Feds look into ‘serious deficiencies’ at Saint Louise

 Saint Louise Regional Hospital has acknowledged “serious deficiencies” with its contracted

dialysis services, resulting in the suspension of the hospital’s status as a provider deemed OK to meet Medicare conditions for participation, according to a Feb. 28 letter addressed to Hospital CEO Joanne E. Allen from the U.S. Department of Health & Human Services.

“It is kind of ironic, that a cell phone launched an entire survey,” said Marilyn Gerrior, VP chief nurse executive at Saint Louise.

She said the hospital has a strict “no cell phones” policy.

An inspection of the hospital’s contracted dialysis services was launched Jan. 18 by the Centers for Medicare & Medicaid Services (CMS) after the family of a dialysis patient called the Department of Health & Human Services, according to Gerrior. She said the family was upset that one of Saint Louise’s contracted employees was talking on a cell phone as a patient received dialysis, according to Gerrior.

“Much of this was corrected as soon as it was brought to our attention,” added Gerrior, who declined to provide the name of the dialysis contractor but confirmed “we have stopped using their services.”

Saint Louise is currently working out the details of contracting with another dialysis service provider, Gerrior said. Hospital Spokeswoman Jasmine Nguyen said Saint Louise caters to an average 22 dialysis patients per month.

Allen declined Thursday to return phone calls or emails for comment.

The Feb. 28 letter obtained by South Valley Newspapers through the Freedom of Information Act was sent to Allen along with the results of a Jan. 18 complaint survey conducted by the CMS. Saint Louise did not pass the Jan. 18 survey; the results of which are not publicly available until next week.

The letter addressed to Allen states that “consequently, effective the date of this letter, we are removing the hospital’s status as a provider deemed to meet Medicare CoPs (conditions of participation) and placing you under the California Department of Public Health’s survey jurisdiction until full compliance is demonstrated.”

Saint Louise can still accept Medicare patients and bill Medicare, according to CMS Spokesman Jack Cheevers.

CMS Public Liaison Dan Hersh – who responds to Freedom of Information Act requests for the U.S. Department of Health and Human Services – clarified the survey process.

A number of things can trigger a state survey, or inspection of a hospital, Hersh explained. In the case of Saint Louise, it was a complaint.

General protocol entails a survey team arriving at the hospital unannounced, conducting its survey, and sending the information back to the U.S. Department of Health & Human Services.

“Then we look at it and decide how we want to proceed,” said Hersh. “Then we write a report and letter, stating that ‘we found the following deficiencies, you need to correct them.’ And then we require (the hospital) to produce a plan of correction.”

Hospitals have 30 days to submit a plan of correction, although Hersh said most respond quickly “because their federal funding is at stake, and that’s a big chunk of their budget.”

By “big chunk,” he means anywhere from 40 to 70 percent.

Normally, Hersh said the survey cycle will continue until the problem(s) are resolved.

If the issues don’t get straightened out, the U.S. Department of Health & Human Services will eventually notify the hospital that it will be cut off from federal funding, Hersh said.

News of the survey comes at a time where Saint Louise is also exploring the possibility of putting a local sales tax before voters during the November 2012 general elections. The hospital is searching for a means to expand its emergency room; a project Nguyen said will cost $25 to $30 million.

Having its status as a provider deemed to meet Medicare CoPs means the hospital will be placed under the survey jurisdiction of the California Department of Public Health. Because of this, future surveys will be conducted by the California Department of Public Health and submitted for review by the federal government until “the hospital comes up with no problems,” Cheevers explained.

While South Valley Newspapers was able to obtain the Feb. 28 letter sent to Allen by the U.S. Department of Health & Human Services, the actual results of the Jan. 18 complaint survey chronicling “serious deficiencies” at Saint Louise are not available. The statement of deficiencies will become available to the public sometime next week, according to Hersh.

In the interim, Saint Louise will have the opportunity to prepare a response and “submit evidence documenting actions taken by the hospital to correct these deficiencies,” according to the letter from the U.S. Department of Health & Human Services. The letter does not divulge details regarding the “deficiencies.”

It does state that “specifically, Saint Louise Regional Hospital does not meet the following conditions of participation: Governing body.”

Gerrior explained that the hospital’s governing body “has the ultimate responsibility for quality of care provided in a hospital.”

Nguyen reiterated Wednesday that having its status as a provider deemed to meet Medicare suspended “does not effect patient care at all…we just have to provide (a plan of correction) to the Department of Health.”

Prior to this, Saint Louise has never had its status removed as a provider deemed to meet Medicare CoPs, according to Nguyen.

She identifies Medicare as the nation’s largest insurance program, which includes coverage for people older than 65, those with disabilities and those with permanent kidney failure.

The U.S. Department of Health & Human Services, Centers for Medicare & Medicaid last initiated a routine survey at Saint Louise in November 2009, according to Nguyen.

Gerrior said the hospital is currently writing a plan of correction to be submitted to the U.S. Department of Health & Human Services.

“It takes a while for the wheels to turn. The Department of Health sends us our issues that we have to work on, and now we’re responding to that,” she said. “When they are satisfied that we are doing everything we are supposed to be doing, (the hospital’s status) will be reversed back to where it was before.”

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