Rush County Memorial Hospital

“Medical staff. The governing body must: CFR(s): (a)(6)(ii) Medical staff privileges must be periodically reappraised by the REH. The scope of procedures performed in the REH must be periodically reviewed and amended as appropriate. This Standard is not met as evidenced by: 45841 Based on record review, interview, and facility document review, the facility’s governing body failed to ensure medical staff privileges were periodically reappraised for 7 of 7 (Chief Executive Officer [CEO]; Physician Assistant [PA] #2; Advanced Practice Registered Nurse [APRN] #3; APRN #4; APRN #5; Medical Doctor [MD] #6; and MD #7) medical staff reviewed for credentialing. This failure had the likelihood of having unqualified staff provide care for patients. Findings include: A facility document titled, “[Facility Name] By-Law,” dated 01/08/02, revealed, “Section 1. This hospital will be a nonprofit organization for the benefit of all the inhabitants of [county name] and of the surrounding area. This hospital will serve the community by promoting wellness and treating the sick in cooperation with other health care providers...Section 5. The Board of Trustees will hold meeting at least once a month, and will maintain a complete record of all its proceedings. Said records will be available for inspection by the County Commissioners and the public on request. A simple majority of the members serving on the Board will constitute a quorum for the transaction of business...” A facility document titled, “Medical Staff Bylaws,” reviewed 03/14/24, indicated, “1. Board means (Management Board), the governing body of the Hospital, the Executive Committee of the Board or any other committee or individual authorized by the Board to act on its behalf on certain matters. 2. Clinical Privileges or Privileges mean the permission granted to a practitioner to provide those diagnostic, therapeutic, medical, or surgical services specifically delineated to him/her.” Article three of the bylaws revealed, “Appointments to the Medical Staff and grants of clinical privileges are for a period of two (2) years, except that: 1. New appointees to the Staff are subject to an initial provisional period as provided below and upon satisfactory conclusion of that period are placed in the reappointment cycle as determined by the Hospital’s system of reappointment which may result in the appointment period that immediately follows satisfactory conclusion or waiver of the provisional period being less than two full years; and 2. The Board after considering the recommendations of the Medical Staff may set a more frequent reappraisal period for the exercise of particular privileges in general, for a Staff member who has an identified health disability or for Staff members who have reached the age of 70, or for a staff member who has been the subject of disciplinary action; and disciplinary action involving membership and/or clinical privileges may be initiated and taken in the interim under the appropriate provisions of these Bylaws and the related manuals; and 3. In the case of practitioner providing professional services by contract/employment, termination or expiration of the contract/employment may result in a shorter period of membership or privileges if that is the effect under theses Bylaws.” During an interview on 07/16/25 at 3:20 PM, the Clinic Manager (CM) stated the initial medical staff appointment period was for one year for two cycles then reappointment was completed every two years. The CEO (who was also a physician) “Application for Appointment to the Medical Staff” dated 04/23/17, revealed that the chairperson recommended appointment of the CEO on 04/24/17. Further review of the CEO’s credential file revealed “[Facility Name] Application for Reappointment” dated 01/17/19 for reappointment for the years 2019 and 2020 and an application dated 12/28/20 for the reappointment years 2021 and 2022. Further review of the CEO’s credential file revealed no documented evidence the CEO submitted another reappointment application and no documented evidence the CEO had been reappraised/reappointed to the medical staff with delineation of privileges for 2023, 2024, or 2025. The following patient medical records revealed the CEO continued to treat patients at the facility despite no evidence the CEO’s medical privileges had been reappraised since 2020: Patient 2’s “ER [Emergency Room] Physician Note and/or History & [and] Physical” dated 04/20/25, revealed the CEO saw the patient for genital spotting in the first trimester of pregnancy. Patient 5’s “History & Physical Exam [Examination]” dated 03/10/25, revealed the CEO saw the patient for depression. Patient 6’s “History & Physical Exam” dated 