‘Hospital doing its best for CMS accreditation’

Saipan’s lone public hospital continues to work on the areas that it needs to work on to be accredited by the U.S. Centers for Medicare and Medicaid.

“We continue to audit and conduct mock surveys. We’re planning to do additional mock surveys next month to see how we are doing with the entire conditions of participations with CMS,” said Commonwealth Healthcare Corp. hospital administrator Jesse Tudela.

Tudela said they do corrective actions but are challenged when it’s on the technical matters such as the facility itself because that requires additional resources and funding.

“We audit and we do corrective actions if we find ongoing deficiencies but it’s really hard if it is coming from the technical side,” Tudela said. “But besides that, we’re continuously improving on our practice and coming out with new policies to guide out staff to ensure compliance.”

He noted that everyone in the hospital is working together to be able to get the accreditation.

“I’m pretty sure that all of our stakeholders, all of our staff, want to get that accreditation so it will be a joint effort from everyone,” Tudela said.

He said they will just have to do their best once the CMS team arrives on island to do a resurvey.

“It’s unannounced; they will come anytime. Every day we put on our best hat and ensure that we’re doing everything that’s required of us for getting CMS accreditation,” Tudela said. “When they come, we’ll put our best foot forward and hope for the best.”

Saipan Tribune earlier reported that a CMS visit in September 2013 identified 13 deficiencies at the hospital. In January 2014, CMS found that only four citations were considered satisfied and that nine other deficiencies remain unresolved.

Based on their September 2014 survey, CMS identified non-compliance with seven hospital Conditions of Participation or COPs.

In its survey results that were released earlier this year, CMS found that CHC did not meet conditions on medical staff appointments and accountability. CMS also found that CHC did not meet conditions on patients’ personal privacy, care in a safe setting, and restraint or seclusion.

The hospital was also cited for not meeting 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 conditions for form and retention and security.

Other areas cited were 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 outpatient post-anesthesia evaluation.