A Pennsylvania hospital faces termination from the Medicare program following an unannounced complaint investigation by state health authorities in late March that found "there was a significant threat to the well-being of the patients at the facility." A ban on new patient admissions also was put in place by the state, which determined the hospital "does not have the means to obtain the proper equipment and supplies for surgical, outpatient and emergency services." According to local news reports, state inspectors found the hospital lacked basic surgical supplies (e.g., surgical gloves, medicated soap, syringes and needles) and failed to perform routine maintenance required for electrocardiograms, defibrillators, ventilators and similar equipment. Warning that "deficiencies have been determined to be of such a serious nature that they place the patients' health and/or safety in immediate jeopardy," the Centers for Medicare and Medicaid Services (CMS) notified the hospital, which recently filed Chapter 11 bankruptcy, that its provider agreement with the Medicare program would be terminated by April 19 "if the immediate jeopardy has not been removed by that date."
Although the situation at this hospital remains an outlier among Medicare providers, this case highlights the domino effect that an unannounced complaint investigation can have. Providers should be aware that CMS and state survey agencies have begun to employ immediate jeopardy termination rights with greater frequency. For example, last year two Texas hospitals were notified by CMS that the agency was exercising its immediate jeopardy rights following an unannounced inspection. In one of these cases, deficiencies were found in ten categories including patient privacy, unsanitary procedures, an insufficient number of signs advising patients of their rights, patient record documentation and communication involving patient grievances. This year two North Carolina hospitals were placed in immediate jeopardy by CMS with one of the facilities receiving its third immediate jeopardy status notice in as many months. Finally, an Ohio hospital was placed under immediate jeopardy status just last month by CMS for security issues within the facility.
Many of these actions follow the issuance of an October 2011 report by the HHS Office of Inspector General (OIG) on "Adverse Events In Hospitals: Medicare's Responses To Alleged Serious Events" which found that, although complaints generally were being investigated, scrutiny of the errors defined as initiating immediate jeopardy was wanting. The OIG report further urged CMS to follow the agency's policy of notifying accreditors when complaints are made against hospitals they accredit. Accreditors were notified by CMS only about a third of the time, according to the report.
The OIG also urged CMS to exercise greater consistency in the enforcement and monitoring of corrective actions. This more intrusive monitoring may require hospitals to implement systemic condition of participation reviews following an immediate jeopardy event to avoid a series of immediate jeopardy findings. For example, as a result of an October 2011 complaint investigation, a Florida hospital system was placed in immediate jeopardy status for events associated with the death of a patient. Subsequent to the submission of a plan of correction, CMS lifted the immediate jeopardy status after a follow-up survey by the state confirmed compliance with the Medicare conditions of participation. However, the system also was advised at the time that "a full Medicare survey" could be expected in the future. Upon the full Medicare survey in January, immediate jeopardy was imposed again for a day as a result of quality performance, infection control and governance deficiencies. The deficiencies that led to the second immediate jeopardy -- which included construction dust from a renovation project that had not been fully sealed off from surgical patient waiting areas; a student nurse carrying a narcotic syringe in his shirt pocket; staff members using their hands to turn off the sink spigot instead of a paper towel; improper monitoring of hazardous waste in the dialysis department and improperly cleansed glucometers -- were not particularly unusual.
Providers should be on alert for such inspections, as recent OIG audits also indicate a trend toward treating violated conditions of participation -- such as minimum continued education training -- as violated conditions of payment and using such deficiencies as a basis for payment recovery.
