2011 07 08 CMS to GMH RE CMS Certification

DEPARTMENT OF HEALTH & HUMAN SERVICES C E N T E R S FOR M E D I C A R & E M E D I C A I DSERVICES y.

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OVERNIGHT MAIL

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IMPORTANT NOTICE PLEASE READ CAREFULLY July 8,201 1

Rey M. Vega, Hospital AdministratorICEO Guam Memorial Hospital Authority 850 Gov. Carlos G Camacho Road Tamuning, GU 969 1 3 RE:

CMS Certification Number: 650001 (Previously Medicare Provider Number)

Dear Mr. Vega: As you are aware, the Centers for Medicare and Medicaid Services (CMS) conducted recertification and complaint surveys of Guam Memorial Hospital Authority on May 27, 201 1 (health and LSC). After carehi review, the Department of Health and Human Services; Centers for Medicare and Medicaid Services (CMS), has determined that Guam Memorial Hospital Authority, located at the above address, no longer meets the Conditions of Participation (COP) for hospitals in the Medicare program established under Title XVIII of the Social Security Act (Act).

To participate in the Medicare program, a hospital must meet the requirements in section 1861(e) of the Social Security Act (the Act) and be in compliance with each of the Conditions of Participation established by the Secretary of Health and Human Services.

The Federal recertification and complaint surveys of your hospital were completed by CMS on May 27,201 1 (health and LSC), documented that Guanl Memorial Hospital Authority was not in -compliance with all applicable Conditions of Participation for hospitals participating in the Medicare program. See generally 42 C.F.R. Part 482.

Detailed in the enclosed 78-page (health) and 30-page (LSC) Statement of Deficiencies (Form CMS-2567s), the contents of which are incorporated by reference herein, the surveys completed on May 27,201 1 (health and LSC) documented deficiencies that, on balance, reasonably support a conclusion under 42 C.F.R. fj 488.26(b) that Guam Memorial Hospital Authority failed to meet the following one (1) Condition of Participation:

42 C.F.R. ยง 482.41

Denver Regional Office 1600 Broadway, Suite 700 Denver, CO 80202

Physical Environment

San Francisco Regional Office 90 7Ih street, Suite 5-300 (5W) San Francisco, CA 94103-6707

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Seattle Regional Office 2201 Sixth Avenue, RX-48 Seattle, WA 98121

Page 2 - Guam Memorial Iiospital Authority (CCN: 650001) (Letter dated July 8,201 I )

CMS further determined that the documented deficiencies (when considered within the context of the Conditions of Participation to which they are related) either individually or in combination substantially limit Guam Memorial Hospital Authority's capacity to render adequate care or adversely affected patient health and safety, thus establishing a basis under 42 C.F.R. tj 488.24(b) for concluding that the above-referenced Conditions of Participation were not met. In addition, CMS also determined that these deficiencies are of such a character as to pose immediate jeopardy to the health or safety of the agency's patients. 42 C.F.R. tj 489.3.

In light of the findings of the May 27: 201 1 (health and LSC) recertification and complaint surveys, CMS has initiated a process that will result in the termination of your Medicare provider agreement unless Guam Memorial Hospital Authority promptly returns to compliance with applicable Medicare participation requirements. See generally 42 C.F.R. $5 488.24(b), 488.24(c), 488,26(b), 489,53(a)(l) & (3).

You may submit evidence documenting actions you have taken to correct these deficiencies.

Please submit your evidence of correction to address the survey findings to this San Francisco Regional office, by close of business, within ten (10) days of receipt of this letter.

The evidence of correction is to be entered on the right side of Form CMS-2567s, opposite the deficiency, and must be signed and dated by the administrator or other authorized official.

The evidence of correction of each item must contain the following: I. How the correction was accomplished, both temporarily and permanently for each individual affected by the deficient practice, including any system changes that must be made.

2. The title of position of the person responsible for correction, e.g. Administrator, Director of Nursing or other responsible supervisory personnel.

3. A description of the monitoring process to prevent recurrences of the deficiency, the frequency of the monitoring and the individual(s) responsible for the monitoring.

4. The date when the immediate correction of the deficiency will be accomplished. Normally this will be no more than thirty (30) days from the date of the exit conference.

Please note that mere plans of correction at some future date or evidence of progress toward correction are not sufficient. If you make such a submittal and if we find that the submission constitutes a credible allegation of compliance, CMS will not move to terminate your hospital's Medicare provider agreement based solely on the survey findings discussed herein, but will exercise our discretion to authorize a resurvey of Guam Memorial Hospital Authority. If, however, your hospital fails to timely submit an acceptable allegation of compliance; or, if an allegation of compliance is submitted but is determined to be unacceptable; or, if a resurvey demonstrates that Guam Memorial Hospital Authority still does not meet the requirements of section 1861(e) of the Act and 42 C.F.R. Part 482 (and all other applicable Federal statutory and regulatory requirements). CMS will initiate a process to terminate your Medicare provider agreement. In that event you will receive a separate notice from this office setting forth the basis for CMS's action, the effective date of the termination, and your rights to administrative review.

Page 3 - Guam Memorial Hospital Authority (CCN: 650001) (Letter dated July 8,201 1)

Should you have any questions concerning this matter, please contact Patricia Jung of my staff at (4 15) 744-3753.

Sincerely,

~ u f u Arther, s Manager Non-LTC Survey, Certification and Enforcement Branch Division of Survey & Certification Enclosure (CMS-2567s - 78 pages and 30 pages) cc:

Hawaii SA Title XIX-HI