02/06/25, revealed PA #2 and the CEO saw the patient for a mental health screening. Patient 8’s “ER Physician Note and/or History & Physical” dated 03/28/25, revealed the CEO saw the patient for chest pain. Patient 10’s “ER Physician Note and/or History & Physical” dated 04/14/25, revealed the CEO saw the patient for a fever. Patient 11’s “ER Physician Note and/or History & Physical” dated 05/05/25, revealed the CEO saw the patient for syncope. Patient 14’s “ER Physician Note and/or History & Physical” revealed the patient was seen on 06/08/25 by the CEO for a sore throat. Patient 15’s “ER Physician Note and/or History & Physical” revealed the CEO saw the patient on 07/03/25 for a fever and sore throat. Patient 17’s “History & Physical Exam” dated 01/27/25, revealed the CEO saw the patient for chest tightness and lightheadedness. Patient 20’s “ER Physician Note and/or History & Physical” revealed the patient was seen on 05/12/25 by the CEO for right arm pain. Patient 21’s “ER Physician Note and/or History & Physical” dated 05/15/25, revealed the CEO saw the patient for right ear pain. Patient 22’s “ER Physician Note and/or History & Physical” revealed the CEO saw the patient on 04/18/25 for a left shin laceration. During an interview on 07/16/25 at 3:43 PM, Health Information Management Consultant (HIMC) #1 stated she did not know where the CEO’s 2022 or 2024 reappointment applications were located. PA #2’s “Application for Appointment to the Medical Staff,” dated 12/16/19, revealed the instructions for the delineation of privileges section indicated, “Request privileges desired by checking those listed on the following pages.” PA #2’s application revealed the PA had not completed the section and no privileges were requested. The application revealed the facility was required to check a box indicating whether each requested privilege was recommended or not recommended; however, nothing was selected. Further review of PA #2’s credential file revealed a “[Facility Name] Application for Reappointment” that was dated 01/14/21. The application revealed the provider requested, “the same privileges that I currently have” for the 2021 through 2022 years of appointment. Even though no privileges had been requested or marked as recommended, the application revealed the facility recommended reappointment on 02/16/21 “with all privileges requested.” Further review of PA #2’s credential file revealed no documented evidence that the PA submitted another reappointment application and no documented evidence that the PA had been reappraised/reappointed to the medical staff with a delineation of privileges for 2022, 2023, 2024, or 2025. The following patient medical records revealed PA #2 continued to treat patients at the facility despite no evidence that the PA’s medical privileges had been reappraised since 2021: Patient 4’s “ER Physician Note and/or History & Physical” dated 03/26/25, revealed PA #2 saw the patient for behavioral health issues. Patient 6’s “History & Physical Exam” dated 02/06/25, revealed PA #2 and the CEO saw the patient for a mental health screening. Patient 9’s “ER Physician Note and/or History & Physical” dated 04/03/25, revealed PA #2 saw the patient for consuming an unlabeled household cleaner/oil lubricant. Patient 12’s “ER Physician Note and/or History & Physical” dated 05/21/25, revealed PA #2 saw the patient for abdominal pain. Patient 18’s “ER Physician Note and/or History & Physical” dated 05/28/25, revealed PA #2 saw the patient for abdominal pain. During an interview on 07/16/25 at 3:46 PM, HIMC #1 stated PA #2’s last appointment was for 2022, and her 2024 reappointment would have been in her file if it had been completed. During an interview on 07/16/25 at 3:48 PM, the CM stated they had not found anything for PA #2 that confirmed the PA’s privileges. APRN #3’s “Application for Appointment to the Medical Staff,” dated 11/10/20, revealed the instructions for the delineation of privileges section indicated, “Request privileges desired by checking those listed on the following pages.” APRN #3’s application revealed the APRN had not completed the section and no privileges were requested. The application revealed the facility was required to check a box indicating whether each requested privilege was recommended or not recommended; however, nothing was selected. Although the application revealed APRN #3’s privileges were not delineated, the facility recommended an appointment to the medical staff on 11/17/20. Further review of APRN #3’s credentialing file revealed no documented evidence that the APRN submitted an application for reappointment and no documented evidence that APRN #3 had been reappraised/reappointed to the medical staff with a delineation