the last time the Medical Staff Bylaws were reviewed was April 2021 when the provider was an acute care hospital. The Medical Staff Bylaws were not reviewed, updated and approved, to indicate that, as a psychiatric hospital, it is primarily engaged in providing, by or under the supervision of a Doctor of Medicine or Osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons including meeting such staffing requirements necessary for the hospital to carry out an active program of treatment for individuals receiving the hospital ' s psychiatric services.
Review on November 7, 2022, of the facility document, "Berwick Hospital Center Organization Chart," last reviewed October 11, 2022, revealed "... Medical Staff." There was no further documentation under the Medical Staff column noting the name of Chief of Staff for the Medical Staff.
Interview on November 8, 2022, with EMP2, at approximately 0900 confirmed there was no assigned or elected Chief of Staff for the Medical Staff, and there was no organized Medical Staff.
Plan of Correction:Plan of Correction:
To remain in compliance with all state and federal regulations, the hospital has taken action set forth in the following plan of correction to ensure compliance with the initial certification conducted on November 7 and November 8, 2022.
The non-compliance was based on review of documents failing to develop an organized medical staff by failure to appoint a leader for the medical staff.
The CEO met and appointed an active member of the medical staff, as the Chief of Staff, as per revised medical staff bylaws.
A letter of confirmation has been placed in the credentialing file of this medical staff member.
With this appointment of a leader of the medical staff this deficient practice has been corrected by December 1, 2022.
An immediate review and revision of the Medical Staff
Bylaws began on November 28, 2022 to develop Medical Staff Bylaws specific to a psychiatric hospital. The revisions will be completed and approved by December 19, 2022, by the Chief of Staff and medical staff.
The organized medical staff will operate under bylaws approved by the governing body by December 19, 2022 and which is responsible for quality medical care and quality psychiatric care provided to the patients by the psychiatric hospital.
The newly revised Medical Staff Bylaws will be reviewed, updated and approved to indicate a psychiatric hospital that is primarily engaged in providing services for the diagnosis and treatment for individuals receiving hospital's psychiatric services with notification to all medical staff members and allied health professionals.
The Berwick Hospital Center's Organization Chart revised with further documentation under the Medical Staff column noting the name, Chief of Staff for the Medical Staff , revisions completed and approved by by 12/19/22.
The Governing Body will be made aware of the facility's deficient practice at the next scheduled Governing Body meeting.
This corrective action will correct the deficient practice by development of an organized medical staff, appointment of a medical staff leader and development of Medical Staff Bylaws specific to a psychiatric hospital.
All corrective action will be completed by 12/20/22.
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