Pineville Community Health Center, Inc.

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) 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. This Standard is not met as evidenced by: 47852 The facility failed to examine the credentials of all eligible candidates for medical staff membership for two (2) physicians, the Chief Medical Officer (CMO) and Surgeon 1. On 01/23/2026, the CMO performed a left eye excision on Patient (P) 4. Review of the CMO’s credentialing file revealed the CMO had not requested, nor been approved, to perform excisions of the eyelid. Review of the surgery schedule revealed Surgeon 1 performed multiple procedures/surgeries in January, February, March, and April 2026. Review of Surgeon 1’s credentialing revealed Surgeon 1 had requested to be able to perform 102 procedures. However, the facility had not approved Surgeon 1 to perform any procedures. The findings include: Review of the facility’s “Bylaws of the Medical Staff,” unsigned and undated, revealed the purpose of the medical staff was to organize the medical staff to credential Practitioners and Allied Health Professionals, recommend clinical privileges based on training and experience, review caregiver performance on a periodic basis, and administer discipline as required to ensure the highest quality and safety of medical care. Further review revealed appointment to the Medical Staff should confer only such clinical privileges as have been granted by the Board of Directors in accordance with the Bylaws. Continued review revealed the designated facility Medical Executive Committee should delegate to the Credentialing Facility Medical Executive Committee the ability to make recommendations on appointment and clinical privileges. Additionally, the Credentialing Facility Medical Executive Committee should review the application and the recommendation of the Credentials Committee. Within 120 days after the date on which a completed application was submitted, the Credentialing Facility Medical Executive Committee should determine whether to recommend to the Board of Directors that the Applicant be appointment to the Medical Staff or rejected for Medical Staff membership with all recommendations to appointment specifically recommending the clinical privileges to be granted. Further review revealed every Practitioner practicing in the facility should be entitled to exercise only those clinical privileges specifically granted to the Practitioner by the Board. Review of the facility’s “Board By-Laws”, amended 02/10/2023, revealed the Board of Directors should receive recommendations from the Medical Executive Committee or the medical staff and make final decisions on all appointments to the hospital’s medical staff and on assignments of responsibilities within the medical staff, including definition of the scope of privileges following completion of credentialing/privileging processing by the medical staff executive committee. Further review revealed the Board of Directors should approve the specific clinic privileges to be granted to each member of the medical staff consistent with the scope of clinical privileges allowed in the institution as determined by the Board By-Laws and the Medical Staff By-Laws. Continued review revealed only an appropriately licensed practitioner with clinical privileges should be directly responsible for a patient’s diagnosis and treatment within the area of his privileges. Review of P4’s Operative Note, dated 01/23/2026 and signed by the CMO, revealed P4’s pre-operative and post-operative diagnosis was uncertain neoplasm of the left eyelid. Further review revealed the procedure included P4 given medication for anesthesia, the entire left eyelid prepped, and an incision carried through the entire thickness of the skin to completely excise the cystic lesion. Review of the CMO’s Privileges in General Surgery credentialing file, signed 02/01/2025, revealed eye surgery was a specific category with lid-excisions of lesions specifically designated as a subcategory. Further review the CMO had not requested privileges to perform any eye surgery, including lid excision. Review of the facility’s surgical schedule log, dated from 12/22/2025 to 04/13/2026, revealed Surgeon 1 had performed surgery at least 41 times. Review of the Surgeon 1’s Privileges in General Surgery credentialing file, signed 11/01/2025, revealed Surgeon 1 had requested permission to perform 102 procedures/surgeries. However, no procedures/surgeries had been approved. During an interview, on 04/20/2025, the Director of Physician Services, stated she was certain the credentialing files were a mistake and the surgeons had both been approved for surgeries they performed. However, she was unable to provide any additional credentialing files. During an interview, on 04/20/2026 at 3:35 PM, the Chief Executive Officer (CEO) stated the medical staff credentialing committee met with all physicians and made recommendations to the Board of Directors to approve physician credentials. She further stated she was sure the Board had approved these physician credentials but was unable to state when or provide any supplemental documentation regarding the credentialing files.”

