By M.E. Sprengelmeyer
Federal officials have accepted Mission Hospital’s plan of corrective action related to delays in triage and medical screening in the emergency department, although the facility still remains in jeopardy of having its Medicare provider agreement terminated by early summer, according to correspondence obtained Monday by 828newsNOW.com.
In a notice dated March 26, the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) notified the hospital that its plan of correction “has been reviewed and found acceptable.”
“When the North Carolina State Survey Agency has determined that the noncompliance with (federal Emergency Medical Treatment and Labor Act) requirements has been corrected, CMS will withdraw its current termination action,” the notice stated. “Failure to correct the deficient practice by June 5, 2024, will result in the termination of your Medicare provider agreement.”
The correspondence, including a detailed report of deficiencies found in November 2023 and Mission’s plan of corrective actions, was first obtained by Asheville Watchdog and later obtained independently by 828newsNOW.com.
The report includes minute-by-minute details on the case of “Patient #2,” a 66-year-old who was brought to the hospital by ambulance on Oct. 17, 2023, faced delays in getting evaluated and treated, and subsequently had a fatal cardiac arrest.
One Emergency Medical Service (EMS) provider told investigators that it was at least one hour and 17 minutes after arrival before EMS was able to give a hand-off report to a nurse. “Interview revealed waits had gotten more common recently and it seemed like a staffing issue,” an investigator summarized in the report.
CMS began investigating a complaint last year and held an on-site Conditions of Participation survey. At that time, the North Carolina State Survey Agency identified “Immediate Jeopardy” level findings related to emergency services. That ominous “IJ” designation was removed in late February, after the survey agency verified steps the hospital had agreed to take toward a more rapid triage process. Other areas of alleged non-compliance remained.
Stressing that Mission “holds the safety of all patients, staff and visitors as its highest priority,” the hospital submitted a plan of action that over the past four months has included:
* A review of arrival-to-triage performance, and implementation of a time-stamp process to capture accurate arrival times, plus additional staff training on triage.
* Educating staff that patients arriving in the emergency department need to be seen “promptly,” with a goal of 10 minutes upon arrival, and about the need to accurately document the time between a patient’s arrival and triage.
* Creating an “escalation pathway” to bring additional staff support when more than three patients are in the triage line.
* New systems for “timely and frequent” communication regarding various aspects of patient care.
* Additional training for lab staff and other hospital personnel.
* Tracking and trending of appropriate Emergency Severity Index (ESI) levels of patients, and additional staff education.
* An update of the Mission Hospital Surge Plan “to ensure adequacy of resources and the safe delivery of care during high influx of patients.”
On Monday, Mission Hospital spokesperson Nancy Lindell said the letter received this week was “an expected part of this process and means that specific elements of our approved plan of correction were examined and re-surveyed to ensure that this EMTALA finding has been addressed. We are pleased that our amended plan has been accepted.”
“As we continue to state, we take these matters very seriously and have made significant process changes to improve our patient care experience,” she stated. “Ongoing measurement of varioius indicators, including EMS offload times and patient satisfaction, validates what we are hearing from our patients, providers and EMS partners — that our care teams are excellent and significant improvement in emergency care has been recognized.”