Muña: Issues in 2012 will likely not reoccur

With the many changes implemented at the Commonwealth Health Center since the Commonwealth Healthcare Corp. took over in 2011 up until last year, chief executive officer Esther Muna now believes the conditions that could have terminated the hospital’s certification with the Centers for Medicare and Medicaid Services will not happen again.

In her Dec. 31, 2014, annual report and in a letter to Gov. Eloy S. Inos, Muna gave this assurance: “From a state that was clearly leading to termination, with the systematic changes [now], we are encouraged that the resurrection of the issues noted in the September 2012 survey [by the Centers for Medicare and Medicaid Services] will likely not reoccur.”

Back in September 2012, CMS did a resurvey of compliance at the hospital and came up with numerous findings and “13 condition-level violations of non-compliance” that placed the hospital in “immediate jeopardy” of losing its certification and losing funding from both the Medicare and Medicaid programs.

“The findings were extremely serious and it risked patient safety and quality of care,” Muña said.

Since then, turning the hospital around was a big task, considering CHCC did not receive additional appropriation and was still in a transition state, she said.

“Since funding from Medicare and Medicaid was for services provided to the hospital, any funding received in the form of reimbursement from them needed to be directed to correcting the systems of providing care and complying with the ‘conditions of participations’ or CoPs.”

Corrective measures included hiring personnel for critical positions and purchasing critical equipment and other tools necessary to make “systematic changes” throughout the hospital and dialysis center and bring itself to compliance.

The hospital incorporated a “quality assurance and performance improvement” approach that ensures monitoring, tracking, and sustainability and reorganizing its organizational chart and strengthening its governing body.

Since the 2012 survey, structural improvements included kitchen equipment additions that meet safety standards of the National Fire Protection Association.

The pharmacy services department successfully implemented a Resource Patient Management System electronic health record, allowing all medication orders and allergy assessment to comply with CMS standards.

Facilities improvements included replacement of a fire pump and fire sprinklers with funding acquired throughout the years. CHCC also had a change in its discharge planning process, reducing its readmissions to 16.35 percent through the beginning of 2014.

Muña noted that resurveys in 2013 and last year showed a reduction in the number of condition-level violations of non-compliance and CMS always had positive feedback for CHCC’s staff and management.

CHCC is now in correcting deficiencies found by CMS last year in September, with the hospital’s plan of correction awaiting approval.

CHCC’s condition of participation in Medicare will either be decided in April this year or extended.

“We stress the statements from CMS because it is significant to acknowledge the fact that while we continue to be discouraged that we have yet to receive full compliance, CMS, on the other hand, is encouraging us to maintain the same trajectory as they have clearly seen the improvements,” Muña said.