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CHCC now awaiting CMS decision on recertification
Repairs and maintenance an issue, several findings corrected
The Commonwealth Healthcare Corp. is now awaiting a decision whether it will be recertified or not by the Centers for Medicare and Medicaid Services.
A three-person survey team, after nearly a week of inspections at the Commonwealth Health Center, left after giving the hospital its notice and findings in an exit conference that lasted 30 minutes Friday afternoon.
The CMS team started its resurvey on Monday. They looked at medical records, medical staff files, and several areas of the hospital that included the pharmacy, laboratory, and operating room.
According to CHCC chief executive officer Esther Muña, the CMS team took notice of the hospital’s Quality and Assurance and Performance Improvement and Discharge Planning process.
Muña said the Quality and Assurance and Performance Improvement were barely looked at during the last survey and the discharge planning process was not included in the last survey as well.
“We expect something before the end of the month, but of course, it depends on the workload they have and if there are any other inspections they are working on,” she said.
In an earlier interview, hospital administrator Jesse Tudela said the hospital was also praised for its corrective actions in the family care area, in which CMS was satisfied with.
One structural area that the hospital is still working on is the heat, ventilation, and air-conditioning system or HVAC.
Muña said that prior to the latest inspection a new fire pump was installed.
She also said that CMS was notified of the hospital’s lack of a chief financial officer.
“The interview with the acting CFO went very well,” she said. The hospital’s acting CFO is Cora Ada.
Tudela said that CMS is doing the resurvey in line with the hospital’s application to have its Condition of Participation with Medicare and Medicaid programs recertified.
CMS put off its decision on CHCC’s recertification in mid-January this year and again on June 27 due to lingering concerns. A letter to Muña dated June 25 gave CHCC another five months to correct issues previously cited by CMS.
In the June 25 letter to Muña, CMS gave CHCC more time to demonstrate capacity and commitment to achieve and sustain compliance with all Conditions of Participation, in consideration of the extent of the deficiencies, complexity of making fundamental, systemic changes, and in recognition of the importance of maintaining access to hospital services for CNMI residents.
