Site visits prompt changes at hospital


Staff Writer

The Pagosa Springs Medical Center (PSMC) has undergone two routine site visits and one non-routine site visit from the Colorado Department of Public Health and Environment (CDPHE) over the last 45 days. Another routine visit is pending and expected at any time.

The first site visit included a recertification survey conducted by the CDPHE and the Emergency Medical Services Division (EMSD). According to a letter from CEO Brad Cochennet, the site visit is conducted to determine if PSMC is in compliance with the federal participation requirements for hospitals participating in Medicare and/or Medicaid programs. And that includes punctiliously conforming to the tenets of providing proper insurance care, like adumbrated here at

According to Claire Bradshaw, director of development and marketing, “Pagosa Springs Medical Center is not being singled out. There are three or four other locations in Colorado that have also had a recertification audit.

“To be licensed, there is an oversight organization, and that is the CDPHE. They make sure that we are adhering to the rules and regulations of providing quality care and that our systems and processes show that. Really, the corrections have to do with our processes and they are working really hard and we have already fixed most of what they wanted us to.”

While the recertification survey is a routine survey of infrastructure at the hospital, it occurs unannounced, at any time. Past certification surveys include one in 2008, after the facility opened and received its initial license. Another occurred in September 2008, due to a Critical Access Hospital application.

“This is the first recertification survey,” Cochennet explained. “They said they would be back in about three to five years, and it’s been five years, and they have come back and we have participated in a survey here. It was a comprehensive audit.”

Deficiencies identified during the survey include: contract tracking and renewal, licensing, credentialing, policies and procedures, facility life-safety, chart review and initialing, and pharmacy.

PSMC has been required by the CDPHE to form a Plan of Correction (PoC) in order to continue Medicare/Medicaid certification.

According to Cochennet, “Our plan of correction is a top priority for the entire organization, and the management team in particular. Since the survey, many of the corrections have already been addressed, including, new human resource process improvements, development of a new contract review and tracking system, additional technological support, and staff update (and review by board members) of all policies and procedures that reflect our growth.”

“We basically had areas of correction in four main areas,” Operational Lead and Nursing Director Kathee Douglass explained to the district board Tuesday. “The first one being policies and procedures. As you might recognize, we opened the hospital in 2008 with policies that were meant to take care of patients that we thought we might have and our practice today is very different than it was in 2008. And those policies always didn’t reflect what we currently do, so we were held to our own standard, and our standard was that of an empty hospital. All of the policies in this building have been reviewed, revised, retyped, re-everything. For the past three weeks, we have spent every day on it, so all of the policies are coming to you today for signature.

“The next part has to do with licensing and credentialing. As you know, we have a totally manual system here; we are looking at different software programs to help us track licensing and credentialing and certificates in a much more meaningful way and, thirdly, integration of QI (Quality Indicators). We have been doing QI all along, but we had not documented it in a format that was critical to them and they found that, basically saying that ‘you don’t actively participate with your QI,’ even though we’ve been doing it. The last area being of outdates and expirations; we had no real way to look at supplies and those kinds of things for outdates and expirations and those kinds of things, and those processes have now been in place and are being monitored. Those are the four areas.”

After submission on May 29, it is likely that the CDPHE will continue to make unannounced visits for the recertification process until they determine the process is complete. According to Cochennet, he is considering improvements that include changes in 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) is responsible for provider loan repayment. They evaluated the PSMC primary care clinic and loan repayment during the second routine site visit.

According to Cochennet, the comment made by the CHSC in the follow-up report is as follows:

“Overall, the site visit was highly successful and educational. Overall, PSMC’s commitment to the providers in terms of offering solid benefits and professional opportunities is exceptional in contributing to overall retention. There appears to be consistent and open lines of communication between clinical staff and administration, which is also a great contributor to longer term retention. When recruiting new providers, I recommend the continued practice and focus of integrating the provider family members into the community, as that affects overall satisfaction and ensures longer term stake in the community.”

According to Cochennet, only one compliance issue was identified by the CHSC, which stated, “The site does not have an appropriate sliding fee schedule.” Due to this compliance issue, PSMC is required to make the following changes and updates to the sliding fee scale schedule within 30 days:

• 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 site visit focusing on Emergency Medical Treatment and Active Labor (EMTALA). This was a site visit resulting from a violation self-reported by the PSMC.

According to Cochennet, Q1/Risk Manager Jan Miller was contacted by Mercy Regional Medical Center stating that an individual claimed to have been turned away from the PSMC’s emergency room. After investigation, Miller followed protocol and “self-reported” the incident to the CDPHE. It was concluded that this incident was an isolated incident, due to the individual presenting an international insurance card to the registration clerk. Out of confusion over the international insurance card, the individual was recommended to Mercy Medical Center in Durango for care.

“This has happened once before with the delivery on the way to Durango. That was our only other experience with self-reporting, so we looked at it and made a determination that we did need to self-report,” Cochennet explained. “There was a question of whether care was delayed at the registration window. When you self-report, they detail and a person comes out to your facility and they did an investigation. They spent three days here. They concluded that there was a question of delay of care. There was a couple other issues — the poster wasn’t lettered enough for the investigator to really believe that people understood. The primary issue was there a delay of care. After they took the case back and evaluated, they concluded that they did not delay care, but there still would be a recommendation in the final report, they still may ask us to change our process some.”

According to Cochennet, while an official report has not been received, verbal findings from the CDPHE include:

• Requirement to change EMTALA signage, which has been done.

• Training of all ER staff regarding the issue will occur in an effort to prevent it from happening in the future.

There is another pending routine site visit in the near future — a life-safety component that focuses on safety issues such as fire drills.

The PSMC was required to submit a plan of action by May 29 to deal with issues raised in the visits. According to Cochennet, faculty of PSMC have been working on updating new policies and procedures.

According to Cochennet, these audits are common and he calls them a “continuing plan.”

“The reason we say it’s a continuing plan is because they came out to visit, they supplied findings, we responded today, and along the way we have been making changes to align with their recommendations. That will continue.

“The idea is that everything that they came in and identified we could eventually say, ‘Yes, those are the things that we should be doing and we are working really hard to do everything that was indicated.’

“In the end, these efforts will translate into streamlined systems of operations, increased efficiency, and improved workplace environment, a new commitment to continuous improvement, and most importantly, quality health care.”