State cites deficiencies, forces hospital district to act

The local hospital district has been scrambling in October to respond and address a broad list of deficiencies identified by the Washington State Department of Health and the Washington State Patrol Fire Protection Bureau.

The deficiencies were cited by the agencies during a state hospital licensing survey of the facility on Sept. 24-26. The results of the survey stated the hospital failed to meet several Medicare Critical Access Hospital Conditions of Participation.

The multi-page Statement of Deficiencies is complex and at times repetitive. The hospital district provided The Journal with a copy of the document.

According to an Oct. 1 letter to the district from Marieta L. Smith, from the Department of Health’s Investigation and Inspections Office based in Davenport, the district failed to meet Conditions of Participation in three categories: Organizational Structure, Provision of Service and Periodic Evaluation, and Quality Assurance Review.

The state’s findings set in motion a series of deadlines the hospital district must meet in order to maintain its designation as a Critical Access Hospital and keep its federally issued Medicare provider agreement. Without that agreement, the district would not be able to bill Medicare for services provided to Medicare patients.

Within 90 days, Dec. 24, 2013, the district must take action in order to avoid the termination of its Medicare provider agreement.

Other condition-level deficiencies identified by the survey must be corrected within 45 days, Nov. 9, in order for the hospital district to be in compliance with regard to the identified Medicare and the state fire inspection deficiencies.

The most egregious deficiencies identified by the survey team focus on the hospital’s aging substandard electrical system and the lack of fire suppression sprinklers on the main floor of the building.

During the survey, under the category of Physical Plant and Environment, the survey team determined the “Critical Access Hospital failed to provide a safe and secure environment for the provision of patient care.”

The survey team also determined the district’s governing board “… failed to meet the requirements for the Condition of Participation for Organizational Structure.”

In the Statement of Deficiencies issued by the Department of Health, it was noted that, “The CAH has a governing board or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’s total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.”

The Statement of Deficiencies pointed out that the district has not met the standards of operation. “Due to the citation of repeat deficiencies, including the serious Life Safety Code deficiency related to the Essential Electrical system and detailed accompanying Life Safety Code survey, the Condition of Participation for Periodic Evaluation and Quality Assurance Review was not met.”

The report noted that on Aug. 18, 2011, the district was cited for failure to separate the life safety and critical branches of the Essential Electrical System.

While some of the survey results focused on the policies and procedures of the hospital district’s governing board, administration and departmental management, the deficiencies regarding the electrical system and the fire suppression sprinklers appear to be the most severe.

In response to the state’s findings, the commissioners conducted a special meeting on Oct. 8 to discuss the issues and set a course of action. The commissioners voted unanimously to adopt a resolution authorizing the repair of the existing hospital building.

The commissioners and CEO Gary Bostrom have long been aware of concerns aired by the state and the federal government about the condition of the hospital. A year ago, the district’s response to the survey team’s previous concerns was to launch an effort to construct a new hospital funded by a general obligation bond supported by property tax dollars.

That bond measure failed at the ballot in August.

Prior to the state survey conducted in late September, the commissioners planned to prepare a new proposal to present to voters via a bond measure in April 2014.

The commissioners have turned all of their focus to the urgency of addressing the deficiencies outlined in the Department of Health report. Electing to expend the necessary funds to repair the current facility, the board has not yet acted on whether or not it will withdraw the April bond.

Bostrom sent an email to The Journal on Monday, Oct. 21, that included updated information from the Department of Health’s Smith.

According to Smith’s email to Bostrom, representatives from the department of Health, the WSP Fire Protection Bureau and CMS Region 10 participated in a conference call on Friday, Oct. 18.

“During the call, the participants determined that an acceptable completion date for the hospital remodeling project is May 1, 2015,” Smith wrote.

Smith also indicated the agencies would consider a request for a waiver of the Medicare compliance requirements for the sprinkler system and electrical system separation. The waiver, if accepted, would give the hospital district an 18-month reprieve in order to provide sufficient time to complete the mandated improvements. That would halt the current 90-day timeline which runs out near the end of December.

The hospital district has, in an effort to be transparent about the issue, provided The Journal with all of the documents outlining the deficiencies.

Calls to the Department of Health’s Communications Office in Olympia for comment on the report have not been returned.