Geisinger Wyoming Valley Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to comply with 489.24(f) related to Recipient Hospital Responsibilities. Findings include: Review on January 31, 2025, of facility documents, review of medical record (MR1) and staff interview (EMP) revealed the facility’s Emergency Department (ED) on-call Obstetrical and Gynecology (OBGYN) physician failed to accept a patient (MR1) requiring specialized OBGYN treatment which was within Geisinger Wyoming Valley Medical Center’s capabilities to treat. Cross reference: 489.24(f) Recipient Hospital Responsibilities.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility’s Emergency Department on-call Obstetrical and Gynecology (OBGYN) physician failed to accept a patient requiring specialized OBGYN treatment which was within Geisinger Wyoming Valley Medical Center’s capabilities to treat for one of one applicable medical record reviewed (MR1) and the facility failed to ensure all Obstetrical and Gynecology (OBGYN) physicians were re-educated regarding compliance with the facility’s Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations for one of one applicable Credential Files reviewed (CF1). Findings include: Review on January 31, 2025, of the Outside Hospital 1 (OSH1) memo to the Department of Health (Department) dated March 5, 2024, revealed this hospital ceased Emergency Department call coverage for GYN services at the facility effective May 5, 2024. Review on January 31, 2025, of the facility’s “EMTALA System Policy”, last template version January 27, 2023, revealed “Purpose ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations ... Definitions Capability mean that an organization provides the requested medical services ... Procedure ... Patient Transfers to Geisinger Facilities The hospital will accept transfers from other facilities to provide the specialized services when the requesting facility does not have the capability to provide such specialized service and the hospital has the capability and capacity to provide the needed emergency care ...” 1. Review on January 31, 2025, of MR1(medical record from transferring facility) revealed this patient was admitted to OSH1 on December 31, 2024, for vaginal bleeding, shortness of breath and acute anemia; MR1 required several blood transfusions to replace blood loss and on January 3, 2025, MR1 had a total laparoscopic hysterectomy with bilateral salpingectomies for abnormal uterine bleeding. MR1 was discharged to home on January 8, 2025. Review on January 31, 2025, of MR1 revealed this patient presented to OHS1’s Emergency Department (ED) on January 26, 2025, with a chief complaint of significant abnormal vaginal bleeding with large clots and this patient required a blood transfusion while in OHS1’s ED. Review of MR1 on January 31, 2025, revealed physician documentation by OTH1 at OSH1 dated January 26, 2025, at 1324, indicating OTH2 (the physician who performed MR1’s total laparoscopic hysterectomy with bilateral salpingectomies) was out of town and this physician’s partner was also out of town, leaving no coverage for this physician practice. At 1548, OTH1 documented the conversation with CF1 at Geisinger Wyoming Valley Medical Center that CF1 stated they were not able to see OTH2’s patients per a Geisinger memo and declined the transfer of MR1 to Geisinger Wyoming Valley Medical Center. CF1 suggested OTH1 call Outside Hospital 2 (OSH2). Further review of MR1 revealed documentation by OTH1 on January 26, 2025, at 1645 indicating OTH1 called OSH2; received instructions from the OBGYN to pack MR1’s vagina with gauge to try and slow the bleeding and to transfer MR1 to OSH2. MR1 was transferred to OSH2 on January 26, 2025, at 1709 by ambulance accompanied by Advanced Life Support (ALS) and cardiac monitoring. Review on January 31, 2025, of MR1 revealed OTH2 (ED physician at OSH2) assessed this patient and determined that MR1 continued to have abnormal vaginal bleeding accompanied with pelvic and back pain; a blood clot was removed from the vagina which resulted with bleeding bright red blood. OTH4, OTH5 and OTH6 determined MR1 required additional surgery; MR1 was taken to surgery on January 27, 2025, for vaginal cuff dehiscence after a recent hysterectomy with a suspected pelvic abscess / infected hematoma and foul-smelling drainage from the vaginal cuff. MR1 continued to be an inpatient in OSH2 at the time of the survey on January 31, 2025. Review on January 31, 2025, of the facility provided audio recording from the Communications center dated January 26, 2025, revealed the conversation between OSH1 and CF1 indicating MR1 continued to have abnormal vaginal bleeding and the request for acceptance of this patient’s transfer to Geisinger Wyoming Valley Medical Center. CF1 was heard to say they were not able to see OTH2’s patients per a Geisinger memo and declined the transfer of MR1 to the