HomeMy WebLinkAboutMINUTES - 01162007 - SD.7 TO: BOARD OF SUPERVISORS ; yEAL Contra
FROM: William Walker, MD •'f __�- g-� ,
Health Services Department , Costa
DATE: January 11, 2007 rT� cboh�� County
SUBJECT: Plan of Correction For Citations by
Centers for Medicare & Medicaid Services
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SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
1. ACCEPT report of the Health Services Director regarding the CMS Citations.
2. COMMIT to assure that all of the Plans of Corrections are implemented in an appropriate timeline.
3. COMMIT to appropriate ongoing oversight and monitoring of the Hospital and Clinics
BACKGROUND:
CMS is the federal agency that manages and provides funding for the Medicare and
Medicaid (Medi-Cal in California) health insurance systems. CMS regulates all agencies
and providers who provide services to beneficiaries of these health care systems, and the
responsibilities and authority of CMS'are delineated in the Federal Code of Regulations.
As applied to hospitals and health systems like CCRMC and the Health Centers, CMS has
the responsibility to assure that such'systems of care comply with the "Conditions of
Participation." These "Conditions" are also spelled out in the Federal Code of Regulations.
After a survey visit to CCRMC in Iate�September, CMS provided us with a Statement of
Deficiencies and a warning letter. The entire Statement of Deficiencies is 114 pages long
with 52 citations, sent to you under separate cover. Essentially, CMS has made a finding
that CCRMC is out of compliance with the "Conditions of Participation" in three areas:
Quality Assurance and Performance Improvement plans; Patient's Rights and Safety; and
oversight. Because of that finding, there is a threat that we will be removed from
participation in the Medicare and Medi-Cal programs in mid March if we do not correct the
deficiencies and pass another site visit before that time period. The Department take these
finding very seriously and has been Iorking
diligently to correct deficiencies.
CONTINUED ON ATTACHMENT: X YES SIGNATURE:
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�/RECOMMENDATION OF COUNTY ADMINIISTRATOR RECOMMENDATION OF BOARD COMMITTEE
_�PPROVE OTHER
SIGNATURE(S):
--------------- - ------- , ----------------------------- ------------ - ACTION OF
BOARD ON �"' APR ROVE AS RECOMMENDED—S� OTFI-R
VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE
/ AND CORRECT COPY OF AN ACTION TAKEN
V UNANIMOUS(ABSENT L�~ ) AND ENTERED ON THE MINUTES OF THE
BOARD OF SUPERVISORS ON THE DATE
AYES: . NOES: I SHOWN.
ABSENT: ABSTAIN:'
ATTESTED II(a ort��
CONTACT: JOHN CULL4 ,CLERK OF THE BOARD OF
USUPERVISOKS AND COUNTY ADMINISTRATOR
CC:
BY DEPUTY
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The root issues of concern have been related to the issues of patient and staff safety in the
inpatient psychiatric units and the psychiatric emergency unit. We have addressed these
concerns with a number of changes in the care of psychiatric patients, including scaling
down the unit size, retraining staff, and changing the patient care processes.
Another significant area of concern is the quality assurance and performance improvement
plan as it applies to psychiatry, pharmacy, and dietary. These areas will be addressed with
a care facilitation plan.
The final major area of concern is related to governing body oversight and monitoring. In
these citations, CMS is making the point that it is critical that sufficient resources and
oversight are provided to the health system.
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In our effort to respond to these citations, we have retained legal advice from Foley, Lardner,
Inc., and expert advice from Greeley Group. Both are nationally recognized experts in
compliance related issues.
We anticipate another site visit by CMS in February, at which time CMS will monitor our
corrective action progress. We also anticipate numerous future surveys and reviews.
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ADDENDUM TO ITEM SD.7
January 16, 2007
On this day, the Board of Supervisors ACCEPTED the report from the Health Services
Department regarding the citations received from the Centers for Medicare and Medicaid
Services at Contra Costa Regional Medical Center.
Supervisor Glover expressed the need for the Health Services to update the Board on a much
more regular basis. The reports could be in written form as a consent item not requiring an oral
presentation.
Supervisor Gioia concurred the Board needs updates from the Joint Conference Committee as
well as full reports to the Board from Health Services.