“SUPERVISION OF EMERGENCY SERVICES CFR(s): 482.55(b)(1) The emergency services must be supervised by a qualified member of the medical staff. This Standard is not met as evidenced by: 47852 The facility failed to ensure emergency services were supervised by a qualified member of the medical staff. On 01/23/2026, the Chief Medical Officer (CMO) signed a medical screening exam (MSE) for Patient (P) 11 while simultaneously signing he was performing surgery on P12. The findings include: Review of the facility’s policy, “Emergency Medical Treatment and Labor Act (EMTALA)/Transfers,” revised 04/2025, revealed any patient who came to the emergency department (ED) requesting exam and/or treatment would receive a medical screening examination (MSE) by a qualified health provider (QHP). Further review revealed the QHP would be a physician or mid-level (an Advanced Registered Nurse Practitioner or Physician Assistant). Continued review revealed the QHP would determine if the patient had an emergency medical condition. Additionally, a MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether the individual had an emergency medical condition or not. Review of the facility’s policy, “Initial Appraisal and Intervention of a Medical Emergency Screening,” revised 02/2025, revealed the purpose of the policy was to ensure the facility met the needs of patients by providing timely initial assessment, screening, and intervention in a medical emergency. Further review revealed the facility defined a medical emergency as a medical condition that manifested itself by acute symptoms of sufficient severity (including psychiatric disturbance) such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the health of the individual, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Continued review revealed the facility had the capability to address the care needs of patients experiencing a medical emergency consistent with its scope of services within the limits of its capabilities, including all patients presenting for care. Additionally, all individuals presenting to the Emergency Department (ED) requesting examination or treatment should receive a Medical Screening Examination (MSE) in accordance with Emergency Medical Treatment and Labor Act (EMTALA). Review of the screening requirements revealed the MSE must be performed by qualified medical personnel (QMP), which might include physicians, advanced practice providers (Nurse Practitioners or Physician Assistants), or Registered Nurses (RN) if permitted by hospital policy and scope of practice. Further review revealed the purpose of the MSE was to determine whether an emergency medical condition existed. Continued review revealed the MSE must be timely and appropriate to the patient’s presenting symptoms and documented in the medical record. Additionally, the facility assessment of a medical emergency required a physician to be on-site or on-call at all times and was responsible for direct patient assessment or providing medical oversight and direction to RN/Advanced Health Providers. Review revealed patients should receive safe and appropriate initial treatment within the capabilities of the care setting which included, at a minimum, physician availability for direct care or clinical oversight. Review of the facility’s surgical log revealed the CMO performed six (6) surgeries on 01/23/2026 while also acting as the only physician for the ED. Review of the ED Physician On Call Schedule revealed the CMO and an APRN were on call for the ED for 01/23/2026. However, there were no times listed for either provider. Review of P12’s Operative Note, dated 01/23/2026 and signed by the CMO at 11:33 AM, revealed P12 had a surgical procedure for an upper gastrointestinal endoscopy and biopsy. Review of P12’s Operating Room Notes, dated 01/23/2026, revealed P12’s surgery began at 11:15 AM and ended at 11:22 AM. Review of P11’s Record of Admission revealed the facility admitted P23 on 01/23/2026 at 11:19 AM with no diagnosis listed. Review of P11’s ED Provider Note, dated 01/23/2026 and signed by the CMO, revealed the provider saw P6 on 01/23/2026 at 11:20 AM with a chief complaint of a fall with head injury. Further review revealed P11 had “increasing dizzy spells” which “resulted in having a fall and hit his right side of the forehead and sustained closed head injury with mild bruising.” During an interview, on 04/17/2026 at 4:10 PM, the Chief Nursing Officer (CNO) stated she was aware the Chief Medical Officer (CMO) had performed surgeries “in the past” while functioning as the only ED provider but was unaware it continued to occur. During an interview, on 04/17/2026 at 5:26 PM, the CMO stated he did not perform surgery without an APRN or physician being on duty covering the ED. He further stated he was certain there had been a mistake in the times of his signature for ED patients MSE while simultaneously performing surgery on different patients. However, he was unable to provide the name of the APRN or physician covering the ED on 01/23/2026 while he was performing surgeries. During an interview, on 04/20/2026 at 3:35 PM, the Chief Executive Officer (CEO) stated she was aware the CMO had performed surgeries while also being the ED physician of record in the past, but “thought that had stopped”. She was unable to state how the hospital was ensuring the CMO did not continue to perform surgeries while also providing care to the ED patients, including MSEs.”