facility and CF1 suggested OTH1 call Outside Hospital 2. Interview with EMP1, EMP2, EMP3 and EMP4 on January 31, 2025, confirmed the above findings. EMP1 revealed CF1 was the on-call OBGYN physician on January 26, 2025. Telephone interview with CF1 on January 31, 2025, at approximately 1230 confirmed this physician received a phone call from OTH1 at Outside Hospital 1 requesting transfer acceptance of MR1, who was bleeding following a hysterectomy; CF1 stated they were not able to see OTH2’s patients per a Geisinger memo and declined the transfer of MR1. CF1 suggested OTH1 call Outside Hospital 2. Interview with EMP1, EMP2, EMP3 and EMP4 on January 31, 2025, confirmed the above findings. Review on January 31, 2025, of a facility provided documentation distributed by CF2 on September 2, 2024, at 1332 to all OBGYN providers revealed instructions to the OBGYN physicians to be mindful of the information they would disclose to OTH2 since this physician no longer had security clearance at Geisinger and to refrain from assuming the care of any of OTH2’s private practice patients or assisting in any surgical cases. Telephone interview with CF2 on January 31, 2025, at approximately 1320 confirmed the above instructions to the OB physicians to be mindful of the information they would disclose to OTH2 since this physician no longer had security clearance at Geisinger and to refrain from assuming the care of any of OTH2’s private practice patients or assisting in any surgical cases. 2. Review on January 29, 2025, of the facility report to the Department revealed documentation the facility was reporting a potential EMTALA violation regarding a transfer of a GYN patient that was refused by the facility’s GYN service for admission. The Transfer center reached out to the on call GYN provider who refused the patient due to surgery being done by a private practice physician. The provider recommended the patient be sent to another facility. The facility stated there would be a mandatory review of EMTALA policy with all of OBGYN physicians. Review on January 31, 2025, of the facility provided education of all OBGYN physicians revealed no documentation that CF1 received the mandatory education or review of the facility’s EMTALA policy. Interview with EMP1 on January 31, 2025, revealed the facility forgot to include CF1 in the mandatory education and review of EMTALA policy. Cross reference 489.20(l) Compliance with 489.24”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21559 Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure operating room personnel did not prepare a patient’s surgical site with a documented allergy to ChloraPrep (A0144). The failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. On December 22, 2023, the survey team toured the pre-op area and conducted interviews with staff regarding the new allergy communication process, and reviewed the immediate education that was provided to staff to determine compliance for the removal of the immediate jeopardy. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed on December 22, 2023, at 1033. Cross reference 482.13 (c)(2) Patient Rights: Care in Safe Setting”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a patient’s discharge order was written after completion of the surgical procedure and the patient is determined safe for discharge (A0347). The failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. On December 22, 2023, the survey team reviewed the education documentation the facility provided the practitioners and conducted interviews with staff regarding anticipatory documentation of a patients discharge to determine compliance for the removal of the immediate jeopardy. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed on December 22, 2023 at 1033. Cross reference 482.22 (b)(1), (2), (3) Medical Staff Organization & Accountability”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 21559 Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure a physician disclosed the use of ChloraPrep surgical prep on a patient with a documented severe allergy (A0951). The failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. On December 22, 2023, the survey team reviewed the education documentation the facility provided the practitioners and conducted interviews with staff regarding the practitioner ’ s responsibility to disclose issues to patients. The survey team verified these immediate interventions were implemented and confirmed the IJ was removed on December 22, 2023, at 1033. Cross reference 482.51 (b) Standard: Delivery of Service”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure operating room personnel did not prepare a patient’s surgical site with a documented allergy to ChloraPrep for one of one applicable medical record reviewed (MR1). Findings include: Review on December 21, 2023, of the facility’s “Patient rights & responsibilities” brochure, dated