Mountrail County Medical Center Inc.

“GOVERNING BODY AND TELEMEDICINE SERVICES CFR(s): §485.616(c)(3) The governing body of the CAH must ensure that when telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the agreement is written and specifies that the distant-site telemedicine entity is a contractor of services to the CAH and as such, in accordance with §485.635(c)(4)(ii), furnishes the contracted services in a manner that enables the CAH to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in this section with regard to its physicians and practitioners providing telemedicine services. §485.616(c)(4) When telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the CAH’s governing body or responsible individual may choose to rely upon the credentialing and privileging decisions made by the governing body of the distant-site telemedicine entity regarding individual distant-site physicians or practitioners. The CAH’s governing body or responsible individual must ensure, through its written agreement with the distant-site telemedicine entity, that the following provisions are met: (i) The distant-site telemedicine entity’s medical staff credentialing and privileging process and standards at least meet the standards at (c)(1)(i) through (c)(1)(vii). (ii) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides a current list to the CAH of the distant-site physician’s or practitioner’s privileges at the distant-site telemedicine entity. (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the CAH whose patients are receiving the telemedicine services is located. (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the CAH whose patients are receiving the telemedicine services, the CAH has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site telemedicine entity such information for use in periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the CAH’s patients and all complaints the CAH has received about the distant-site physician or practitioner. This Standard is not met as evidenced by: 20497 Based on bylaws review, agreement review, document review, and staff interview, the Critical Access Hospital’s (CAH’s) governing board failed to ensure medical staff reappointment followed the bylaws for 1 of 1 distant-site telemedicine entity physician (Physician #2) reviewed who provided emergency care services to the CAH’s patients through telemedicine. Failure to follow the bylaws for reappointment of telemedicine providers placed the CAH’s patients at risk of receiving services from unqualified providers. Findings include: Review of the governing board’s “Bylaws of Mountrail County Medical Center, Inc. [incorporated]” occurred on 11/20/23 at 3:30 p.m. These undated bylaws, stated, “. . . Article 6 - Medical Staff . . . 6.2) Medical Staff Applications. . . . the Board shall act on Medical Staff applications that have been approved by the Executive Committee. . . .” Review of the “Bylaws Medical Staff Mountrail County Medical Center, Inc. Stanley, North Dakota” occurred on 11/20/23 at 12:35 p.m. These bylaws, effective 04/21/23, stated, “. . . Article IV Membership . . . Section 5. Term of Appointment a. Appointments to the Medical Staff shall be made by the Governing Board and shall be for a period of two years. . . . Section 7. Credentialing from outside hospital or entity The medical staff . . . will also accept credentialing and privileging of telemedicine practitioners thru [sic] [name of telemedicine entity] . . .” Reviewed on 11/21/23, the CAH’s “Agreement for Credentialing and Privileging of [name of entity],” dated 02/26/20, stated, “. . . Now, therefore, the parties do hereby agree as follows: . . . 6. Hospital’s Responsibilities. Hospital agrees to perform the following: A. Rely upon the credentialing and privileging decisions and protocols as established by Distant Site to grant telemedicine privileges to Distant Site’s Telemedicine Practitioners who will be providing telemedicine services to Hospital’s patients. . . .” Review of providers’ 2021-2023 credentialing files occurred on 11/21/23 and indicated the following: - Physician #2: lacked evidence of reappointment since 07/23/20. Upon request on 11/21/23, the CAH failed to provide evidence of Physician #2’s reappointment since 2020. During interview in the afternoon of 11/21/23, two administrative staff members (#2 and #3) responsible for medical staff credentialing confirmed the CAH had not reappointed emergency telemedicine Physician #2 since 2020.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 20497 Based on bylaws review, record review, and staff interview, the Critical Access Hospital’s (CAH’s) governing board failed to ensure medical staff reappointment followed the bylaws for 1 of 4 consulting physician’s file reviewed (Provider #1). Failure to follow the bylaws for reappointment of medical staff members placed the CAH’s patients at risk of receiving services from unqualified providers. Findings include: Review of the governing board’s “Bylaws of Mountrail County Medical Center, Inc. [incorporated]” occurred on 11/20/23 at 3:30 p.m. These undated bylaws, stated, “. . . Article 6 - Medical Staff . . . 