of privileges for 2022, 2023, 2024, or 2025. The following patient medical records revealed PA #2 continued to treat patients at the facility despite no evidence APRN #3’s medical privileges had been reappraised since 2020: Patient 3’s “ER Physician Note and/or History & Physical” dated 05/23/25, revealed APRN #3 saw the patient for genital bleeding in the first trimester of pregnancy. Patient 7’s “History & Physical Exam” dated 02/04/25, revealed APRN #3 saw the patient due to ingestion of a dishwasher rinse aid. Patient 13’s “ER Physician Note and/or History & Physical” dated 06/24/25, revealed APRN #3 saw the patient for a foot injury. During an interview on 07/16/25 at 3:35 PM, the CM stated APRN #3’s last appointment was in 2020, and there were no requested privileges documented at that time. She stated she was unable to find any other credentialing documentation for APRN #3. APRN #4’s “Application for Appointment to the Medical Staff,” dated 07/11/20, revealed the instructions for the delineation of privileges section indicated, “Request privileges desired by checking those listed on the following pages.” APRN #4’s application revealed the APRN had not completed the section and no privileges were requested. The application revealed the facility was required to check a box indicating whether each requested privilege was recommended or not recommended; however, nothing was selected. Although the application revealed APRN #4’s privileges were not delineated, the facility recommended appointment to the medical staff on 11/17/20. Further review of APRN #4’s credentialing file revealed no documented evidence that APRN #4 submitted an application for reappointment to the medical staff and no documented evidence that APRN #4 had been reappraised/reappointed to the medical staff with delineation of privileges for 2022, 2023, 2024, or 2025. The following patient medical records revealed PA #2 continued to treat patients at the facility despite no evidence APRN #4’s medical privileges had been reappraised since 2020: Patient 1’s “History & [and] Physical Exam” dated 02/27/25, revealed APRN #4 saw the patient for trauma to their right arm. Patient 16’s “ER Physician Note and/or History & Physical” dated 07/03/25, revealed APRN #4 saw the patient for right otitis media. Patient 19’s “ER Physician Note and/or History & Physical” dated 04/27/25, revealed APRN #4 saw the patient for an electrical shock. During an interview on 07/16/25 at 3:20 PM, the CM stated APRN #4’s last appointment was in 2020. APRN #5’s “Application for Appointment to the Medical Staff” dated 01/14/24 revealed the instructions for the delineation of privileges section indicated, “Request privileges desired by checking those listed on the following pages.” APRN #5’s application revealed the APRN had not completed the section and no privileges were requested. The application revealed the facility was required to check a box indicating whether each requested privilege was recommended or not recommended; however, nothing was selected. Although the application revealed APRN #3’s privileges were not delineated, the facility recommended an appointment to the medical staff on 01/25/24. There was no documented evidence APRN #5 submitted an application for reappointment to the medical staff and no documented evidence that the facility reappraised APRN#5 for appointment to the medical staff in 2025. During an interview on 07/16/25 at 3:37 PM, the CM stated she believed APRN #5 started in 03/2024 and would have been due for reappraisal in 03/2025. MD #6’s “Application for Appointment to the Medical Staff” dated 05/01/18 revealed the MD requested privileges for radiological procedures that included mammography and dual-energy x-ray absorptiometry (DEXA). The application and the MD’s file revealed no documented evidence the requested privileges were approved. There was no documented evidence MD #6y had been reappraised/reappointed to the medical staff since the original appointment recommendation on 05/24/18. MD #7’s “Application for Appointment to the Medical Staff” dated 05/08/2018 revealed the MD requested privileges for radiological procedures that included mammography and DEXA. The application and the MD’s file revealed no documented evidence the requested privileges were approved. There was no documented evidence MD #7 had been reappraised/reappointed to the medical staff since the original appointment recommendation on 05/24/18. During an interview on 07/17/25 at 10:53 AM, HIMC #1 stated there should have been another file that had the reappointment information for MD #6 and MD #7, but she was unable to find them. The facility medical staff meeting minutes for 07/28/20 and 08/25/20 revealed APRN #4’s name was