Supervisor Uilkema stressed the importance of keeping the public informed about the psychiatric
care situation in the County in simple terms, and suggested daily one-page updates similar to
those done for Doctor's Medical Hospital.
Dr. Walker informed the Board the Health Services Web site has posted a brief summary of the
Centers for Medicare and Medicaid Services response and the actions being taken as well as a
summary of other efforts in terms of patient safety and quality assurance.
Chair Piepho requested the Medical Services Committee determine how to communicate these
issues and report back to the Boari.
Dr. Jeff Smith, Director, Contra Costa Regional Medical Center responded there is more demand
for high quality care, but at the same time there is less money available and more needs in the
community. Dr. Smith stated the only solution to these problems is to completely redesign the
system of care.
Chair Piepho thanked Drs. Walker and Smith, saying external oversight is very valuable and all
efforts on this issue are appreciated.
By a unanimous vote with none absent, the Board of Supervisors took the following action:
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ACCEPTED the report from the Health Services Director regarding the Centers for Medicare
and Medicaid Services Citations; COMMITTED to assure that all of the Plans of Corrections are
implemented in an appropriate timeline; COMMITTED to appropriate ongoing oversight and
monitoring of the Hospital and Clinics.
FAX N0. P. 02
JAN-11-2007 THU 11 ,35 AM i
..ytiykRY(rp�•C
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DEPARTMENI' OF HEALTH & HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Y I WESTERN CONSORTIUM
r?� I DWISION OF SURVEY AND CERTIFICATION
FAXED AND SENT BY OVERNIGHT MAIL
IMPORTANT NOTICE—PLEASE READ CAREFULLY
December 15, 2006 i
Jeffrey V Smith, MD, JD, Executive Director
Contra Costa Medical Regional Center
2500 Alhambra Ave i
Martinez, CA 945533
?Medicare Provider Number. 'U5-0276
Dear Mr. Smith:
This is to inform you that based on a careful review of the findings of an authorized full
survey, completed on September 27, 2006 by the California Department of Health Services
(CADHS), the Centers for IMedicare and Medicaid Services (CMS) has concluded that
Contra Costa Regional Medical Center is not in oompliance with the applicable Conditions of
Participation for a provider of hospital services in the Medicare program, established by Title
XVIII of the Social Security Act. Accordingly, with this notice we are initiating a
process, which could result in termination of the hospital's !Medicare provider
agreement on or before March !S, 2007, under 42 C.F.R. §489.53.
As you are aware, to participate in the Medicare program, a hospital must meet the statutory
requirements in 42 U.S.C. § 1395x(e) and be in compliance with each of the applicable
regulatory Conditions of Participation fir hospitals at 42 C.F.R. fart 482. Indeed, when
Contra Costa Regional Medical Center entered into a Medicare provider agreement it
specifically undertook to comply with Federal statutes and regulations governing 114edicare
certified hospitals, see section•1861(e) of the Soy;ial Security Act, 42 L.S.C. § 195x(e); 42
C.F.R. Parts 482 and 488.
While Federal law provides that hospitals accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAH"O) are deemed (with certain exceptions) to
meet all Medicare Condition§jof Participation for-hospitals (see 42 C.F.R. § 488.5), such law
also provides a mechanism for CMS to validate (by means of a validation survey) this
deemed status. 42 C.F.R. § 4$8.7,
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Deriver Regional Office San Francisco Regional Office Seattle Regional Office
1,600 Broadway, Suite 700 75 Hawthorne Street, 4th Floor 2201 Sixth Avenue, RX-48
Denver, CC)80202 I San Francisco, CA 94105 Seattle,WA 98121
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FAX N0. P. 03
Page two —Contra Costa Regional Medical Center
As a result of the complaint validation survey completed by CADHS on December 1, 2006,
CMS concluded that Contra)Costa Regional Medical Center was not in compliance with.the
requirements for participation as a Medicare provider of hospital services. Specifically, the
following Conditions of Participation were not met:
42. C.F.R. 482.111 Compliance with Federal, State, and Local Laws
42. C.F.R. 482.13 Patients' Rights
42, C.F.R. 482.21; Quality Assessment and Performance Improvement
By letter dated April 25, 2006 we informed you that as a consequence of the findings of the
December 1, 2005 survey; iContra Costa Reuional Medical Center's deerned status as a
hospital accredited by JCAHQ was removed.' 42 C.F.R. 488.7(d). This letter enclosed a
Statement of Deficiencies (Form CMS-2567) detailing the survey findings.
