Hospital gets April ultimatum

The Centers for Medicare and Medicaid Services has given the Commonwealth Healthcare Corp. up to April next year to resolve nine remaining deficiencies or its condition of participation in Medicare will be terminated.

CHCC chief executive officer Esther Muna assured yesterday that the hospital is now working on its plan of correction to ensure that they meet the Dec. 22, 2014, submission deadline.

In a Dec. 4, 2014, letter from Rufus Arther, CMS Hospital and Community Care Operations for San Francisco Regional Office branch chief, he stated that based on a fourth Medicare follow-up survey of CHC, it has been determined that the hospital remains out of compliance with the requirements for participation as a provider of services in the Medicare program.

The hospital now has to come up with a plan of correction showing evidence that they will be addressing the deficiencies cited by CMS. The hospital is required to submit the plan by Dec. 22, 2014.

For now, the hospital’s condition of participation in Medicare is being extended up to April 3, 2015, at exactly 12am, Arther said, after which the hospital’s condition of participation will be terminated unless the hospital can submit by Dec. 22, 2014, its plan of correction.

“However…we are prepared, under certain conditions, to offer CHC an opportunity to retain Medicare certification for an additional time period, notwithstanding the September 2014 survey and the facility’s previous record of noncompliance,” Arther stated in his letter.

CHC’s condition of participation got extended in recognition of six factors:

The continued productive efforts by leadership of the hospital, including the CHCC CEO [Muna] 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.

CHC’s extraordinary financial, staffing, infrastructure and operational challenges.

Your 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 CHC 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 CHC plays in providing access to essential acute care services to the residents of the Commonwealth.

According to Muna, “we commend everyone’s efforts in the improvements. Also notable is that CMS recognizes that improvements were made, despite our challenges.”

Two out of nine deficiencies addressed

CMS noted that, of the nine deficiencies earlier found at the hospital, only two have been addressed while seven remain out of compliance.

Arther stated in his letter that these seven are the governing body, patient rights, medical staff, medical record services, physical environment, infection control, and discharge planning.

“It is notable that from the last survey when we had nine conditions with noncompliance, we are now at seven conditions. We are also very pleased that Quality Improvement & Performance Improvement (QAPI), a condition that had never been met before by CHC, is no longer a condition on the list. Nursing Services was also removed on this list at this survey,” Muña said.

Arther stated that these deficiencies are what hamper the hospital’s ability to provide adequate care.

What CHC has to do

In his letter to Muña, Arther said that CHC’s Medicare provider agreement will be terminated at 12am on April 3, 2015.

“Importantly, effectuation of this termination action may be postponed if by Dec. 22, 2014 (10 days from the presumed date of receipt of this notice) CHC submits credible written evidence documenting and demonstrating correction of each deficiency,” Arther stated.

“Upon receipt of such evidence, CMS will schedule a letter termination date to allow time to verify the corrections and further consult with CHC as necessary and appropriate. If we do not timely receive acceptable evidence of correction we will notify you that we will proceed with termination on April 3, 2015, and provide information about public notice, payment limitations, the readmission process and appeal rights,” he added.

CHC’s plans of correction must include: 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 on corrections, and title of staff responsible for implementing the plan for correction.

“As much as there are improvements, however, CMS follows a zero tolerance policy and only considers the action plan to be successful when the specified goals are achieved 100 percent of the time. Our team is already working on our plans of corrections to submit to CMS before Dec. 22,” Muña said.