June 2021, revealed “... Care delivery You or your legally authorized representative or guardian have the right to: ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. Expect good management techniques to be implements within this hospital considering effective use of your time and to avoid your personal discomfort ...” Review on December 21, 2023, of the facility’s “Amended and Restated Bylaws of the Medical Staff of Geisinger Wyoming Valley Medical Center Bylaws of the Medical Staff,” last approved by the Board of Directors on September 21, 2022, revealed “... Article II Purposes and Responsibilities ... Section 2.2 Responsibilities ... The responsibilities of the Medical Staff are: (a) to account for the professional performance, ethical conduct and appropriateness of patient care rendered by all Practitioners ... Article III Medical Staff Membership ... Section 3.3 Basic Responsibilities of Staff Membership Each member of the Medical Staff shall: (a) Provide his patients with care that is consistent with generally recognized standards of professional performance and efficiency ...” Review on December 21, 2023, of the facility’s “Geisinger Wyoming Valley Outpatient Surgery CenterPoint Patient Safety Program and Plan”, last approved February 8, 2023, revealed “Purpose Geisinger Wyoming Valley Outpatient Surgery CenterPoint (GWV OSCP) is dedicated to creating, supporting, and disseminating a culture of safety throughout the organization. ...” Review on December 21, 2023, of the facility’s “Universal Protocol - System Policy,” last approved July 22, 2021, revealed “... Policy By ensuring that systems are in place, the following steps, taken together, comprise the Universal Protocol for eliminating wrong site, wrong procedure and wrong person surgery or procedures. ... Responsibilities The attending surgeon or individual performing the procedure oversees the Universal Protocol process. The entire OR/procedural team actively participates in the Time-Out ... Procedure I. Applicability The Universal Protocol is applicable to all invasive procedures as defined above ... II. Mandatory The Universal Protocol includes 3 mandatory elements: pre-procedure verification, marking of the site (see exceptions), and time out. ... III. Pre-Procedure Verification Pre-procedure verification consists of 3 parts: Verification of patient ID, verification of correct site/procedure and verification of available special equipment (implants, etc.), blood products, medications (antibiotics), as required for the patient. A. Verification of patient identification must be completed by utilizing 2 patient identifiers and the consent form. B. Verification of correct site/procedure must be completed by utilizing the correct patient’s H&P/office notes, pre-anesthesia evaluation, diagnostic studies including radiology and/or pathology reports, and a properly completed and signed consent form ...VI. Documentation of Universal Protocol A. Primary procedure(s) in the OR: 1. The pre-op nurse shall document in the patient’s medical record that the site was marked by the attending surgeon. Refer to the appropriate nursing flowsheets and/or checklists for specific documentation requirements. ... Pre-procedure Verification A. Pre-procedure Verification The Pre-Op nurse shall admit the patient to the Pre-Op/In and Out Unit and perform the following tasks: 1. Ask the patient to state their name and date of birth. Confirm the name and date of birth with the wristband and medical record. 2. Place the wristband on the patient. ...” Review on December 21, 2023, of the facility’s “Duties of the Circulating Nurse in the Operating Room”, policy, last approved July 23, 2022, revealed “... Policy The policy of Circulating Nurse Responsibilities is to ensure the surgical suite circulating nurse anticipates, plans for and responds to the needs of the patient, surgeon and other team members. ... Responsibilities ... Assure that a member of the nursing staff will remain with the client at all times because the primary commitment of the surgical nurse is the health, welfare and safety of the client. ... Performs duties to provide the highest level of patient care and safety to maximize patient satisfaction. Safeguards patient from dangers and hazards ...” Review of MR1 on December 20, 2023, revealed this patient presented to Geisinger Wyoming Valley CenterPoint for a scheduled Arthroscopically Aided ACL (Anterior Cruciate Ligament - a structure that stabilizes the knee joint and prevents forward movement) surgical procedure of the left knee on September 6, 2023, at 1007. Review of MR1 on December 20, 2023, revealed documentation by CF1, CF2, EMP2 and EMP6 indicating this patient’s allergy to ChloraPrep causing severe blistering. Interview with EMP1 and EMP2 on December 21, 2023, at approximately 1015 confirmed CF1, CF2, EMP2 and EMP6 were operating room (OR) staff present in