Biographical sketch, kathy matzka, cpmsm, cpcs



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Criminal Background Checks


POLICY AND PROCEDURES

[Facility Name]

Policy:
It is the policy of the facility and Medical Staff to require verification of all relevant information provided on applications for Medical Staff appointment and/or clinical privileges (“Application(s)”. Criminal background checks are provided for in the Medical Staff Bylaws and by the Facility’s policy on employee criminal history background checks for employed physicians or other employed privilege-holders. Medical Staff Bylaws require applicants to include with their application, any current criminal charges pending against the applicant and any past convictions or pleas. In addition, Bylaws require that a practitioner shall notify the CEO and the Chief of Staff within seven (7) days of receiving notice of the initiation of any criminal charges, and shall acknowledge the Facility’s right to perform a background check at appointment, reappointment and any interim time when reasonable suspicion has been shown.


Procedure:


  1. Each applicant for clinical privileges or appointment to the Medical Staff (“Applicants”) shall be required to sign an authorization to allow the Facility to conduct a criminal background check on the Applicant (“Authorization”) as part of his/her Application.




  1. Failure to sign the Authorization or withdrawal of the Authorization by the professional shall constitute a material omission from the Application which shall result in the Application being incomplete, and the Facility may decline to process the Application further. A material omission shall also be grounds for automatic and immediate rejection of the Application resulting in denial of appointment and/or privileges.



  1. With respect to Facility employees (or prospective employees) who are also Applicants, such individuals shall also be required to comply with the Employee Background Checks policy of the Facility. The Human Resources Department may share results of Employee Background Checks of such individual with the Medical Staff Office and the others involved in the credentialing process in the same manner as if it were a Medical Staff Background Check. The Medical Staff Office may share reports on employee Applicants with the Facility’s HR Department.




  1. Denial of appointment and/or privileges based solely on failure to provide or revocation of the Authorization shall not entitle the Applicant to the procedural rights of hearing and appellate review provided in the Medical Staff Bylaws, and it shall not be deemed to be an adverse action or professional review action for purposes of reporting to the National Practitioner Data Bank.




  1. The Medical Staff Office shall include the results of the Background Check in the Applicant’s credentialing file.




  1. If an Applicant makes a misrepresentation or omission on his/her Application concerning his/her criminal history which is revealed as a result of further investigation, including, but not limited to, the Medical Staff Background Check (or the Employee Background Check, if applicable), such action shall be grounds for automatic and immediate rejection of the Application, resulting in denial of appointment and/or clinical privileges. Denial of appointment and/or privileges based solely on such misrepresentation or omission shall not entitle the Applicant to the procedural rights of hearing and appellate review provided in the Medical Staff Bylaws, and it shall not be deemed to be an adverse action or professional review action for purposes of reporting to the National Practitioner Data Bank.




  1. The Applicant may refute the information in the report with the CRA pursuant to the requirements of the CRA.




  1. If the report (or Employee Background Check, if applicable) reveals that the Applicant has a criminal history, the Medical Staff Office shall and share the reports with the Chief of Staff (COS), the Chief Executive Officer (CEO), and the applicable Department Chair or Service Chief.




  1. The Facility shall investigate any adverse information in such report(s) by inquiring with the Applicant to provide clarification or more information, among other means. In all cases, the Applicant should be given an opportunity to explain the circumstances of the arrest through a written submission or through a meeting with the COS and CEO. The facility may also request additional information including, contacting the arresting officer and/or obtaining a copy of the arrest record.




  1. The COS and CEO shall consider the criminal history information and make recommendations to the Credentialing Committee.




  1. The Credentialing Committee shall consider criminal history information in light of how the conduct relates to the Applicant’s qualification for appointment to the medical staff including, but not limited to, the applicant’s practice, maintaining patient safety and protecting the reputation of the Facility and Medical Staff. The committee should take into consideration whether the crime has a relationship to the treatment of patients, and whether or not it may be a reflection of poor moral conduct or unethical character.




  1. A disqualifying offense may be a felony conviction, guilty plea or plea of no contest to a felony possession or sale of narcotics or controlled substances, murder, manslaughter, armed robbery, rape, sexual battery, sex offenses listed in state codes, child abuse, arson, grand larceny, burglary, gratification of lust, or aggravated assault, or felonious abuse and/or battery of a vulnerable adult which has not been reversed on appeal or for which a pardon has not been granted.




  1. Mitigating circumstances which may be considered include, but are not limited to, age at which the crime was committed; nature and gravity of the crime; circumstances surrounding the crime; length of time since the arrest, conviction or prison time; criminal history since the conviction; work history; current membership and character references; and other evidence demonstrating the individual’s ability to perform their privileges competently and that the person poses no threat to the health and safety of patients. In any such instance, documentation will be produced and maintained outlining any mitigating circumstances and recommendations as to whether or not the Applicant’s membership and/or privileges shall be granted.
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