Federal inspectors find more problems at Luis Hospital
Published: December 10, 2013
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ST. CROIX - After a weeklong inspection by federal regulators last week, Luis Hospital released a statement saying that the inspection had turned up some deficiencies and some improvements.
It gave few details about the findings by the inspection team from the U.S. Centers for Medicare and Medicaid Services, or CMS.
"They did not make any mention of decertification, for or against. What they said was they would have to review their findings and give us a report in two weeks," Luis Hospital Interim Chief Executive Officer Dr. Kendall Griffith said Monday evening.
The hospital has been under the regulatory microscope and intense scrutiny by CMS in recent years. In November 2011, after an inspection uncovered a multitude of deficiencies, hospital officials signed a systems improvement agreement with CMS, aimed at forcing the hospital to correct the deficiencies so that it could maintain CMS certification.
Thus far, the hospital has not achieved compliance with the agreement.
CMS spokeswoman Courtney Jenkins did not respond to Daily News questions on Monday about the survey or about the CMS survey process.
Griffith said that Gov. John deJongh Jr. met with CMS surveyors for about an hour at the hospital Friday, the final day of the inspection.
The release from Luis indicated that the CMS inspectors later met with about 75 members of the hospital executive team and staff Friday night to provide a preliminary report on findings from the survey. The survey was twofold: to follow up on previous surveys and also to follow up on a complaint CMS recently received about the hospital.
The hospital's release quotes the leader of the CMS inspection team, Sharon Roberson, saying that "none of us sitting here are independent in our decision towards JFL" and that "the findings we have made this week are preliminary. We will compare them with the Plan of Correction you submitted to us in March as a determination is made on your accreditation."
The release said Roberson and the other inspectors addressed the group on their individual findings. However, it did not say what those findings were.
"What they said is that the findings they presented to us they had to review them when they got back to headquarters to determine which ones were observations and which ones were true deficiencies," Griffith said.
"Observations," according to Griffith, are considered less serious that "deficiencies."
Pressed for details about the findings, Griffith said that one area that was discussed was electronic medical records and some difficulties nursing staff had navigating them.
Another area discussed was the physical plant. Griffith said inspectors noted some improvements, but they also "did note what we already knew, that the fire sprinkler pump was not working." He said inspectors are aware the hospital has a plan to resolve that issue.
Griffith declined to provide further details, saying he would wait for the report and that he is "cautiously optimistic" about the inspection.
"I do know that they told us that they saw improvement, and that makes me feel good about the hard work we have been doing for the last few months," he said. "We have not accomplished everything we set out to do, but I felt good that they could at least notice we had been making attempts to improve the organization and they saw that."
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