Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531311 (X3) Date Survey Completed 11/17/2011
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0195 AGREEMENTS - CREDENTIALING & QA
CFR(s): 485.616(b)

Each CAH that is a member of a rural health network shall have an agreement with respect to credentialing and quality assurance with at least - (1) one hospital that is a member of the network; (2) one QIO or equivalent entity; or (3) one other appropriate and qualified entity identified in the State rural health care plan.


This STANDARD is not met as evidenced by:
Based on staff interview and review of policies and procedures, staff credentialing files, and the "Medical Staff Bylaws and Rules & Regulations," the facility failed to have a credentialing services agreement with a qualified entity for credentialing for 5 of 5 physicians (#1, #2, #3, #4, #5) and 2 of 2 (#6, #7) physician extenders whose files were reviewed. The findings were: Review of the policies and procedures for the facility's initial and reappraisal credentialing processes and credentialing files for physicians #1 through #5 and physician extenders #6 and #7 revealed the credentialing processes that resulted in approval for these professionals did not include the services of another qualified entity as required. Interview with the clinic manager on 11/15/11 at 11:55 AM revealed she was responsible for ensuring staff credentialing, privileging, and licenses were current. She stated she had only had this duty since October 2011 and was unaware the credentialing process required review and approval by both the medical board and governing body. Review of the "Medical Staff Bylaws and Rules & Regulations" confirmed there was no agreement or involvement with another qualified entity.