Results of CMS survey out

Results of the Centers for Medicare and Medicaid survey of the Commonwealth Health Center are now out, including the findings from last September’s resurvey of the hospital.

According to Commonwealth Healthcare Corp. CEO Esther Muña, the 117-page, two-columned document notes of CMS’ findings on their fourth visit last Sept. 12 also include the hospital’s plan of correction, which was submitted on Dec. 22, 2014.

Muña said the hospital has continued to address all the deficiencies that were cited by CMS and have already been in action before and after the CMS’ last visit.

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

CMS reason for extension

Rufus Arther, CMS Hospital and Community Care Operations for San Francisco Regional Office branch chief, cited six reasons behind the decision to extend CHC’s condition of participation up to April:

The continued productive efforts by leadership of the hospital, including Muña and hospital administrator, in addressing areas of noncompliance;

The noticeable improvements in a number of areas when compared to the 2013 survey findings, including the area of filling key essential positions;

CHCC’s extraordinary financial, staffing, infrastructure and operational challenges;

A demonstrated commitment to continue to seek the necessary resources, and otherwise work diligently toward the goal of achieving and maintaining compliance with all applicable Medicare conditions of participation or CoPs;

The expectation that CHCC will draw upon an array of public and private resources to assist in identifying and resolving the root causes of non-compliance in a sustained manner; and

The key role CHCC plays in providing access to essential acute care services to Commonwealth residents.

Survey findings

In its latest survey results, CMS cited CHCC for its governing body, patient rights, medical staff, nursing services, medical records, verbal orders authenticated based on law, delivery of medical prescriptions, directory of dietary services, physical environment, emergency gas and water; facilities, supplies, equipment, and maintenance; ventilation, light, and temperature controls; infection control, discharge planning, and out-patient post anesthesia evaluation.

All the findings did not cite any major or immediate jeopardy, noting that the hospital’s plan of correction is addressing these problems.

For the governing body, CMS found that it did not meet conditions on medical staff appointments, and the medical staff’s accountability.

For patient rights, CMS found that it did not meet conditions on personal privacy, care in a safe setting, and its restraint or seclusion.

For the medical staff, CMS found that it did not meet conditions on periodic appraisals, credentialing, and its bylaws.

For the nursing services, CMS found that it did not meet conditions on registered nurse supervision of nursing services.

Medical records also did not meet the conditions for its form and retention and security.

For the most part, majority of the findings are confidential and could not be disclosed.

Plan of correction

Majority of the hospital’s plan of correction includes reassessing its policies and procedures so that everyone is in line with their work at the hospital.

Integrating more teamwork into play and giving more ownership to the staff and management in implementing the policies are also part of the plan of correction.

It also includes correcting each deficiency, improving processes that led to the deficiency cited, procedure for implementing the plan of correction, completion date of correction, tracking and monitoring of corrections, and title of staff responsible for implementing the plan of correction.

Part of the plan is to address patient rights, to encourage patients to speak out if they are not getting the care they need or if they have any concerns, and that patient rights posters are posted where hospital patients could see them.

“CHC has come a long way from before the September 2014 survey. We are grateful that CMS recognized the improvements made by the hardworking staff and management of CHC and that CHCC leadership is serious in making sure the corrective actions are made. With both CHCC leadership, CHC management, and CHC staff working together, we are seeing positive things and rightfully so—our residents deserve this progress,” said Muña.