Officials at the Gov. Juan F. Luis Hospital are working to avoid sanctions that could devastate the facilities revenues, but there will have to be some "culture changes" as well as technical ones to do so, the hospital’s board of trustees was told Tuesday night.
The hospital was inspected by the Centers for Medicare and Medicaid Services, known as CMS, and found wanting in 12 of the 23 areas surveyed.
The hospital board first learned of the survey deficiencies this summer, and the staff has been working since then to rectify the problems. At the board meeting, hospital CEO Jeff Nelson told the board that earlier Tuesday he had received a letter setting a deadline of Jan. 18, to rectify the problems.
CMS inspects and certifies whether U.S. medical facilities meet its standards of care. Certification means the hospital or facility will be reimbursed for services to Medicare patients and, to a lesser extent, Medicaid patients. Not being certified means CMS halts reimbursements for treatment of Medicare and Medicaid patients, which can have a catastrophic impact on hospital revenues.
Nelson said the deficiencies run across a broad range of hospital activities, from policies and procedures to communication and record keeping, and even the size and condition of doors. He said estimates are that meeting all the requirements will cost about $3 million, and he has already been talking to members of the executive branch about finding the funding.
"It’s what comes from years of putting off maintenance," said Nelson, who will meet with the CMS Nov. 4, to negotiate the agreement on how the issues will be resolved..
But not everything can be solved with money, said Dr. Coleridge Francis of the hospital’s Medical Executive Committee. He told the board the medical staff has been meeting to address the CMS report, and has already made some adjustments. For example, the medical staff gathers each Wednesday morning to plan patient management for every patient in the hospital.
"We’re making headway. It’s going to be an ongoing process," Francis said.
But changing longstanding practices can be difficult, he admitted, and there needs to be a "culture change."
"Change can be difficult," he said after the meeting. "Things have been done a certain way for a long time, and now CMS is pulling us forward … When you go from ‘This is the way we’ve always done it,’ it’s not reluctance, I’d say, but there’s a certain reticence."
But all the staff is working together towards one goal, he said. "It’s all about patient safety."
Nelson likened the current situation to the report from CMS a year ago that put the hospital’s dialysis center under restrictions, which forced it to reduce the number of patients it could treat. The hospital took the situation as an opportunity to improve its service, he said, and has recently applied to resume treating its former patient load.
At the same time, he added, in the longterm there is really no solution that doesn’t include an infusion of fresh capital and a new physical plant.