CHCC: Three survey results from CMS issued in January

The U.S. Centers for Medicare and Medicaid Services issued three separate survey results to the Commonwealth Healthcare Corp. in the span of one month, specific to three areas of the hospital: the laboratory department, the dialysis unit, and the Commonwealth Health Center.

All these areas were inspected by federal health teams last year.

“We received three reports over the past month. The first one is for the laboratory, which we did receive our CLIA certification, the other is for the dialysis unit, and the latest is for the hospital’s Condition of Participation,” said interim corporation CEO Esther Muña.

The lab was at risk of having its CLIA certification revoked in 2012 as a result of multiple citations. January’s results showed the Clinical Laboratory Improvement Amendments lifting the suspension of the lab’s certification after all deficiencies were deemed fully rectified.

CMS conducts CLIA inspections every two years. The January decision is for the lab’s CLIA certification for 2012-2014. The next inspection—for 2014-2016—is expected this summer.

The next report the corporation got was a nine-page report on the dialysis unit, indicating some issues that need to be corrected within the 10 days allotted by the federal agency. Muña said the corrective action plan for the unit has been submitted and is awaiting a response from Medicare.

“Mainly, those [citations] are housekeeping issues and we addressed them. We’re now waiting CMS’ response,” she said.

Saipan Tribune learned that three areas were cited: the lack of a registered dietitian, the credential of the social worker, and issues involving patient’s rights.

According to Dr. Sherleen Osman, the corporation’s director for Medical Affairs, unlike other CMS surveys, the result for the dialysis unit is not a “pass or fail” rating.

“It is not ‘pass or fail.’ They found some concerns and they wanted more documents from us. And we addressed them,” said Osman, adding that no hospital comes out without any citation because the health survey is an ongoing process.

Just five days after receiving the dialysis report middle of last month, CMS then issued its findings on CHC’s Condition of Participation, Muña said.

In the 183-page document, CMS put off again its decision on the termination status of the public hospital, giving the corporation more time to rectify remaining concerns noted by a visiting team in September last year. The new deadline is June 27, 2014. This means that the hospital is not off the hook yet and may potentially lose its provider’s agreement with CMS if it fails to satisfy the federal agency in its response.

CMS found concerns in nine areas of the hospital, mostly dealing with administrative matters. There was no immediate jeopardy uncovered in the report; however, CHCC still must address the citations incorporated in the report. The corporation’s response was turned in on Feb. 7.

CHCC officials said that both surveys in the hospital and laboratory require CMS’ decision whether certifications will continue or be revoked.

When CMS was on island in September last year, they did a separate survey of the hospital for its “Hospital Condition of Participation” and one for the Dialysis for ESRD (End Stage Renal Disease) “Facility Conditions of Participation.”