Officials at Gov. Juan F. Luis Hospital learned Monday that its hemodialysis unit meets all the conditions required to participate in the Center of Medicare & Medicaid Services, the hospital announced.
The news came during an exit interview Monday, concluding a three-day site visit by a CMS surveyor. The verbal report emphasized significant improvements in infection control, water treatment, clinical oversight and overall patient safety, according to a news release from the hospital.
A written report is expected shortly.
Under pressure from CMS, the hospital last spring reduced the patient load of the dialysis unit to give the staff more time for education and improvements. At the hospital’s board meeting Oct. 25, CEO Jeffrey Nelson said the dialysis unit had made the requested changes and asked for permission to resume the 90-patient load but had not received a response.
Monday’s announcement of the CMS approval did not specify whether the patients that had been transferred to a private dialysis center would be allowed to return to the hospital.
At maximum capacity last year, hemodialysis unit ran for three shifts, serving 90 patients a day, six days a week.
CMS had flagged the unit for procedural problems during an April 2009 survey and worked with JFL to bring it up to its standards since then.
The hemodialysis unit and JFL officials focused intently on meeting CMS’s Conditions of Participation, the hospital said in its announcement, requiring daily meetings and a comprehensive plan to sustain the improvements.
“The entire JFL team, particularly the hemodialysis team, needs to be celebrated for this recent success," Nelson said. "Our goal is to always improve, so as a team we continue to provide better patient care for more patients. This is awesome … just awesome!”
Monday’s CMS site visit occurred less than a month after the hemodialysis unit was awarded its "fifth diamond" from the Quality Insight Renal Network 3’s "Five Diamond Patient Safety Program." That award was made Sept. 29.
JFL’s hemodialysis unit is the 25th in QIRN3 (which consists of New Jersey, Puerto Rico and the U,S. Virgin Islands) to receive Five-Diamond status. It is also the first outside of New Jersey to receive the honor.
The Five-Diamond program helps dialysis facilities improve both staff and patient awareness of patient safety. Further information on the program can be obtained by visiting the QIRN3 website.