Surprise survey of Luis Hospital's laboratory turns out clean

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ST. CROIX - Luis Hospital's laboratory had a surprise survey Friday from the Joint Commission, but Luis Hospital Interim Chief Executive Officer Dr. Kendall Griffith said the inspection turned out clean.

"The surveyor said there were no findings," Griffith said Saturday morning.

The Daily News was unable to reach the Joint Commission after Luis Hospital made the announcement on Saturday, although the Joint Commission website shows the hospital's lab is accredited.

The hospital announced in October after a September Joint Commission survey of its laboratory that the lab had been reaccredited.

Griffith said that officials did not know why the one-day survey Friday was done, although the surveyor did mention that the Joint Commission had some concerns. According to Griffith, the surveyor did not expound, but the single-day survey did not turn up any issues.

"So it was very positive," he said.

The surveyor did three "tracers," where a patient's chart is chosen at random, and documentation throughout the patient's hospital stay is reviewed, Griffith said.

The Luis Hospital lab is certified through the Joint Commission - although the hospital itself is not. The nonprofit Joint Commission is the nation's top credentialing agency for health care organizations.

The hospital itself remains under the direct supervision of the U.S. Centers for Medicare and Medicaid Services, or CMS, and continues to operate under a systems improvement agreement aimed at bringing conditions up to CMS standards.

Once the agreement with CMS was signed in November 2011 and the hospital was under the direct oversight of the federal regulatory agency, Luis officials chose not to seek hospital-wide re-accreditation under the Joint Commission.

However, the hospital's laboratory is accredited separately and has remained accredited through the Joint Commission.

Griffith said the hospital tries to stay ready for inspections.

"We were very surprised that the Joint Commission was showing up again, but we were prepared," Griffith said. "I am very pleased but not surprised with what they found. They found we are practicing quality care."

He thanked the hospital's staff.

"I just want to congratulate the staff at JFL for their continued hard work, all that they're doing to make the hospital better," he said. "While we're going through challenging times, these challenges are making us better."

- Contact Joy Blackburn at 714-9145 or email

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