Skip to main content

Exeter Hospital on 'Termination Track,' Says State Official

 |  By cclark@healthleadersmedia.com  
   October 23, 2012

The 100-bed New Hampshire hospital where an employee dubbed the "serial infector" for allegedly infecting 32 patients with hepatitis C faces new federal challenges to its reputation with the release of a third investigative report, this one threatening its ability to receive Medicare or Medicaid reimbursement.

"They (Exeter) are on a termination track," says John Martin, Manager of the Bureau of Licensing and Certification for the state of New Hampshire, whose team helped with the federal investigation. The findings resulting from the hospital's third inspection means that "some point between now and Dec. 28 we'll have to go back in and verify that they're in full compliance."

Martin noted that rarely does the federal government follow through with threats to terminate a hospital's ability to receive Medicare or Medicaid payments, because providers generally are able to correct all deficiencies to get back in compliance. "That's certainly what we hope will happen here," Martin says.

The latest report, based on a survey Sept. 17-18, said Exeter does not meet four conditions of participation. The conditions pertain to the hospital's governing body, patients' rights, its quality assessment and performance improvement program and infection control.

All three investigations stem from the finding this spring that a hepatitis C-infected radiology or scrub tech, who worked in Exeter's catheterization lab, had allegedly injected syringes containing the drug fentanyl intended for patients, a practice called drug diversion.

After injecting, he returned the now-contaminated syringes so they could be used as planned for particular patients, 32 of whom were subsequently infected with the same viral strain the lab tech. Some of them became acutely ill.

In July, the New Hampshire Attorney General's office arrested and filed charges against David Kwiatkowski, then 32, for obtaining controlled substances by fraud and tampering with a consumer product.

The latest action by the Centers for Medicare & Medicaid Services comes in two documents, which were released by Exeter last week. (Federal and state officials say they are prohibited by law from releasing the documents until a plan of correction has been approved. The hospital, however, distributed the survey report and the letter at a press conference Friday, which HealthLeaders Media did not attend. Exeter declined direct requests for the documents, but a copy of the letter was provided by a media source who attended the press conference.)

The letter, dated Oct. 11, is from J. William Roberson, CMS's associate administrator for the northeast region, to Exeter Hospital President and CEO Kevin Callahan.

"CMS has determined that the deficiencies are of such a serious nature as to substantially limit the hospital's capacity to provide adequate care.  Accordingly, CMS will terminate the Medicare provider agreement between Exeter Hospital and the Secretary, effective Dec. 28, 2012," Robertson's letter says.

The letter says Exeter must develop "an acceptable plan of correction" to fix address six issues:

  1. The plan for correcting each specific deficiency cited.
  2. Efforts to address improving the processes that led to the deficiency cited.
  3. The procedure for implementing the acceptable plan of correction for each deficiency cited.
  4. A completion date for correction of each deficiency cited.
  5. A description demonstrating how the hospital has incorporated systemic improvement actions into its Quality assessment and Performance Improvement (QAPI) program in order to prevent the likelihood of the deficient practice from reoccurring.
  6. Procedures for monitoring and tracking to ensure that the plan of correction is effective and that specific deficiencies cited remain corrected and/or in compliance with the regulatory requirements and the title of the person responsible for implementing the acceptable plan of correction.

The second document details each regulation or standard, and the specific finding as to how the CMS investigation determined the hospital was not in compliance.

In releasing the documents, and in a statement posted on its website, Exeter acknowledged that the added scrutiny stemming from the hepatitis C cases "were caused by the alleged criminal activity of ex-hospital employee David Kwiatkowski."

Kwiatkowski, who worked at Exeter for about a year, had also worked in 11 other hospitals in about eight other states. That has prompted many of those hospitals to try to locate patients who had contact with Kwiatkowski to determine if they may be infected with his strain of hepatitis C.  Several lawsuits have reportedly been filed.

Exeter emphasized that "the role of CMS surveyors is to vigorously pursue each hospital's compliance with their standards, especially those connected with patient safety. In this new world, following the revelation of Mr. Kwiatkowski's alleged criminal activities that resulted in the infection of 32 of our patients, we embrace CMS's efforts to ensure 100% compliance with all standards."

The statement added that the surveys "are opportunities to further identify areas to improve" patient care.

The Exeter statement notes that part of the federal report deals with a new accusation that the hospital "did not follow the CMS administrative investigative process for identifying the cause of the hepatitis C infections.

"Although this would have been our normal process, the launch of the States'  epidemiological investigation, our own internal investigation, and the State and federal criminal investigations took precedent [sic]. 

"Since the survey in September, we have taken steps to complete all of the necessary requirements and we look forward to sharing our efforts with CMS when we submit our formal action report."

CMS also cited as cause for concern an unlocked refrigerator that held medications, which Exeter officials said, "was in a secure unit and did not contain any controlled substances."

CMS also noted "that Pyxis machines that contain controlled substances allowed individuals to change their own biometric identifier without creating a reported audit trail. This is an issue that is inherent in Pyxis machines and not unique to Exeter."

Other issues CMS officials noted pertained to emergency department access, the structure of the hospital's Quality Assessment and Improvement Program, and lapses in infection control precaution practices by housekeepers.

"We take each (issue) very seriously," the hospital said in its statement. "Ultimately it will be up to the CMS surveyors to determine if we have met their standards. We are confident we will be able to work with CMS to find satisfactory resolutions to all of their concerns."

In closing, the hospital statement said "hospitals and regulators both need to embrace the need for increased review of even commonly used practices. As a result of our identifying Mr. Kwiatkowski's alleged criminal activities, we are thankfully (in) the final chapter in a national tragedy that has affected hospitals and, sadly, many of their patients across the nation."

In a July survey report, problems were identified with infection control policies and procedures that did not comply with recognized standards in the following areas:

  • Cleaning and disinfecting of equipment between patient uses on five of seven distinct hospital areas.
  • The appropriate gowning when entering the room of a patient on infection precaution on one of seven areas.
  • The criteria for employees with potential infectious process for being able to work in direct patient care.
  • Allowing an employee with draining wounds to work in an environment where invasive procedures were being performed.


Other deficiencies cited included:

  • The hospital "failed to follow proper practice of securing controlled medications from potential unauthorized use until the administration of medication has occurred."
  • The hospital's ceiling tiles located in semi-restricted corridors were perforated, meaning that they were not scrubbable or capable of withstanding cleaning and/or disinfecting chemicals.
  • The hospital lacked a policy for cleaning glucometers between patient use.
  • The hospital failed to assure that staff members working in surgical units wore contact precaution gear.
  • The hospital allowed a scrub technician to work with three open lesions and a finger cut that needed stitches at times during his employment.

Tagged Under:


Get the latest on healthcare leadership in your inbox.