CMS approves CHC’s corrective action plan, hospital not recertified yet

The Center for Medicare and Medicaid Services has approved the hospital’s corrective action plan, according to Commonwealth Healthcare Corp. chief executive officer Esther Muna.

Muna confirmed with Saipan Tribune that while the hospital was not recertified yet, CHCC had received an unofficial statement that its corrective plan has been approved and CMS will be sending an official letter soon.

Muna noted that it was the first time the corrective action plan was accepted by CMS and that CMS executive Rufus Arthur sent the letter..

“What we need to do now is make sure that the plans are still active and [that we] still [need to] enforce the plans,” Muna said.

Muna said that CMS will be monitoring the way the plan is set. Muna said that they have an instructor as of now from the University of Hawaii who is training CHC staff on quality improvement for both public health and the hospital.

“It’s all about changing the values and that this [corrective plan, training] is important for the patient, important for the Commonwealth Healthcare Corp., and the staff,” she said.

CMS put off its decision on mid-January of this year and again on June 27, issuing a letter to Muna dated June 25, giving the healthcare corporation running the hospital another five months to correct citations previously cited by CMS.

On the June 25 letter to Muna, the extent of the deficiencies, complexity of making fundamental, systemic changes, and in recognition as well of the importance of maintaining access to the hospital services for CNMI’s residents; CMS gave a chance to CHC to demonstrate the capacity and commitment to achieve and sustain compliance with all Medicare Hospital CoPs or Condition of Participation.

The prospective date of termination of CHC’s Medicare provider’s agreement was extended until Nov. 14, 2014.

CMS last September visited CHC and identified 13 deficiencies at the hospital. In January of this year, CMS found that only four citations were considered satisfied, in which nine other deficiencies remain unresolved.

Muna said that they have addressed the concerns but are still working on a few, which is why the corrective action plan was approved.

“Before we gave the corrective action plan we had already been enforcing the plan,” she said.

The nine deficiencies included the areas of the governing body’s quality assurance and performance improvement, medical staff, nursing services, medical record services, food and dietetic services, physical environment, infection control, and discharge planning.

However, based on the September 2013 CMS survey results, no immediate jeopardy was uncovered.

Immediate jeopardy is issued to a provider if a deficiency is likely to cause serious injury, harm, impairment, or death. The September 2012 survey identified three immediate jeopardy area that were later addressed.

“As soon as the plan is accepted it will lead to recertification, but CMS might visit to see if the corrective action plan is being really addressed. But it is possible that the hospital might receive recertification today or tomorrow. We can’t really tell,” Muna said.