included in the credentialing report. The meeting minutes for 11/17/20 revealed APRN #3’s name was included in the credentialing report, and the minutes indicated that her first day would be 01/11/21. The facility medical staff meeting minutes for 2021, 2022, 2023, 2024, and 2025 revealed no documented evidence the facility recommended reappointments for the CEO, PA #2, APRN #3, APRN #4, APRN #5, MD #6, or MD #7. The facility board of trustees meeting minutes for 2020, 2021, 2022, 2023, 2024, and 2025 revealed no documented evidence credentialing recommendations for the CEO, PA #2, APRN #3, APRN #4, APRN #5, MD #6, or MD #7 were presented or approved by the board. During an interview on 07/14/25 at 2:39 PM, the CM stated HIMC #1 worked part time and was responsible for monitoring medical staff reappointments. She stated they believed that the CEO, PA #2, APRN #3, and APRN #4 were due for reappointment in 2024. According to the CM, HIMC #1 was behind on the providers’ reappointments. She stated she did not know how the medical staff reappointments got behind or whether they were forgotten. During a follow-up interview on 07/14/25 at 2:52 PM, the CM stated HIMC #1 told her 2024 reappointments for APRN #3 and APRN #4 should have been completed; however, e-mail correspondence dated 07/14/25 at 4:15 PM from the CM revealed HIMC #1 was unable to locate reappointment applications for APRN #3 and APRN #4. During an interview on 07/16/25 at 3:22 PM, HIMC #1 stated in the past, provider applications, with or without requested privileges, went to the chief of staff who reviewed the application and took it to the board. Per HIMC #1, if no one questioned the application, they would be approved. During a follow-up interview on 07/16/25 at 3:24 PM, HIMC #1 stated provider reappointments should be taken to the medical staff and to the board for approval. During an interview on 07/17/25 at 12:53 PM, the Chief Operations Officer (COO), who also attended the Board of Trustee meetings, stated during her review of the medical staff meeting minutes, she did not see any additional documentation for the CEO, PA #2, APRN #3, APRN #4, APRN #5, MD #6, or MD #7. She stated the governing board (Board of Trustees) minutes referenced provider groups, but not specific providers.”

“Contracted Services. CFR(s): (b)The governing body must be responsible for services furnished in the REH whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the REH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 45841 Based on interview and facility document review, the governing body failed to ensure 4 of 4 (two radiology services, a mobile imaging service, and a pulmonology service) services furnished under contract met conditions of participation and standards for the service provided. This failure had the potential for the contracted services to be out of compliance. Findings include: A facility document titled, “[Facility Name] By-laws,” signed 01/28/02, revealed no documented policy/procedure regarding governance of contracted services. Email correspondence dated 07/17/25 at 8:45 AM from the Chief Operations Officer (COO) revealed she did not find any policies or procedures regarding contracted services. A facility document titled, “[Facility Name] Contracted Services 2025,” revealed a list of four company names, two radiology services, a mobile imaging service, and a pulmonology service. During an interview on 07/16/25 at 4:49 PM, the COO stated they periodically talked about the services the facility contracted, but did not have any documented evidence contracted services were evaluated.”

“Contracted Services. CFR(s): (b)(2) The REH must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 45841 Based on interview and facility document review, the facility failed to ensure a list of contracted services was maintained that included the scope and nature of the services provided. This failure had the likelihood of no facility oversight, which could result in unknown services being provided. Findings include: A facility document titled, “[Facility Name] Contracted Services 2025,” revealed a list of four company names, two radiology service providers, a mobile imaging service provider, and a pulmonology service provider. There was no documented evidence the list contained the scope or nature of the services provided. During an interview on 07/16/25 at 4:49 PM, the Chief Operations Officer (COO) stated the only list she had was the “[Facility Name] Contracted Services 2025,” which only included the names of the four companies. During a follow-up interview on 07/17/25 at 12:53 PM, the COO stated she was unable to locate a list of contracted services that included the nature and scope of the services provided.”

