Hospital lab undergoes CMS resurvey

A team from the U.S. Centers for Medicare and Medicaid Services was once again on island last Thursday, this time to resurvey the public hospital’s laboratory unit.

Commonwealth Healthcare Corp. interim CEO Esther Muña confirmed this with the Saipan Tribune and she expressed optimism that the final results will be positive.

It will be recalled that CMS notified the hospital a year ago that the CHC lab is at risk of having its CLIA certification revoked. CLIA stands for clinical laboratory improvement amendments, which is a federal regulatory standard that applies to all clinical lab testing performed on humans in the United States. The objective of CLIA is to ensure the accuracy, reliability, and timeliness of test results regardless of where the test was performed.

“We did get surveyed [last Thursday] at the lab by CMS CLIA, and we did pretty good,” Muña told Saipan Tribune.

The lab resurvey is separate from the resurvey on the entire hospital itself, Muña said.

“When CMS was here in September, they had a separate survey for “Hospital Conditions of Participation” and one for Dialysis for ESRD (End Stage Renal Disease) “Facility Conditions of Participation.” Division of Laboratory Services under CMS is the division that does the survey to recommend or not recommend CLIA certification,” explained Muña.

If CHC loses its CLIA certification, this will affect the entire hospital’s recertification with CMS, she said.

“When CMS conducts a hospital survey like they did in September, they are looking at all Hospital Conditions of Participation and laboratory services are included in that survey. However, when they are surveying laboratory services, they are looking at how that affects patient care in the hospital as required by CMS,” she said.

Muña revealed that last week’s CLIA survey on the lab is to review the violations found in 2012 as part of the conditions for maintaining CLIA certification. 

Back in 2012, CLIA came close to revoking CHCC’s certification. Had the certificate been revoked, that would have resulted in CHC not being allowed to own or operate its laboratory for at least two years.

As the agency responsible for the health and wellness of the people of the CNMI, Muña said it would be detrimental if CHCC cannot operate a laboratory and be able to guarantee that services would be available for the hospital and for all patients, including those with Medicare and Medicaid as their primary payer.

Muña said the latest CLIA survey would still need to be reviewed by the CMS Office in Region 9. However, she disclosed that the survey showed that they meet most of the conditions of maintaining CLIA certification.

Noting the great strides made at the hospital’s lab in the past year, Muña commended the cooperation and collaboration demonstrated by certain individuals and groups.

“We had an opportunity over the past year to improve our services in the laboratory as well as throughout the hospital. This recent survey, with the help of DOI, HHS, USPHS Commission Corps, the laboratory directors, including Dr. Phillip Dauterman, the hospital administrator, Dr. Esther Kanayjorn, and the laboratory staff, we were able to accomplish our goal that the laboratory services, a critical service in the diagnosis and treatment of our patients, will be a reliable and available one,” added Muña.