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Luis Hospital Fails To Gain Accreditation

Nov. 1, 2008 — Gov. Juan F. Luis Hospital has been preliminarily denied accreditation by the Joint Commission on Accreditation of Health Care Organizations, placing critical Medicare and Medicaid payments to the hospital in potential jeopardy. The hospital's pathology and clinical laboratory is still fully accredited.
The Joint Commission is the main hospital and health care accreditation organization in the U.S. Established in 1951, it is an independent, non-profit organization that evaluates and accredits nearly 15,000 health-care organizations and programs in the U.S. The commission re-accredits hospitals every three years. Representatives came to St. Croix for an unannounced inspection visit of the hospital in June, staying for three days. The denial of accreditation is dated June 20 on the Joint Commission website, but it announced the decision recently and issued a statement last week.
A preliminary denial happens when there are enough unmet standards to justify denial of accreditation at the time of the survey, according to the website. The decision is preliminary, pending all appeals, and the hospital retains its accredited status until appeals are exhausted.
The hospital may opt to ask the Joint Commission for a hearing, putting the case before the commission's Review Hearing Panel, which would forward its findings to the Accreditation Committee for reconsideration. But the hospital must show it was in compliance at the time surveyors were on site, not evidence that the problems have been remedied, making the task more difficult.
If appeals of the preliminary denial are unsuccessful, the denial of accreditation will take effect, jeopardizing tens of millions of dollars in Medicaid and Medicare funds. According to testimony in V.I. Senate budget hearings last year, the entire territory received $37 million from Medicare and $6 million from Medicaid, with a considerable portion going to the territory's two hospitals.
If the hospital chose not to appeal, the denial of accreditation would take immediate effect.
The Luis hospital board of directors is planning to send a delegation to the Joint Commission's headquarters in Chicago to press the appeal in person, according to a report in the St. Croix Avis by Taylor R. Moore.
There are many benefits to accreditation, including simple reassurance that the care you can expect from the hospital meets national standards. Approval says a lot to insurers and affects the Medicaid and Medicare dollars received. Accreditation makes it easier to hire professionals to work at the hospital, makes the hospital more competitive in the market and allows the hospital to take advantage of educational and training offered by the Joint Commission.
Below is a condensed list of the Joint Commission's list of "requirements for improvement" for Juan Luis.
— Before all surgery, conduct a "time out" immediately before starting the procedure and conduct a pre-operative verification process, described in the Joint Commission's Universal Protocol;
— Make the hospital's leadership more effective and designate qualified staff allowed to accept and transcribe verbal or telephone orders from authorized individuals;
— Ensure medications are available, secure and well managed, with a program to avoid errors involving look-alike and sound-alike drugs and with patient-specific information readily accessible to those managing medicine;
— Ensure pain is assessed in all patients;
— Ensure resuscitation services are available throughout the hospital;
— Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
— Analyze identified environment issues and develop recommendations for resolving them;
— Maintain fire-safety equipment and building features and manage fire safety risks;
— Develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital;
— Assess the needs of patients receiving psychosocial services to treat alcoholism or other substance use disorders;
— Have the organized medical staff define when a medical practitioner’s professional performance requires monitoring and evaluation, then evaluate and act upon reports of concerns about a practitioner's practice or competence;
— Ensure written or verbal orders for initial and continuing use of restraint and seclusion are time limited and more information is gathered on admission to help minimize restraint or seclusion.

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Nov. 1, 2008 -- Gov. Juan F. Luis Hospital has been preliminarily denied accreditation by the Joint Commission on Accreditation of Health Care Organizations, placing critical Medicare and Medicaid payments to the hospital in potential jeopardy. The hospital's pathology and clinical laboratory is still fully accredited.
The Joint Commission is the main hospital and health care accreditation organization in the U.S. Established in 1951, it is an independent, non-profit organization that evaluates and accredits nearly 15,000 health-care organizations and programs in the U.S. The commission re-accredits hospitals every three years. Representatives came to St. Croix for an unannounced inspection visit of the hospital in June, staying for three days. The denial of accreditation is dated June 20 on the Joint Commission website, but it announced the decision recently and issued a statement last week.
A preliminary denial happens when there are enough unmet standards to justify denial of accreditation at the time of the survey, according to the website. The decision is preliminary, pending all appeals, and the hospital retains its accredited status until appeals are exhausted.
The hospital may opt to ask the Joint Commission for a hearing, putting the case before the commission's Review Hearing Panel, which would forward its findings to the Accreditation Committee for reconsideration. But the hospital must show it was in compliance at the time surveyors were on site, not evidence that the problems have been remedied, making the task more difficult.
If appeals of the preliminary denial are unsuccessful, the denial of accreditation will take effect, jeopardizing tens of millions of dollars in Medicaid and Medicare funds. According to testimony in V.I. Senate budget hearings last year, the entire territory received $37 million from Medicare and $6 million from Medicaid, with a considerable portion going to the territory's two hospitals.
If the hospital chose not to appeal, the denial of accreditation would take immediate effect.
The Luis hospital board of directors is planning to send a delegation to the Joint Commission's headquarters in Chicago to press the appeal in person, according to a report in the St. Croix Avis by Taylor R. Moore.
There are many benefits to accreditation, including simple reassurance that the care you can expect from the hospital meets national standards. Approval says a lot to insurers and affects the Medicaid and Medicare dollars received. Accreditation makes it easier to hire professionals to work at the hospital, makes the hospital more competitive in the market and allows the hospital to take advantage of educational and training offered by the Joint Commission.
Below is a condensed list of the Joint Commission's list of "requirements for improvement" for Juan Luis.
-- Before all surgery, conduct a "time out" immediately before starting the procedure and conduct a pre-operative verification process, described in the Joint Commission's Universal Protocol;
-- Make the hospital's leadership more effective and designate qualified staff allowed to accept and transcribe verbal or telephone orders from authorized individuals;
-- Ensure medications are available, secure and well managed, with a program to avoid errors involving look-alike and sound-alike drugs and with patient-specific information readily accessible to those managing medicine;
-- Ensure pain is assessed in all patients;
-- Ensure resuscitation services are available throughout the hospital;
-- Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
-- Analyze identified environment issues and develop recommendations for resolving them;
-- Maintain fire-safety equipment and building features and manage fire safety risks;
-- Develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital;
-- Assess the needs of patients receiving psychosocial services to treat alcoholism or other substance use disorders;
-- Have the organized medical staff define when a medical practitioner’s professional performance requires monitoring and evaluation, then evaluate and act upon reports of concerns about a practitioner's practice or competence;
-- Ensure written or verbal orders for initial and continuing use of restraint and seclusion are time limited and more information is gathered on admission to help minimize restraint or seclusion.

Back Talk


Share your reaction to this news with other Source readers. Please include headline, your name and city and state/country or island where you reside.