SAIPAN – The Centers for Medicare and Medicaid Services, or CMS, found two areas of noncompliance in the Commonwealth Healthcare Corp. based on a survey conducted on April 21-29.
CHCC Chief Executive Officer Esther Muna said the deficiencies involved medical staff and nursing services.
"For medical staff, it was mainly administrative with some conflicts between the policies versus the bylaws. We also need to strengthen the privileging process," she said.
As for the nursing services, Muna did not specify the deficiency but added that one of CMS' concerns is the documentation in the electronic health record.
In a report to the CHCC board of trustees on Thursday evening, Muna said she had sent a corrective action plan to CMS on June 15 and is now waiting to hear if it has been accepted.
The last survey on CHCC was conducted in 2014 when CMS found seven areas of deficiencies including the hospital's governing body, patient rights, medical staff, medical record services, physical environment, infection control and discharge planning.
"We submitted a plan of correction back in 2014 and we expected them to return and validate it, but of course, two typhoons came and consideration was given to wait until recovery," Muna said, referring to Typhoon Soudelor in 2015 and Supertyphoon Yutu in 2018.
She said CMS did accept CHCC's corrective action plan right after its submission in 2014.
"If the typhoons did not happen and had they come back with a resurvey, (it) would focus on those seven deficiencies and if they found noncompliance, then an overall survey would be conducted," she added.
A CMS team arrived on island in April 2019. Instead of focusing on the seven areas of concern noted in 2014, the surveyors conducted an overall survey, Muna said.
"They surveyed all 21 conditions of participation applicable to CHCC," she added. "They found no immediate jeopardies but found noncompliance in two areas and we are correcting them as we speak."
The hospital needs CMS certification in order to continue its participation in the Medicare program.
The CMS team also surveyed CHCC's Life Safety Code, the hospital's physical environment and disaster planning.
Muna said the inspection found that the hospital did not have a documented preventive maintenance for the sprinkler system.
"It has been fixed," she added.
The survey team also stressed the need to update CHCC's emergency disaster plan, Muna said.
"Prior to a typhoon, CHCC must have a checklist as part of the hospital and public health preparedness plan. Those items on the checklist need to be included in the facility's emergency preparedness plan and our policies and procedures, and the emergency disaster committee must review the plan and the policies annually," she said.
For example, Muna said they saw the need for a social admission plan which they never had before during previous typhoons because patients usually went home after the government issues an "all clear" advisory.
"But in August 2015, (after Typhoon Soudelor hit Saipan), patients remained in the hospital because they either didn't have homes to go to or because they needed access to electricity for their medical equipment," Muna said.
"So we need to ensure that what we say we do and what we say we will do is exactly stated in the emergency plan and in our policies and procedures."