The deadline has lapsed for the Guam Memorial Hospital to comply with the conditions set by the Centers of Medicare and Medicaid Services but administrator Lillian Posadas told Patti Arroyo in an interview at K57 “she is not worried about losing CMS accreditation.”
CMS informed GMH that the hospital’s Medicare provider agreement could be terminated by March 30 if they failed to comply with the conditions of participation.
GMH had until Mar. 29 to submit documentation to support that action has been taken to address the issues. Posadas says that CMS has previously granted extensions to all hospitals to correct deficiencies.
GMH has already corrected 8 out of 10 initial deficiencies cited to maintain CMS provider status. A CMS revisit on Feb. 7 showed that the hospital remains out of compliance with two conditions, namely: quality assessment and performance improvement (QAPI) and anesthesia services.
According to CMS findings, the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.
The hospital also failed “to ensure performance improvement activities of the hospital analyzed collected data and that the analysis would lead to actions resulting in improved outcomes of care,” according to CMS.
The termination of GMH’s provider agreement may still be avoided if by Mar. 29, the hospital shows compliance with the conditions of participation.
At a minimum, CMS said the submission must include the corrective actions for each deficiency; the title or position of the person responsible for the correction; and the monitoring process established to prevent recurrence of the deficiency.
CMS may also request additional evidence, as necessary, to establish that the hospital has implemented its corrective plan.
Posadas said during the interview, “They recognize that we do a collection and that we are collecting data on indicators regarding health efficiency.”
She said the hospital needs to take it a step further by looking at the data analysis process and connecting it to improving patient care outcomes.
While the hospital has made improvements, short-staffing remains an issue.
According to Posadas, the underlying issue has nothing to do with medical supplies but with staffing shortages.
The hospital does not have enough ICU and ER nurses. Clinical nurses are assigned to do data-collection and non-clinical patient care activities.
Some of the hospital staff are working extra hours and days to help close the gap, according to Posadas.
The hospital has been without an associate administrator of clinical services and assistant administrator of professional support for years. Despite the shortfalls Posadas is confident that CMS accreditation will not be lost.
“I don’t think they are out to shut us down, to deny us federal funding. They just want to make sure that we follow through on these conditions and standards,” Posadas said.