cms_AK: 38
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 38 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-10-11 | 839 | F | 1 | 0 | 566T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure a physician retained a current licensure under Alaska Statute (AS) 08.64.170 and 12 Alaska Administrative Code (AAC) 40. This failed practice placed 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10) out of 27 residents at risk for receiving care and services from an unlicensed physician. Findings: Review of the facility provided physicians' schedule, dated [DATE] to [DATE], revealed Physician #1 was scheduled and employed by the facility. Record review of the CareConnect Provider Activity Report, dated [DATE] to [DATE] revealed Physician #1 provided care and/or services to 10 residents (#s 1; 2; 3; 4; 5; 6; 7; 8; 9; and 10). Review of Alaska's Division of Corporations, Business and Professional Licensing under the Department of Commerce, Community, and Economic Development website, accessed at https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing.aspx on [DATE], revealed Physician #1 had a lapsed licensure status from [DATE] to [DATE]. Record review of the facility document Actions to Notify (Physician #1) Professional Licensure Expiration, undated, revealed the following timeline: [DATE] - Credential Verification Office (CVO) sent notification to the Provider Administrative Coordinator (PAC) of Physician #1 licensure expiration on [DATE]. [DATE]; [DATE]; [DATE]; [DATE]; [DATE] - The PAC sent email communication to Physician #1 with no response. The document indicated the facility did not have documentation to confirm these communication attempts. [DATE] - The PAC sent a copy of Physician #1's licensure to the CVO stating his/her license had been renewed and had a new expiration of [DATE]. However, the PAC sent a copy of the current licensure that had an expiration of [DATE]. The license for Physician #1 was not renewed at this time as indicated by the PAC. [DATE] - The CVO notified the PAC that he/she sent the expiring licensure for Physician #1 and confirmed it had not been renewed through the state licensing entity. [DATE] - Medical Staff Office (MSO) attempted to notify Physician #1 via phone but the number was not working. An email was then sent to Physician #1 and Clinical Manager (CM) #1. No response from either party could be provided by the facility. [DATE] - CVO notified MSO that Physician #1's licensure was still not renewed and a letter was allegedly sent to Physician #1. The facility was not able to provide evidence of this action. [DATE] - CVO contacted the state licensing entity for status update. The CVO contacted the PAC requesting licensure update. In addition, the CVO contact the MSO to request a Systems Credit Verification Office Change Form be completed and show a status of suspended as of [DATE]. [DATE] - CVO stated they contacted the PAC and the MSO again. [DATE] - CVO received a Systems Credit Verification Office Change Form from the MSO that changed Physician #1's status to suspended. The Cactus software (a software used to track credentialing information) was reportedly updated with the change in status. [DATE] - [DATE] - The CVO stated they monitored the state licensing entity for licensure updates on a weekly basis. [DATE] - CVO verified Physician #1's license was reinstated with an expiration of [DATE]. The Physician's status was changed to current. CVO documented the state licensing entity would not retroactively reinstate the licensure due to a status of inactive from [DATE] to [DATE]. Record review of the facility provided document Systems Credit Verification Office Change Form, dated [DATE], revealed the Medical Staff Coordinator sent the request form to Credential Verification Office Staff #1 indicating Physician #1's status was changed from Active/Current to Suspended. Further review revealed the form indicated that CVO Staff #1 the form was processed and changes made in Cactus. Review of the facility provided email, dated [DATE], revealed Physician #1 was sent an email by the Provider Administrative Coordinator (PAC) that indicated he/she had recently became aware of Physician #1's medical licensure was expired (62 days post expiration). The PAC further indicated the physician's name did not come up for renewal in the systematic report and There are other checks and balances in place but they failed. During an interview on [DATE] at 1:11 pm, the Director of Credential Verification Office (DCVO) stated it was the duty of the CVO to notify the MSO of upcoming expiration of licensure for physicians. During the same interview The Medical Staff Coordinator (MSC) stated a notification was sent to Physician #1 on [DATE], but no confirmation or validation of this notification was able to provided to the Surveyor. The DCVO further stated the CVO office received the change form of Physician #1's suspension, but the Cactus software did not tell the facility's medical record software that Physician #1 was not eligible to provide services. As a result, the Physician was able to continue to use and chart in the electronic medical records system. During the same interview, the DCVO was asked what the expectation of the MSO was in the credentialing process and notification of appropriate individuals. The DCVO stated due to the unlicensed physician event, it was noted that the MSO did not have a listed job duty that explained the process to support the Medical Staff Bylaw requirements. During an interview on [DATE] at 1:00 the facility's Medical Director stated he/she was Physician #1's direct supervisor. When asked about at what point was he/she made aware of Physician #1 working without a valid licensure, the Medical Director stated the information was sent to him around [DATE]. During an interview on [DATE] at 1:00 am, the facility Chief Executive Officer (CEO) stated the process for ensuring the medical staff maintained current licensure was in the process of being relayed to the facility's Credential Committee (CC), Medical Executive Committee (MEC) and Community Health Board (CHB) for review in November. Review of the PEACEHEALTH KETCHKIAN MEDICAL CENTER MEDICAL STAFF BYLAWS AND PEACEHEALTH NEW HORIZONS TRANSITIONAL CARE CENTER, dated [DATE], revealed the duties of the CC were to include review and make recommendations regarding appropriate threshold eligibility criteria for clinical privileges within the hospital. Further review revealed the duties of the MEC included recommending directly to the Board mechanisms used to review credentials and performance revealed improvement activities. In addition, the document revealed the BOARD refers to the CHB, which is responsible for the credentialing, privileging, and peer review activities at the facility. Further review of the Medical Staff Bylaws revealed medical staff members' qualifications include all physicians .much satisfy the following requirements in order to eligible to practice .have a current, unrestricted license . Review of the Alaska Statute 08.64.170(a), accessed at http://w3.legis.state.ak.us/index.php on [DATE], revealed A person may not practice medicine, podiatry, or osteopathy in the state unless the person is licensed under this chapter . | 2020-09-01 |