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CEO's Corner: Issue #205

on in LVMC News

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 proud of our culture, which focuses on opportunities to improve the wonderful care we provide.

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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 proud of our culture, which focuses 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. 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 of 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 of 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 has always been considered substantial compliance.

The majority of the CDPH citations at LVMC were technical in nature and easily resolved by modifying our current policy or procedures. 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.” To read the full text of his letter, visit lompocvmc.com/quality.

Read the full text of his letter and the Board or Directors response.