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Methodist Dallas Corrective Action Plan Accepted

 |  By Margaret@example.com  
   September 12, 2011

The Centers for Medicare & Medicaid Services announced on Friday that it has accepted the corrective action plan submitted by Methodist Dallas Medical Center to address “immediate jeopardy” deficiencies

identified during an August review of the facility.

The 515-bed medical center is part of the five-hospital Methodist Health System. Methodist Dallas could lose as much as $208 million in federal funding if the problems aren’t resolved.

Problems with infection control and emergency room care were the most serious deficiencies identified in the 128-page review. The initial review and the CAP were released by CMS via e-mail on Friday.

Among the deficiencies identified:
  • Lack of ER screening by a qualified medical professional
  • Failure to dispose of soiled gloves and wash hands after treating patients
  • Failure to maintain adequate medical records for every patient
  • Failure to administer the correct medications

Officials at Methodist Dallas addressed each deficiency separately and identified the steps that will be or have already been taken to correct the problems, including:

  • Revising staff rules to require medical screening to be performed by a qualified medical professional
  • Enforcing infection control procedures to reduce contamination
  • Implementing daily audits of medical records to ensure compliance with documentation of verbal and telephone orders
  • Enforcing requirements that directions for administering medications be made in writing

A follow-up review is expected to verify removal of the immediate jeopardy conditions at Methodist Dallas. Bob Moos, spokesperson for the Dallas office of CMS, said in an email to HealthLeaders Media that if the immediate jeopardy conditions continue, the hospital’s termination from the Medicare program will be effective September 23. However, “if the hospital removes the immediate jeopardy conditions, a full Medicare survey of all of the conditions of participation will be scheduled within 60 days. If any condition-level deficiencies remain following that survey, the hospital will again be asked to submit a corrective action plan, and the surveyors will return for one final revisit,” Moos wrote.

In a statement posted on its website, Methodist Dallas officials said medical center personnel “immediately began addressing the findings shared by the surveyor even before the completion of the survey, including policy and procedure updates relating to the emergency department. Most of the proposed changes were corrected either during the survey or have been implemented based on verbal feedback received from the surveyor.”

Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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