THE Centers for Medicare and Medicaid Services earlier this week conducted a revisit survey of the Commonwealth Healthcare Corp., resulting in favorable findings in the areas of quality of care and patient safety, CHCC said.
The revisit survey at the CNMI’s only hospital was conducted from Aug. 12-14, 2024.
CHCC Chief Executive Officer Esther L. Muna said CMS’s initial visit in September 2022 resulted in standard findings on some of the conditions of participation in Medicare and Medicaid programs.
Medicaid is CHCC’s major payor.
For this week’s resurvey, the CMS surveyors came up with standards findings that CHCC is in compliance with all the conditions of participation, Muna said.
“CHCC appreciates the CMS surveys as an important regulatory process. The outcome of this latest survey shows that your hospital is compliant with the conditions of participation set by CMS, which reflects the commitment of our staff and leadership to deliver quality and safe care for our patients,” she added.
She said the purpose of the survey was to assess the hospital’s compliance with the “rigorous” standards set by CMS. “The results were favorable, with CHCC receiving only three standard level findings and no conditional or immediate jeopardy findings,” Muna said.
The conditions of participation are critical health and safety standards that hospitals must meet to participate in Medicare and Medicaid programs, she added. These standards are designed to ensure that hospitals provide safe, high-quality care to all patients, she said.
The standard level findings indicate minor deficiencies where the hospital does not fully meet specific regulatory standards, “but these issues do not pose an immediate threat to patient safety,” she added.
Conditional findings are more serious and suggest that a hospital’s compliance is at risk, potentially leading to a loss of certification if not corrected, Muna said. Immediate jeopardy findings are the most severe, indicating situations where patient health or safety is at immediate risk, requiring urgent corrective action.
CHCC’s receipt of only standard level findings is a positive outcome, Muna said, adding that while there are areas for improvement, the hospital’s overall operations remain fundamentally sound and compliant with essential regulations. The absence of conditional or immediate jeopardy findings underscores the high standard of care and safety maintained at the hospital, she added.
She said this means that the hospital remains fully certified and in compliance with CMS requirements. However, “this is only a general statement, and it is essential to wait for the official Form 2567, which will provide detailed results and specific corrective actions required,” Muna said.
CHCC Board Chair Juan N. Babauta commends the CEO and the entire CHCC management team for a job well done. He noted how critical it is to get CMS’ findings in two main areas, which are patient care and patient safety. Based on the findings, he said CHCC is in compliance with the standards set by CMS on patient safety and patient care.
