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\u00a0scathing review of JFL’s Governing Body.<\/p>\n
“Based on review of hospital documents and\u00a0interviews, this hospital failed to have an\u00a0organized and effective Governing Body\u00a0responsible for the operation of the hospital,” Pg. 2 of the report states.<\/p>\n
The report went on to explain that “there must be an effective governing body that is\u00a0legally 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.<\/p>\n
According to VI Code, the CMS report revealed, “the\u00a0authority to supervise the day-to-day operations\u00a0of the hospital is delegated from the Territorial\u00a0Board (TB) to the St. Croix District Board (SCDB)\u00a0for as long as the district board exists.” However, due to JFL’s “insufficient numbers of SCDB\u00a0members,” it became “inactive” and the TB took over the Governing Body functions for the hospital.<\/p>\n
Territorial Board meeting minutes from the period of Jan.\u00a010, 2014, to April 2, 2014 revealed that the board conducted its meetings “to provide oversight on two\u00a0(2) territorial hospitals at the same time.” However,\u00a0the CMS report states, the\u00a0minutes showed\u00a0there\u00a0were “no quality of care issues or quality assessment and performance reports\u00a0discussed” at any of those meetings.<\/p>\n
Additionally, when it comes to medical staff oversight, JFL’s Governing Body was found to be in non-compliance.<\/p>\n
The CMS report states “[the governing body must] appoint members of\u00a0the medical staff after considering the\u00a0recommendations of the existing members of the\u00a0medical staff.” However, based on evidence shown in\u00a0hospital documents\u00a0and personnel files, this standard was not being met, as the hospital’s medical staff bylaws states, “temporary privileges\u00a0may be granted by the CEO acting on behalf of\u00a0the board, upon written concurrence of the\u00a0chairperson of the service in which privileges will\u00a0be exercised, or by the President of the Medical\u00a0Staff.”<\/p>\n
The CMS report revealed that\u00a0a review of six physician\u00a0files shows “the privileges of these physicians to\u00a0practice at this hospital were awarded by the\u00a0Chief Executive Officer (Interim), Chief Medical\u00a0Officer (Interim), and the Chief of Service,” adding that “these\u00a0appointments were not brought up to the\u00a0governing body for approval before these\u00a0physicians started practicing at the hospital.”<\/p>\n
And, in turn, there was no medical staff accountability to\u00a0JFL’s Governing Body, despite the body’s requirement to “ensure that the\u00a0medical 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.”<\/p>\n
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\u00a0imply surprise\u00a0when he said he learned of CMS\u2019s decision to do so. He pointed out he was\u00a0misled by CMS representatives on the scope of the organization\u2019s audit.<\/p>\n
\u201cWe were informed that a new hospital-wide survey was being conducted during CMS\u2019s last visit, and would only reflect events that occurred from July 28, 2014 to August 1, 2014,\u201d he explained.\u00a0However, Griffith continued, \u201cthe report includes an accumulation of events from 2011 to 2014; thus, there is no justification for decertification and we will appeal this decision.\u201d<\/p>\n