Cape Fear Valley Medical Center Averts Medicare Defunding

Cape Fear Valley Medical Center in Fayetteville, NC has entered into a systems improvement agreement with the Centers for Medicare & Medicaid Services that will allow the 485-bed safety-net hospital to retain its Medicare funding while it works to correct deficiencies that have resulted in three immediate jeopardy status reports since October 2011.

"The SIA agreement is effective immediately and outstanding notice of termination for this facility is stayed/lifted," CMS said in an email Thursday night.

CMS confirmed that until reaching the "rare agreement" with CFVMC, it had intended to publish a public notice that "the Medicare provider agreement between Cape Fear Valley Medical Center (CFVMC) and the Secretary of Health and Human Services (HHS) would be terminated effective January 19, 2012."

In an e-mail exchange, Vince Benbenek, vice president of marketing and outreach at CFVMC, said the agreement "is not a typical SIA. CMS has accepted Cape Fear Valley Medical Center's Plans of Corrections. Cape Fear Valley has voluntarily entered into this SIA to allow us the opportunity to step back and take a methodical, comprehensive review of all policies and procedures before completing a CMS survey. We estimate our review will take around 180 days, after which we will have a Medicare certification survey."

Benbenek declined to release any additional details of the agreement.

CFVMC has engaged The Greeley Company to consult on the review process. Cape Fear Valley has been working with Greeley since December to make improvements in its emergency department and the discharge documentation process. According to CFVMS, improvements include the addition of a physician in the triage area and the addition of a clinical person in the emergency department waiting room to perform reassessments on patients. (Full disclosure: The Greeley Company is a division of HCPro, as is HealthLeaders Media.)

CFVMC has faced a series of CMS surveys in recent months. The first, in October 2011, stemmed from an April 2011 incident that involved the death of a patient. According to CMS documents released to HealthLeaders Media as part of a request under the Freedom of Information Act, a 27-year-old behavioral health patient was physically restrained on the floor of his emergency department room by two contracted police officers "who were not trained in patient de-escalation or therapeutic hold techniques."

After the October survey visit, CMS notified CFVMC that it faced immediate jeopardy status in four broad categories: governing body, patient rights, quality assessment/performance improvement and nursing services. While the immediate jeopardy status put Cape Fear Valley's Medicare participation at risk, its status as a safety-net hospital made it unlikely that CMS would take that step.

At that time, the medical center developed a corrective action plan, but in a November 29 letter, CMS notified Cape Fear Valley that a follow-up survey indicated that the four original deficiencies remained. And new deficiencies in physical environment and emergency services were identified.

Before CFVMC could respond to that letter, CMS received a complaint allegation related to a patient who died in November within an hour of his involuntary discharge from Cape Fear Valley. According to CMS documents, the nursing staff failed to reassess the patient after dispensing pain medication and at discharge, and failed to initiate the hospital's rapid response team after receiving telephone calls from two sources concerned about the patient's condition.

A survey noted additional deficiencies in the categories of patient rights, nursing services, and patient rights. The medical center's CAP, submitted on December 8, noted the hiring of The Greeley Company.

A second complaint allegation related to the death of a patient in CFVMC's telemetry unit was received in December. A complaint investigation conducted by CMS between December 20 and December 22 found that the nursing staff failed to report, respond and assess a change in the patient's heart monitor.

In a January 3, 2012 letter, CMS said the follow-up survey found the medical center in compliance for emergency services, quality assessment and performance, and physical environment, but that it remained in immediate jeopardy status for governing body, patient rights, and nursing services.

Parkland Memorial Hospital in Dallas faced a similar set of circumstances late last summer and signed an SIA in late September. At that time, officials in the Dallas office at CMS said Parkland was provided with "an opportunity to enter into a systems improvement agreement" in recognition of the hospital's importance to the community it serves.