Tuesday, June 20, 2017, from 6:00pm to 7:30pm
LVMC Chief Executive Officer Jim Raggio will discuss and answer questions about recent surveys conducted at the hospital, including the successful Center for Improvement in Healthcare Quality (CIHQ) Triennial inspection, a state Department of Public Health validation survey that resulted in a determination of non-compliance and a state licensing division follow-up validation survey that found LVMC in substantial compliance.
Statement from our Board of Directors
Lompoc Valley Medical Center (LVMC) has provided quality medical care to the residents of this community for 71 years. In recent weeks, there has been much attention on the accreditation surveys conducted at the hospital in the past 14 months, including a state Department of Public Health validation survey completed in February, with a resolution of substantial compliance on June 7. To allay any lingering concerns, we say to you emphatically: Lompoc Valley Medical Center and its entire medical and professional staff provide safe and quality care for our community.
We, the Board of Directors, want to assure our community that LVMC meets or exceeds nationally accepted standards of quality patient care and we commend the work of our more than 700 employees. Chief Executive Officer Richard Curtis of the Center for Improvement in Healthcare Quality – the Medicare-approved accrediting organization for LVMC – said in a letter June 11, 2017, to LVMC:
“Our survey of LVMC was thorough, rigorous, but fair. Our survey did not identify serious issues related to the safety and quality of care provided by LVMC to its community.”
We stand by that statement and our hospital.
The Board of Directors of LVMC
- Ray Down, Board President
- David L. McAninch, III, MD
- Mary Sharp
- Roger McConnell
- Linual A. White, Jr.
- Michael Gill, MD, Chief of Staff
Statement from our CEO
As Chief Executive Officer of Lompoc Valley Medical Center, I want to address the recent survey process our hospital experienced.
I am so confident in our preparation that we look forward to each and every unannounced survey. No one here would argue with the benefit of having a fresh set of eyes looking at our operation.
We are also proud of our culture, which is laser-focused on opportunities to improve the wonderful care we provide. We have found that most surveys result in minor adjustments to policies and procedures that are easily implemented and ultimately positively impact our services.
All surveys are unannounced, which requires hospitals to maintain vigilance towards shifting federal and state standards. To understand how often this occurs, during the past 14 months LVMC has been subjected to eight unannounced surveys. In these surveys, hospitals are deemed either “not in compliance,” or “in substantial compliance.”
LVMC’s surveys in the past year were:
- Vaccines for Children Inspection - April 2016 (LVMC in Substantial Compliance)
- CDPH Licensing Division Inspection - Aug 2016 (LVMC in Substantial Compliance)
- Board of Pharmacy Inspection - Oct 2016 LVMC in Substantial Compliance)
- Center for Improvement in Healthcare Quality (CIHQ) Triennial CMS (Centers for Medicare & Medicaid Services) Inspection - Jan 2017 (LVMC in Substantial Compliance)
- CDPH Licensing Division - CMS Validation Survey Feb 2017 (LVMC found NOT in Substantial Compliance)
- CA Medical Waste Inspection - May 2017 (LVMC in Substantial Compliance)
- Board of Pharmacy Inspection - May 2017 (LVMC in Substantial Compliance)
- CDPH Licensing Division - Follow-up CMS Validation Survey (LVMC in Substantial Compliance)
You might question how the CMS Validation Survey performed in February could result in such divergent results than all the others in the past year. One explanation is that the survey team believed any deviation from a current policy or procedure was a non-compliant issue.
For example, the February surveyors reviewed 33 charts for pain assessments and found 100 percent of the patients had a pain assessment documented. Unfortunately, we received a citation because one chart had a pain assessment documented 61 minutes after a medication was given and our policy stated that it needed to be completed within 60 minutes. Another example involves nursing assessments. Again, 33 charts were reviewed and 100 percent had a nursing assessment performed, but 1 assessment was not documented in the timeframe outlined in our policy.
The survey team found LVMC in 97 percent compliance with pain and nursing assessments, yet we received 2 citations. The Centers for Medicare and Medicaid Services standards require a hospital to be in “substantial compliance” to pass a survey. Our rate of 97 percent chart accuracy is fantastic -- and has always been considered substantial compliance.
Every hospital inspection results in findings of some level and the majority of the CDPH citations at LVMC were technical in nature and easily resolved by modifying our current policy or procedures.
LVMC’s Plan of Correction was submitted to the state on May 5 and all CMS recommendations were implemented on that date.
LVMC is confident of its ability to care for our community and is proud to have been found in substantial compliance by CMS on June 7.
In a letter dated June 11, 2017, Chief Executive Officer Richard Curtis of the Center for Improvement in Healthcare Quality – the Medicare-approved accrediting organization for LVMC – said the hospital “meets or exceeds nationally accepted standards for the provision of safe, quality patient care.”
Read the Letter
From Chief Executive Officer Richard Curtis
of the Center for Improvement in Healthcare Quality
regarding Lompoc Valley Medical Center's CPHD Survey.
Thank you for trusting Lompoc Valley Medical Center with your healthcare needs.
Jim Raggio, CEO