The island’s lone public hospital is not off the hook yet in the possible termination of its certification with the U.S. Centers for Medicare and Medicaid Services after the federal agency once again put off making a decision on the facility’s Condition of Participation by five more months, or until June 27.
The extension was issued after the CMS found nine areas of substantial non-compliance with Medicare standards and requirements during the September 2013 survey of the team.
The new extension is the third given to the hospital since the CMS survey in September 2012 when it uncovered multiple deficiencies that prompted the issuance of “termination status.”
These are all contained in a 183-page report sent by Rufus Arther, branch chief of the survey certification and enforcement of the Western Division of Survey and Certification of CMS, to Commonwealth Healthcare Corp. interim CEO Esther Muña on Jan. 24.
In the report, Arther said that CHCC has to address specific concerns in the areas of governing body; quality assurance and performance improvement; medical staff; nursing services; medical record services; food and dietetic services; physical environment; infection control; and discharge planning.
CMS required the hospital to provide a corrective action plan or response within 10 days after receipt of the notice.
Muña said yesterday that the response-documents were actually submitted on time last Feb. 7, indicating that each and every concern have been rectified and addressed.
“Extending the termination [status] means we’re not off the hook yet,” Muña said, adding that the new extension was provided as a result of the improvements CMS noted in the hospital and the willingness of the governing body to commit to full compliance.
After the Feb. 7 submission of CHCC’s response, it expects a conference call from CMS to discuss whether additional documentations and evidence are needed.
The “final” decision—whether CHC’s Medicare provider agreement will be terminated or not—will be known after June 27 this year.
With the new extension, CHC is given a chance to retain Medicare certification for an additional time, Arther said.
CMS identified in its letter five areas where progress and developments have been noted at CHC. These include the key role CHC plays in providing access to essential acute care services to CNMI residents and CHC’s extraordinary financial, staffing, infrastructure and operational challenges.
Also noted were the modest but noticeable improvements in a number of areas when compared to the 2012 survey findings.
Medical Affairs director Dr. Sherleen Osman said the citations in the new report are mostly “administrative things” and have very little to do with the kind of care people actually receive at CHC.
Osman pointed out that most deal with rules, procedures, and policies that are often violated or not adhered to by people who come to the hospital. She cited as examples the CHCC’s rules on prohibiting betel nut chewing/spitting and policy disallowing food in certain stations, which is often ignored by patients and visitors, among others.
“People break the rules and when they do that, CHC gets in trouble [with Medicare],” said Osman.
She asked for the cooperation of families and community members whenever they are at the hospital.
In order to comply with all the “administrative” concerns raised by CMS, CHC has to change the “culture and system” at the hospital, Muña said.
According to her, the latest correspondence from CMS is “not a bad letter” at all. It simply gave CHCC more time to address remaining issues, she added.
“Without the commitment [from the organization], I believe they would easily pull out the plug,” said Muna.
‘New report 100-page less than in 2012’
According to hospital administrator Jesse Tudela, CMS’ latest report is actually 100 pages fewer than what the hospital got in 2012 when it received the 297-page citation report. This, he said, only indicates the many progress made at the hospital.
“Improvements have been made in our hospital and the only way for us is to go up,” said Tudela.
Cindy Hoeper, the hospital’s quality department director, pointed out yesterday that the citations are being monitored routinely. That monitoring system, she said, is institutionalized now at CHC. Two years ago, CHC hasn’t had a quality department, contributing to the fall of standard care at the facility.