Subsequently, you submitted a plan for correcting each of the cited violations and further
alleged that the deficiencies detected by the December 1. 2005 complaint validation survey
had been rectified. Based on your representations in this submission, we authorized DHS to
undertake a resurvey to verify that the hospital had in fact come back into compliance with
all Conditions of Participation, as alleged. Ibis full survey, which was completed on
September 27; 2006, demonstrated instead that the hospital remains out of compliance with
one Condition of Participatio'. Specifically you do not comply with the following:
42. C.F.R. 482.12- Governing Body
42. C.F.R. 482.13 Patients' Rights
42. C.F.R. 482.21 Quality Assessment and Performance Improvement
The findings of the Se temb Ir 27, 2006 full survey are set forth in two enclosed Statements
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of Deficiencies, Form CIMS-21567.
We have further determined that the cleficiencies ,identified by the September 27, 2006 survey
substantially limits the hospital's capacity to render adequate care to patients or are of such
character as to adversely affect patient health and safety, thus establishing a basis under 42
C.F_R. § 488.26(b) for concluding that the above-referenced Conditions of Participation were
not met. Because Contra Costa Regional Medical Center is not in compliance with all
applicable Conditions of Participation at 42 C.F.R. Part 482, as determined by the September
27, 2006 survey, we must take steps to terminate the hospital's Medicare provider agreement
effective March 15, 2007. 42 C.F.R. §§ 458.24(b), 488.24(c), 488.26(b), 489.53(a)(1) &(3).
This action did not affect the hospital's ►CAliC) accreditation.
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Page three— Contra Costa k gional 'Medical Center
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Importantly, termination of Contra Costa Regional Medical Center's provider agreement may
still be avoided if by December 27, 2006 the hospital submits to this San Francisco office
and AHS, Contra Costa district office, credible documentation evidencing correction of the
cited deficiency and that the hospital is othc°rwise in compliance with all Conditions of
Participation applicable to hospitals participating in the Medicare program, as set forth at 42
C.F.R. Part 482. At a minimum, such submittal must include documentation detailing the
actions taken that resulted inlihe alleged correction of each deficiency; the title or position of
the person responsible for implementing the corrective action; and a description of the
monitoring process established to prevent recurrence of the deficiency. 'The evidence of
correction is to be entered ori the right side of Form CMS-2567, opposite the deficiency and
must be signed and dated by Ithe administrator or other authorized official. Please note that
mere plans of future correction or evidence of progress toward correction will not be
sufficient.
If we receive such a submittal by the close of business on December 27, 2006; and if we
find that the submission constitutes a credible allegation of compliance we will notify you of
this finding and authorize a resurvey of the hospital. If such a follow-up survey confirms that
Contra Costa Regional Medical Center is in compliance with all Conditions of Participation,
the hospital's deemed status will be reinstated. Termination may be imposed prior to March
15, 2007 (in accordance with notice requirements at 42 C.F.R. § 489.53(c)) if a credible
allegation is not. timely received by this office;, or if' an allegation is submitted that we
determine it to be unacceptably.
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Federal regulations at 4.2 C.F.R. § 489.53(c:)(4) require public legal notice of this
detemunation. Accordingly, we have made arrangements for such a notice to be published.
In the event termination does occur, there will be no payment for inpatient services rendered
to Medicare beneficiaries admitted on or afterthe the effective date. Payment for those
beneficiaries in the hospital prior to the effective date will be limited to thirty (30) days. See
42 C.F.R. 489.55..
Application for Readmission Following Involuntary Termination
Once tenninated, Contra Costa Regional Medical Center may apply for reinstatement. See
42 C.F.R. § 489.57. However, �a new agreement will not be accepted unless CMS determines
that the reason for termination bf the previous agreement has been removed and that there is
"reasonable assurance" that the hospital can maintain compliance with the applicable
Conditions of Participation. 42 C.F.R. § 489.57(.a). Compliance will be verified by on-site
surveys conducted at the beginning and end of a reasonable assurance period determined by
CNIS. This period will be a minimum of 90 days. Prior to issuance of a new provider
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Page four—Contra Costa Regional Medical Center
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agreement the hospital also must fulfill, or make satisfactory arrangements to fulfill, all of the
statutory and regulatory responsibilities of its previous agreement. 42 C.F.R. § 489.57(b).
