The Juan F. Luis Hospital is waiting for a response from the U.S. Center for Medicaid and Medicare (CMS) to its proposed plan to correct deficiencies pointed out by inspectors.
On Jan. 4, CMS notified the hospital that, after 15 months of corrective action, it would certify the medical center to participate in the the federal healthcare programs. Without that certification, JFL would have lost a significant source of revenue.
However, a number of deficiencies still existed, CMS said, and a plan of correction was expected within 10 days.
The JFL administration crafted a new plan of correction and submitted it, electronically and by Federal Express, several days ahead of schedule, according to Troy de Chabert-Schuster, JFL board president.
CMS will review, accept or reject the document within 10 days – by Jan. 24. As of Saturday, no correspondence has been received from the agency, according to de Chabert-Schuster.
“We don’t anticipate any problem because Greeley fine-tuned it,” de Chabert-Schuster said. Greeley Consultants is the firm that has been guiding JFL towards CMS compliance for the last year or so.
The problems that continue to concern CMS include several alleged physician errors that were not reported to the board, missing signatures on consent forms, the use of restraints, serving unsuitable meals to certain patients, and other lesser infractions.
According to de Chabert-Schuster, the most serious complaints have already been corrected. One involved a patient who self-medicated a prescription pain medication in the emergency room, with the ER physician’s approval but without documentation by the nurse. The nurse has since received a reprimand and additional training.
Another inappropriate-care rating was received after a physician allegedly reported findings to the attending physician without having examined the patient, and another physician reportedly discharged an end-stage renal disease patient inappropriately.
The JFL board president said the responsible physicians were temporary staff members, or locum tenens. They no longer work for the hospital and they will not be rehired.
CMS cited JFL medical staff for excessive use of restraints in September 2014 and reported in December 2015 hospital staff continued to physically restrain patients without written orders justifying the treatment. One patient was in restraints until he/she died four days later, according to the CMS report. The hospital responded that it believes the restraint policies are appropriate but will provide more education and monitoring to avoid misuse.
The kitchen and dietary areas continue to have problems. According to the plan of correction, the kitchen will follow recipes using dietary information and provide meals that fit patients’ diet plans.
CMS also cited the hospital for rusted beds and torn furniture that prevent sanitary conditions. To remedy the problem, useable furniture will be sanded and painted and new beds have been ordered for several areas.
Another recurring deficiency, according to de Chabert-Schuster, was the delay in finalizing patients’ charts after discharge. Without a completed chart, bills cannot be sent nor payment received. He again blamed the problem on temporary staff doctors and said a new policy of withholding final payment until the paperwork has been completed has improved the situation.
The physical condition of the healthcare facility also is deficient in a number of areas, according to CMS. Repairs to smoke barrier doors, door latches, fire sprinklers and proper generator maintenance are scheduled to be completed before Feb. 15, according to the hospital’s response.
In the Jan. 4 correspondence, CMS requested the correction plans to include strategies to improve conditions that led to the deficiencies, when the plan will be implemented, and how and by whom the plan will be tracked and monitored.
De Chabert-Schuster said most of the deficiencies have been remedied already.
“All in all, it’s not that bad. We passed and we passed well,” he said.