the room for MR1’s surgical site prep and for MR1’s surgical procedure. Review of MR1 on December 20, 2023, revealed a physician order dated September 6, 2023, at 0720 instructing the OR staff to prep MR1’s surgical site using Betadine. Further review of MR1 on December 20, 2023, revealed documentation dated September 6, 2023, at 1325 indicating EMP6 prepped MR1’s left upper and lower leg, left ankle, toes, knee and foot with ChloraPrep. Interview with EMP1, EMP2 and EMP3 on December 20, 2021, at approximately 1030 confirmed the above findings. Review of MR1 on December 20, 2023, revealed this patient presented to an Outside Hospital (OSH) Emergency Department (ED) on September 9, 2023, with complaint of large fluid filled blisters located around the incision sites and had multiple blisters already erupted with clear / yellow fluid draining from the erupted blisters. Interview with EMP1, EMP2 and EMP3 on December 21, 2023, at approximately 1100 confirmed the findings noted above for MR1. Cross reference 482.22 (b)(1), (2), (3) Medical Staff Organization & Accountability 482.51 (b) Operating Room Policies”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a patient’s discharge order was written after completion of the surgical procedure and the patient is determined safe for discharge for two of two applicable medical records reviewed (MR1 and MR2). Findings include: Review on December 21, 2023, of the facility’s “Amended and Restated Bylaws of the Medical Staff of Geisinger Wyoming Valley Medical Center Bylaws of the Medical Staff,” last approved by the Board of Directors on September 21, 2022, revealed “... Article II Purposes and Responsibilities ... Section 2.2 Responsibilities ... The responsibilities of the Medical Staff are: (a) to account for the professional performance, ethical conduct and appropriateness of patient care rendered by all Practitioners ... Article III Medical Staff Membership ... Section 3.3 Basic Responsibilities of Staff Membership Each member of the Medical Staff shall: (a) Provide his patients with care that is consistent with generally recognized standards of professional performance and efficiency ...” Review on December 21, 2023, of the facility’s “Discharge Criteria” policy, last approved July 8, 2022, revealed “... Policy To ensure all post-anesthesia patients are discharged properly. ... Responsibilities It is the responsibility of the surgeon to assess if the patient has met discharge criteria including bleeding status and provide a discharge to home order. It is the responsibility of the anesthesiologist to assess the patient prior to discharge from the unit, to ensure all discharge criteria are met, and to provide a discharge order from the unit before the patient leaves the postoperative area. ... Procedure 1. All patients receiving anesthesia must be seen by an Anesthesiologist or their designee before being discharged from the Postoperative Area. 2. All patients must be assessed by the surgeon for discharge criteria including bleeding status before discharge. 3. All patients must meet discharge criteria before discharged home ... 5. Any bleeding beyond what is consistent with that expected from the surgical procedure needs further evaluation by the surgeon. ...” Review of MR1 on December 20, 2023, revealed this patient was admitted to Geisinger Wyoming Valley Outpatient Surgery CenterPoint an outpatient surgery site of Geisinger Wyoming Valley Medical Center on September 6, 2023, for a surgical procedure. Review of MR1 on December 20, 2023, revealed the following: MR1’s surgery started at 1252. MR1’s surgery ended at 1623. MR1 was transferred to the Post Anesthesia Care Unit (PACU) at 1625. MR1 was discharged from the facility at 1729. Further review of MR1 on December 21, 2023, revealed a Discharge Summary Note documented by CF2 on September 6, 2023, at 1146, indicating after examination of this patient, I have determined this patient is ready for discharge to home when the patient meets criteria. Discharge instructions were given to the patient. Bleeding well controlled at time of discharge. Interview with EMP1, EMP2 and EMP3 on December 21, 2023, at the time of the medical record review revealed CF2 documented MR1’s Discharge Summary Note before MR1’s surgery began. Review of MR2 on December 22, 2023, revealed this patient was admitted to Geisinger Wyoming Valley Outpatient Surgery CenterPoint an outpatient surgery site of Geisinger Wyoming Valley Medical Center on September 13, 2023, for a surgical procedure. Review of MR2 on December 22, 2023, revealed the following: MR2’s surgery started at 0831. MR2’s surgery ended at 0932. MR2 was transferred to the PACU at 0937. MR2 was discharged at 1045. Further review of MR2 on December 22, 2023, revealed a Discharge Summary Note documented by CF2 on September 13, 2023, at 0806, indicating after examination of this patient, I have determined