Only 8 work days left until CMS decides hospital’s fate

Hospital plan of corrections OK’d, CMS might do validation survey this week or next

The Commonwealth Healthcare Corp. is counting the days until April 3, the date when the Centers for Medicare and Medicaid Service will make a final decision whether to terminate the hospital’s condition of participation with Medicare or conduct a resurvey.

Last year, CMS extended the hospital’s condition of participation with Medicare up to April 3, 2015, with the plan of corrections to be submitted on Dec. 22, 2014. The hospital did another follow-up submission of its second corrective plans on Feb. 9 this year.

CHCC chief executive officer Esther Muña said she met with CMS regional administrator Stephen Chickering and CMS survey and certification manager Rufus Arther during her visit to the U.S. earlier this month.

“I did meet with CMS on my trip and did go over some of the corrective action plans. I did follow up on corrective action plans and they told us the good news that it was accepted,” she said.

Muña said CMS at first did not accept the corrective action plans due to the Operating Rooms’ temperature control issue.

“Having the facility part was difficult for us considering that CMS didn’t want to accept the plan by waiting for the Heat Ventilation Air-condition or HVAC system project to be completed and it was unacceptable,” she said.

“It was necessary for us to make changes to the building even while the project is ongoing because it became a concern of patient safety because of the humidity level with our OR. There is a certain requirement for the humidity level that must be maintained when you have surgeries and basically we put an hourly monitoring so our staff and maintenance crew will go into the OR on an hourly basis to check on the humidity levels that is appropriate,” she said.

Muña said the HVAC project is expected to be completed sometime in June this year. Considering that April was the deadline they gave CHCC, the corrective action plan could not be approved, so CHCC invested in additional air conditioners and humidifiers to maintain the humidity level in the OR while waiting for the HVAC’s completion date.

They told Muña the news of the corrective action plan’s acceptance on March 3 upon her visit to San Francisco, California.

“They are still coming before April; they might be here this week or next. We’re expecting them and I am praying that we’re ready. One of the things I remind the staff, including our hospital administrator, is if you say you have a plan of correction, you follow it,” she said.

“If they find something else, they will have a complete resurvey or termination, but I am not sure of that. It is possible that the hospital might be terminated or a complete resurvey may occur,” she added.

Jayson Camacho | Reporter
Jayson Camacho covers community events, tourism, and general news coverages. Contact him at

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