6.2) Medical Staff Applications. . . . the Board shall act on Medical Staff applications that have been approved by the Executive Committee. . . .” Review of the “Bylaws Medical Staff Mountrail County Medical Center, Inc. Stanley, North Dakota” occurred on 11/20/23 at 12:35 p.m. These bylaws, effective 04/21/23, stated, “. . . Article IV Membership . . . Section 5. Term of Appointment a. Appointments to the Medical Staff shall be made by the Governing Board and shall be for a period of two years. . . .” Review of providers’ 2021-2023 credentialing files occurred on 11/21/23 and indicated the following: - Physician #1: lacked evidence of reappointment since 06/22/11. Upon request on 11/21/23, the CAH failed to provide evidence of Physician #1’s reappointment since 2011. During interview on 11/21/23 at 10:15 a.m., an administrative staff member (#4) confirmed Physician #1 provided laboratory directorship for the CAH. During interview in the afternoon of 11/21/23, two administrative staff members (#2 and #3) responsible for medical staff credentialing confirmed the CAH had not reappointed Physician #1 since 2011.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. This Standard is not met as evidenced by: 20497 Based on policy review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the services furnished by the CAH for 1 of 1 year reviewed (October 2022 - September 2023). Failure to evaluate the services furnished by the CAH limited the CAH’s ability to ensure the provision of quality services to meet the needs of the CAH’s patients. Findings include: Review of the policy “Quality Assurance Program” occurred on 11/21/23. This policy, revised in 2016, stated, “. . . Annual Assessment: This plan shall be evaluated on an ongoing basis to assure that it meets the quality review needs of the institution. . . . Documentation will include a summary of relevant findings and actions required assuring or improving the coordination of quality assurance and evidence or the program impact on improving clinical performance and patient/resident care. . . .” Review of the Quality Assurance Quarterly Meeting Minutes from October 2022 through September 2023 occurred on 11/21/23. The minutes failed to include a review and evaluation of the services directly provided by the CAH to ensure the services met the needs of the CAH’s patients. Upon request on 11/22/23, the CAH failed to provide evidence of review and evaluation of the services directly provided by the CAH. During interview on 11/22/23 at 10:10 a.m., an administrative staff member (#1) confirmed the CAH had not documented an evaluation of the services directly provided by the CAH.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 20497 Based on policy review, meeting minutes review, document review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 1 of 1 year reviewed (October 2022 - September 2023). Failure to evaluate services furnished by contractors limited the CAH’s ability to ensure the contractors provided quality services for the CAH and its patients. Findings include: Review of the policy “Quality Assurance Program” occurred on 11/21/23. This policy, revised in 2016, stated, “Purpose: To implement a quality assurance program designed to monitor, evaluate, maintain and/or improve the quality and appropriateness of patient/resident care within available resources. . . . Scope: The Quality Assurance Program shall be facility wide, apply to all departments, services and practitioners whose activities within the facility have direct influence on the quality of patient/resident care. . . .” Review of the Quality Assurance Quarterly Meeting Minutes from October 2022 through September 2023 occurred on 11/21/23. The minutes included evaluations of three nursing and eight plant operations contracted services. The minutes failed to include evaluations to ensure the contracted services met the needs of the CAH and its patients for approximately 22 contracted services. Review of the CAH’s list of contracted services occurred on 11/22/23. This undated list showed approximately thirty contractors provided direct and indirect patient care services at the CAH. Upon request on 11/22/23, the CAH failed to provide evidence of evaluation of approximately 22 contracted services used by the CAH to ensure the contractors provided quality services for the CAH. During interview on 11/22/23 at 10:10 a.m., two administrative staff members (#1 and #2) confirmed the CAH had not documented an evaluation of all the contracted services used by the CAH in the past year.”

“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19 Existing Health Care Occupancies in compliance with 42 CFR 482.41(b). The facility was located in a one-story building of Type II (000) construction with a basement. The building had a wet and dry automatic sprinkler system designed to meet the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. Attached to the hospital to the east was a one-story nursing home. A two-hour fire-resistant rated occupancy barrier separated the nursing home from the hospital. Attached to the hospital to the north was a one-story clinic. A two-hour fire-resistant rated occupancy barrier separated the clinic from the hospital. Note: Observation and records review determined the facility to be in compliance with the minimum requirements of the 2012 Life Safety Code and NFPA 99, Health Care Facilities Code.”