CMS Report: JFL Governing Body Unorganized and Ineffective

The much anticipated report of the Centers for Medicare and Medicaid Services (CMS) recent audit of the Juan F. Luis Hospital and Medical Center (JFL) on St. Croix, conducted July 28, 2014 to Aug. 1, 2014, revealed a host of serious deficiencies and non-compliance issues at the hospital, resulting in CMS’s decision last Thursday to withdraw its funding from JFL, effective Oct. 9. One significant blow dealt to the hospital in the extensive 112-page document was a scathing review of JFL’s Governing Body.

“Based on review of hospital documents and interviews, this hospital failed to have an organized and effective Governing Body responsible for the operation of the hospital,” Pg. 2 of the report states.

The report went on to explain that “there must be an effective governing body that is legally responsible for the conduct of the hospital.” As part of its mandate, the Governing Body is to provide oversight of the medical staff, patient care and the other day-to-day functions of the hospital–all of which, the report says–the body was in violation.

According to VI Code, the CMS report revealed, “the authority to supervise the day-to-day operations of the hospital is delegated from the Territorial Board (TB) to the St. Croix District Board (SCDB) for as long as the district board exists.” However, due to JFL’s “insufficient numbers of SCDB members,” it became “inactive” and the TB took over the Governing Body functions for the hospital.

Territorial Board meeting minutes from the period of Jan. 10, 2014, to April 2, 2014 revealed that the board conducted its meetings “to provide oversight on two (2) territorial hospitals at the same time.” However, the CMS report states, the minutes showed there were “no quality of care issues or quality assessment and performance reports discussed” at any of those meetings.

Additionally, when it comes to medical staff oversight, JFL’s Governing Body was found to be in non-compliance.

The CMS report states “[the governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff.” However, based on evidence shown in hospital documents and personnel files, this standard was not being met, as the hospital’s medical staff bylaws states, “temporary privileges may be granted by the CEO acting on behalf of the board, upon written concurrence of the chairperson of the service in which privileges will be exercised, or by the President of the Medical Staff.”

The CMS report revealed that a review of six physician files shows “the privileges of these physicians to practice at this hospital were awarded by the Chief Executive Officer (Interim), Chief Medical Officer (Interim), and the Chief of Service,” adding that “these appointments were not brought up to the governing body for approval before these physicians started practicing at the hospital.”

And, in turn, there was no medical staff accountability to JFL’s Governing Body, despite the body’s requirement to “ensure that the medical staff is accountable to [it] for the quality of care provided to patients.” CMS said based on review of the hospital’s medical records and interviews with key personnel, “the hospital failed to achieve and sustain compliance, and “the Governing Body failed to ensure that the Medical Staff provided quality care to patients in that numerous cases that lead to patient harm were not brought to the attention of the Governing Board.”

At a press conference on Friday, JFL Interim CEO Dr. Kendall Griffith said he does not believe the hospital should have lost its certification and seemed to imply surprise when he said he learned of CMS’s decision to do so. He pointed out he was misled by CMS representatives on the scope of the organization’s audit.

“We were informed that a new hospital-wide survey was being conducted during CMS’s last visit, and would only reflect events that occurred from July 28, 2014 to August 1, 2014,” he explained. However, Griffith continued, “the report includes an accumulation of events from 2011 to 2014; thus, there is no justification for decertification and we will appeal this decision.”

To review the full CMS report, click here.