this patient is ready for discharge to home when the patient meets criteria. Bleeding inspected prior to discharge. Discharge instructions were given to the patient. Interview with EMP7 on December 22, 2023, at the time of the medical record review revealed CF2 documented MR2’s Discharge Summary Note before MR2’s surgery began. Cross reference 482.13 Patient Rights: 482.13 (c)(2) Standard Care in a Safe Setting 482.51 (b) Operating Room Policies”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure a physician disclosed the use of ChloraPrep surgical prep on a patient with a documented severe allergy for one of one applicable medical record reviewed (MR1). Findings include: A request was made of EMP1, EMP2 and EMP3 for a facility policy/procedure/protocol/or guideline medical staff would follow regarding the disclosure of harm or potential harm to a patient that occurs pre-operatively, intraoperatively, and post operatively. None was provided. Review on December 21, 2023, of the facility’s “Amended and Restated Bylaws of the Medical Staff of Geisinger Wyoming Valley Medical Center Bylaws of the Medical Staff,” last approved by the Board of Directors on September 21, 2022, revealed “... Article II Purposes and Responsibilities ... Section 2.2 Responsibilities ... The responsibilities of the Medical Staff are: (a) to account for the professional performance, ethical conduct and appropriateness of patient care rendered by all Practitioners ...” Review on December 21, 2023, of the facility’s “GWV Rules and Regulations for use of the Medical Record,” last approved by the Medical Executive Committee on May 10, 2023, revealed “GWV Rules and Regulations for use of the Medical Record ... XII. Operative / Procedure Reports An operative/procedure report should include date of procedure, description of procedure, a preoperative diagnosis, post operative diagnosis, name of procedure, name of primary surgeon and assistants, type of anesthesia, drains, estimated blood loss, specimens removed, disposition of each specimen, complications, condition of patient, and signature by the surgeon who performed the surgery/procedure. ...” Interview with EMP1 and EMP2 on December 20, 2023, at 1500 revealed it is the physician’s responsibility to notify the patient and / or responsible party regarding harm or potential harm to a patient that occurs pre-operatively, intraoperatively, and post operatively. Review of MR1 on December 20, 2023, revealed documentation by CF1, CF2, EMP2 and EMP6 indicating this patient’s allergy to ChloraPrep causing severe blistering. Interview with EMP1 and EMP2 on December 21, 2023, at approximately 1015 confirmed CF1, CF2, EMP2 and EMP6 were operating room (OR) staff present in the room for MR1’s surgical site prep and for MR1’s surgical procedure. Review of MR1 on December 20, 2023, revealed this patient presented to Geisinger Wyoming Valley CenterPoint for a scheduled Arthroscopically Aided ACL (Anterior Cruciate Ligament - a structure that stabilizes the knee joint and prevents forward movement) surgical procedure of the left knee on September 6, 2023, at 1007. Further review revealed EMP6 completed a surgical scrub with ChloraPrep to MR1’s left knee. There was no documentation in MR1 indicating CF1 disclosed the use of ChloraPrep surgical prep on this patient to the patient or this patient’s responsible party. Interview with EMP1, EMP2, EMP3 and EMP4 on December 21, 2023, at approximately 0945 confirmed the above information. Review of MR1 on December 20, 2023, revealed this patient presented to an Outside Hospital (OSH) Emergency Department (ED) on September 9, 2023, with complaint of large fluid filled blisters located around the incision sites and had multiple blisters already erupted with clear / yellow fluid draining from the erupted blisters. MR1 was treated with intravenous Decadron (a medication that reduces swelling and to treat severe allergic reactions) 10 milligrams (mg) / Milliliter (ml) at 1517 and an order to take Benadryl orally when at home. Interview with EMP1, EMP2, EMP3 and EMP4 on December 21, 2023, at approximately 0950 confirmed the findings noted above for MR1. Review of MR1 on December 21, 2023, revealed an addendum made by CF1 on September 15, 2023, at 1324 indicating after positioning the patient and leaving the room to scrub, OR nursing inadvertently applied ChloraPrep to the operative extremity despite a previous allergy and blister reaction. MR1 was treated with intravenous Decadron (a medication that reduces swelling and severe allergic reactions) 10 milligrams (mg) / Milliliter (ml) at 1517 and an order to take Benadryl orally when at home. Interview with EMP1, EMP2, EMP3 and EMP4 on December 21, 2023, at approximately 1000 confirmed the above information. Cross reference 482.13 (c)(2) Standard Care in a Safe Setting 482.22 (b)(1), (2), (3) Medical Staff Organization & Accountability”