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In May 2013, the Pagosa Springs Medical Center (PSMC) underwent two routine site visits and one non-routine site visit conducted by the Colorado Department of Public Health and the Environment (CDPHE).
The first site visit included a recertification survey conducted by the CDPHE as well as the Emergency Medical Services Division (EMSD). According to a letter by PSMC CEO Brad Cochennet, the site visit during this time was conducted to determine if PSMC was in compliance with the federal participation requirements for hospitals participating in medicare and medicaid. After this site visit it was concluded that PSMC was required by the CDPHE to form a Plan of Correction (PoC) in order to continue Medicare/Medicaid certification.
A PoC became top priority for the PSMC. Corrections that were addressed include new human resources improvements, development of new contract review and tracking system and additional technological support and staff updates (to be reviewed by board members) of all policies and procedures that reflect PSMC growth.
According to Operational Lead and Nursing Director Kathee Douglass, there were four main areas that required corrections.
The first area of correction included policies and procedures. During this time, all policies and procedures were reviewed, revised and retyped.
The second area in need of corrections included licensing and credentialing. Corrections in this area dealt with updating software programs to help track licensing and credentialing.
The third correction made was an integration of quality indicators. While this has been practiced all along, it had not been documented in a format that was critical to the CDPHE. This has been reviewed and updated.
Finally, the fourth correction made was the reviewing new ways to look at out dates and expirations.
Cochennet also considered improvements in the management structure such as,
• “Potential employment of a Chief Operating Officer senior management team member,
• “Possible appointment of a Chief Medical Officer,
• “Employment of support staff for the Quality/Risk Management Department,
• “Enhanced Board oversight and involvement in operational improvements,
• “Development and appointment of a Chief Nursing Officer Position.
• “Development of a Manager of Medical Staff Credentialing and Support,
• “Enhancing Human Resources capabilities.”
The Colorado Health Service Corp (CHSC) evaluated the PSMC primary care clinic and loan repayment in the second routine visit in June.
The only compliance issue identified by the CHSC included the requirement of updating the sliding fee scale within 30 days. These updates include,
• “2013 Federal Poverty guidelines,
• “Base discounts on annual income,
• “More of a ‘sliding’ scale: offer discounts in 10 percent increments,
• “If a patient is at or below 100 percent of the federal poverty guidelines, they must be granted a full discount or be charged only a nominal fee.”
The third visit was a non-routine visit focusing on the Emergency Medical Treatment and Active Labor (EMTALA). This was a self reported violation by the PSMC to the CDPHE. It was concluded that this incident was an isolated incident due to an individual presenting an international insurance card to the registration clerk. Out of confusion over the international insurance card, the individual was recommended to Durango for care. Due to the findings from the CDPHE, required changes included:
• “Requirement to change our EMTALA signage, which we now have done,
• “Training of all ER staff regarding this issue will occur in an effort to prevent this from happening in the future.”
On June 25, Cochennet updated the board of directors on the current status of the CDPHE visits. During this time, Cochennet explained that,
• On the first site visit the CDPHE accepted the Plan of Correction (PoC) with a required change to the timeline. The new date of completion became July 1 rather than July 31.
• A new sliding scale fee structure was developed for medical school loan repayment and was being implemented at that time.
• A life safety survey was conducted. A written report was presented that indicates all areas of deficiencies. These deficiencies were addressed and the estimated cost of compliance was $40,000.
• The routine annual Sate Pharmacy Board presented a written report stating that PSMC did not have deficiencies.
• PSMC received a report from the Colorado Hospital Association Emergency Preparedness stating that PSMC did not have any deficiencies.
• A new update to a previous survey from February 2013, Survey of Medical Records, verbally reported that PSMC did not have any deficiencies.
As of July, the CDPHE came back with PSMC having zero deficiencies. Auditors from the CDPHE spent five hours looking through five different binders, each around three inches thick, which declare what PSMC is doing and what the center will complete in the future.
This concludes the survey for the time being. Other surveys will be conducted in three to five years as part of another routine inspection. This is common for all hospitals.
“It’s a very good thing,” Director of Development Claire Bradshaw said. “It’s pretty unusual (receiving zero deficiencies) and we are excited about it and to show off our work and the quality of our management team and all of our staff quite frankly.”