Guam – Efforts to come into compliance with the Centers of Medicare and Medicaid Services certification requirements are in the works for the Guam Memorial Hospital but the hospital’s administrator says they still need to step it up a notch.
On Thursday, April 11, the Guam Memorial Hospital provided an update to the legislature on its corrective action plan in response to the July 2018 survey conducted by the Centers of Medicare atind Medicaid Services.
Since CMS first issued the citation, they have conducted a follow-up visit noting that the hospital had corrected all but 2 of the 7 citations issued by CMS.
The hospital’s administrator, Lillian Posadas, said there are seven conditions of participation. Within the 7, there are 25 elements – one of them was the governing body at that time.
GMH was not meeting consistently and so they were cited for that. Posadas said, “Because of that, we did not ensure that the quality assessment performance improvement program was not fully operational. And the data collection at that time was not consistently and regularly being collected by the various hospital departments.”
The departments that did not perform active data collection included nursing, medical staff, and non-critical areas. This failure resulted in another sanction.
Posadas said other areas they were cited for included the physical structure, such as doors and walkways. However those issues have been resolved with the exception of the entry into the hospital’s cafeteria.
Posadas said they are trying to meet Americans with Disabilities Act (ADA) compliance standards as well as life safety requirements. Once this is completed, the physical structure citation will be resolved.
The other sanctions involved discharge planning, nurse and care plans. Posadas said, “In addition to QAPI (Quality Assurance and Performance Improvement), we have pretty much done a lot of training and we have brought the many various departments that were not submitting data. About 95 percent are now engaged in data collection.”
However, she said the hospital still needs to step it up a notch. Not just collect data for the sake of collecting data, but also take the time to look at the data and what it means for the hospital. The hospital should also look at how data can be used to improve patient care, according to Posadas.
The hospital has until Friday, April 12 to submit a revised corrective action report to CMS.
Keeping tabs on the hospital’s progress is Sen. Therese Terlaje who had previously stated, “CMS doesn’t want promises they want action.”
According to Terlaje, CMS thinks the wording in GMH’s recent submission “show more plans but not enough action.”
Following a visit to the hospital last week, she stated, “They seem to be very serious in making action instead of making promises and making plans. So now it is up to the hospital and their abilities to demonstrate an active action plan, substantial enough to convince CMS to award accreditation.”
CMS accreditation is crucial to the hospital as Medicare funding is dependent on the hospital’s ability to maintain and meet CMS certification requirements. To ensure that the hospital is moving forward, they assured the legislature that they have enlisted the services of a credible consultant which Posadas said specializes in QAPI and risk management.
Risk management in 2018 was one of the biggest citations issued by CMS to the hospital. The citation was issued as a result of a fire that occurred at the hospital on July 27, 2018.
Posadas said, by engaging with the hospital consultants, GMH is on a path to making risk management a robust program.