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Appeal Rights
If 'you do not agree with) this determination, you may request a hearing before an
administrative law judge of the Department of Health and Human Services, Departmental
Appeals Board, in accordance with 42 C.F.R. fart 498. Such hearing request must be filed in
writing no later than 60 days from receipt of this notice. The request should be sent to the
following address:
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Steven D. Chickering
Western Consortium Survey and Certification Officer
Dii,ision of Survey and Certification
Centers for Medicare& Medicaid Sen�ices .
75 Hawthorne Street, Suite 408
San Francisco, CA 94105
Your request must identify the specific issues as well as the findings of fact and conclusions
of law with which you disagree and explain your basis for contending that the findings and
conclusions are incorrect. You will have an opportunity to present evidence and further .
argmurient at an in-person hearing, where you may be represented by counsel. Completion of
the administrative review process established by 42 C.F.R. Part 498 is a prerequisite to
obtaining judicial review.
We are coordinating this action with the Medicaid State Agency, which will take similar
action under Title XIX of*the Social Security Act.
Copies of this notice are being forwarded to the JCAHO, DHS and State Medicaid.
Should you have any questions)concerning this Matter, please contact Mary Frances Colvin at
415-744-2830.
Sincerely,
i Steven D. Chickering
Western Consortium Survey and Certification Officer
Division of Survey and Certification
Enclosures
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ADDENDUM to Urgency Item 1
Considered as SD 7.5
January 16, 2007
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On this day, the Board of Supervisors voted to add an Urgency Item to receive a report on the Richmond
Chevron Refinery fire that occurred on Monday,January 15, 2007. By a vote of 5-0 with none absent,the
Board voted to add this item to the agenda and consider it as agenda item SD.7.5.
William Walker, M.D., Health Services Director, introduced the item, noting that a timeline of the events
of the day of the fire will be compiled and submitted to the Board. He said that Chevron is to provide a
report on the incident within 72 hours, and that as part of the investigation a more comprehensive report
will be issued within 30 days. He said the main issue was that of community notification.
Lieutenant Jeff Hebei, Sheriffs Office, Department of Emergency Services(OES), said the response to
the incident was unacceptable and he cited two main problems which caused delays: (1)OES receipt of
the information so that a response could be initiated, and (2)the vendor's delay in activating the telephone
notification systema Lt. Hebei added that a Request for Proposal (RFP)for a new vendor to supply phone
notification had already been issued six1 months prior to this incident. He said the responses to the RFP
have been narrowed down to six or seven vendors, and that a contract may be awarded within the week.
Lt. Hebei added that for the OES to receive the information and initiate a response, it needs to be as easy
as possible for the"guy at the refinery"oto initiate the system.
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Supervisor Glover requested a root cause analysis in which Health Services will be a participant.
Supervisor Gioia noted there will be dual reporting from Chevron to both the County and to the City of
Richmond. He said it will be important to examine where the breakdowns occurred, and he commented
that the"Shelter-In-Place"warning sirens went off properly but that they sounded while many people
were still sleeping, and many of those people later woke up and left their homes without knowing. He said
this gets to the importance of the notifying phone calls. He said the calls should be made within 20
minutes of the incident, but in this case,were not made until about an hour had passed. He said it will be
important to have discussions at the Internal Operations Committee(IOC) level to examine what the
issues were and what can be done.
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Supervisor Uilkema suggested that the IOC be involved in the Sheriff's analysis, not to assume
responsibility but to review the criterialused in the analysis and to ask questions. She suggested there
could also be an opportunity for the Board to be included in a discussion with the Sheriff at a regular
Board meeting. She further suggested the RFP process should not go forward until the concerns of the
Board that have and will come to light as a result of this incident have been addressed.
Supervisor Gioia said it would have been good to have had a Board level discussion about the RFP before
it went out. He said the subject should be added to the next iOC meeting agenda.
Dr. Walker noted that the 72-hour report should be available and provided to the Board by the Board's
next meeting [January 23,20071.
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cc: Office of Emergency Services
Health Services
internal Operations Committee Staff
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