Observations
Based on a review of employee records and the Staff Credentialing policy, the facility failed to follow their written personnel policy and procedures.Per the Staff Credentialing policy, the facility is to query the National Practitioner Data Bank for information on Physicians, Nurse Practitioners, Physician Assistants, etc. The NDTP is queried upon hire and at least every two years, thereafter. The results are to be maintained in the individual ' s personnel file. Employee # 1 was hired as the Medical Director on September 5, 2023. There were no National Practitioner Data Bank queries documented in the employee record. Employee # 2 was hired as a Physician Assistant on September 5, 2023. There were no National Practitioner Data Bank queries documented in the employee record. Employee # 3 was hired as a Physician Assistant on April 5, 2024. There were no National Practitioner Data Bank queries documented in the employee record.
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Plan of Correction
The facility has abolished this policy that states we query the NPDB for all providers. The facility does not query upon hire, nor does the facility input a query every 2 years for any provider in the facility.
This policy has been removed from our P&P manual. |