CMS extends CHC’s recertification

The U.S. Centers for Medicare and Medicaid Services has again put off a final decision on the Commonwealth Health Center’s recertification, this time giving the local healthcare corporation that runs the hospital another five months to rectify citations previously uncovered at the CNMI’s lone public hospital.

Commonwealth Healthcare Corp. CEO Esther L. Muña was informed yesterday of this latest development and she expressed gratitude to the federal agency for this new extension.

CMS was expected to issue its final ruling on CHC’s Condition of Participation with Medicare today, June 27. The latest extension is the fourth given CHC.

In its letter to Muña dated June 25, CMS indicated its reasons why a final decision was deferred and moved to a new deadline.

“Due to the extent of the deficiencies, the complexity of making fundamental, systemic changes, and in recognition as well of the importance of maintaining access to hospital services for CNMI’s residents, CMS has decided to allow CHC additional time to demonstrate the capacity and commitment to achieve and sustain compliance with all Medicare hospital CoPs [Condition of Participation],” states the CMS letter.

CMS further extended the prospective date for termination of CHC’s Medicare provider’s agreement to Nov. 14, 2014.

Despite the new extension, CMS pointed out that failure to comply with all CMS requirements before the new November deadline will force CMS to go ahead and revoke the hospital’s certification.

“Please bear in mind that although CMS will continue to consult with CHC concerning compliance matters, ultimately it is CHC’s responsibility to ensure that the facility complies with Medicare requirements,” states CMS.

Accordingly, it added, “if compliance cannot be verified prior to Nov. 14, 2014, we will proceed with the termination action.”

Muña told Saipan Tribune yesterday that she’s grateful to CMS for providing the corporation more time.

“We are grateful to CMS for granting us this extension to allow us more time to demonstrate what we’ve done since the survey conducted in September 2012. We never slowed down to improve and I’m so proud of our hospital team for their commitment and acknowledgement that we must continue to monitor the effectiveness of our plans of correction,” Muña said.

CMS earlier identified 13 deficiencies at the public hospital. In January this year, it found that only four citations were considered satisfied, which means nine other deficiencies remain unresolved. CMS then gave the hospital until June 27 to rectify this.

These outstanding deficiencies are in the areas of governing body; quality assurance and performance improvement; medical staff; nursing services; medical record services; food and dietetic services; physical environment; infection control; and discharge planning.

CMS earlier pointed out that by virtue of the new extension, CHC was given the opportunity to retain Medicare certification for an additional time period, notwithstanding the findings of the September 2013 survey and the facility’s record of non-compliance.

Based on the September 2013 survey of CMS, 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.”

In the September 2012 survey, CHC was issued three IJs, which were all later abated.