“Eligibility and process for appointment CFR(s): (a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 45841 Based on interview and facility document review, the facility failed to ensure the medical staff conducted periodical reappraisals for 7 of 7 (Chief Executive Officer [CEO]; Physician Assistant [PA] #2; Advanced Practice Registered Nurse [APRN] #3; APRN #4; APRN #5; Medical Doctor [MD] #6; and MD #7) medical staff reviewed for credentialing. This failure had the likelihood of having unqualified staff provide care for patients. Findings include: A facility document titled, “Medical Staff Bylaws,” dated 03/14/24, indicated, “...6. Medical Staff or Staff means the formal organization of all practitioners who are appointed to membership and are privileged to attend to patients or to provide other diagnostic or therapeutic services at the Hospital. The Medical Staff as a whole, serves as Medical Executive Committee (MEC).” The Medical Staff Bylaws revealed, “The purposes of this Medical Staff are: 1. To provide a mechanism for accountability to the Board, through defined organizational components and positions, for the appropriateness of the patient care services, and professional and ethical conduct of each individual practitioner holding membership in the Medical Staff, to the end that patient care provided at the Hospital is maintained at that level of quality and efficiency which is consistent with generally recognized standards of care. 2. To serve as the body through which individual practitioners may obtain membership prerogatives and clinical privileges at the Hospital, through which they fulfill the obligations of Staff membership, and through which an environment is created that promotes quality and efficient patient care.” Article Three of The Medical Staff Bylaws revealed, “Appointments to the Medical Staff and grants of clinical privileges are for a period of two (2) years, except that: 1. New appointees to the Staff are subject to an initial provisional period as provided below and upon satisfactory conclusion of that period are placed in the reappointment cycle as determined by the Hospital’s system of reappointment which may result in the appointment period that immediately follows satisfactory conclusion or waiver of the provisional period being less than two full years.” “3. In the case of practitioner providing professional services by contract/employment, termination or expiration of the contract/employment may result in a shorter period of membership or privileges if that is the effect under theses Bylaws.” The CEO (who was also a physician) “Application for Appointment to the Medical Staff” dated 04/23/17, revealed the chairperson recommended appointment of the CEO on 04/24/17. Further review of the CEO’s credential file revealed “[Facility Name] Application for Reappointment” dated 01/17/19 for reappointment for the years 2019 and 2020 and an application dated 12/28/20 for the reappointment years 2021 and 2022. Further review of the CEO’s credential file revealed no documented evidence the CEO submitted another reappointment application and no documented evidence the medical staff reappraised the CEO in 2023, 2024, or 2025 for reappointment to the medical staff. PA #2’s “Application for Appointment to the Medical Staff,” dated 12/16/19, revealed the chairperson recommended the PA for appointment to the medical staff on 12/16/19. A “[Facility Name] Application for Reappointment” dated 01/14/21 revealed PA #2 filed for reappointment for 2021 through 2022 and was reappointed on 02/16/21. Further review of PA #2’s credential file revealed no documented evidence the PA submitted another reappointment application and no documented evidence the medical staff reappraised/recommended reappointment for PA #2 in 2022, 2023, 2024, or 2025. APRN #3’s “Application for Appointment to the Medical Staff,” dated 11/10/20, revealed the facility recommended the APRN be appointed to the medical staff on 11/17/20. Further review of APRN #3’s credentialing file revealed no documented evidence the APRN submitted an application for reappointment and no documented evidence the medical staff reappraised/recommended reappointment in 2022, 2023, 2024, or 2025. APRN #4’s “Application for Appointment to the Medical Staff,” dated 07/11/20, revealed the facility recommended appointment to the medical staff on 11/17/20. Further review of APRN #4’s credentialing file revealed no documented evidence APRN #4 submitted an application for reappointment to the medical staff and no documented evidence the medical staff reappraised/recommended reappointment for APRN #4 in 2022, 2023, 2024, or 2025. APRN #5’s “Application for Appointment to the Medical Staff” dated 01/14/24, revealed the facility recommended an appointment to the medical staff on 01/25/24. There was no documented evidence APRN #5 submitted an application for reappointment and no documented evidence the medical staff reappraised/recommended reappointment for APRN #5 in 25. MD #6’s “Application for Appointment to the Medical Staff” dated 05/01/18, revealed the MD requested privileges for radiological procedures that included mammography and dual-energy x-ray absorptiometry (DEXA). There was no documented evidence the medical staff reappraised/recommended reappointment for MD #6 since the original appointment recommendation on 05/24/18. MD #7’s “Application for Appointment to the Medical Staff” dated 05/08/18, revealed the MD requested privileges for radiological procedures that included mammography and DEXA. There was no documented evidence the medical staff reappraised/recommended reappointment for MD #6 since the original appointment recommendation on 05/24/18. The facility medical staff meeting minutes for 2021, 2022, 2023, 2024, and 2025 revealed no documented evidence the facility recommended reappointments for the CEO, PA #2, APRN #3, APRN #4, APRN #5, MD #6, or MD #7. During an interview on 07/16/25 at 3:24 PM, Health Information Management Consultant #1 stated provider reappointments should initially be taken to the medical staff for approval. During an interview on 07/17/25 at 12:53 PM, the Chief Operations Officer, who also attended the Board of Trustee meetings, stated during her review of the medical staff meeting minutes, she did not see any additional documentation regarding reappraisals/reappointments for the CEO, PA #2, APRN #3, APRN #4, APRN #5, MD #6, or MD #7.”