Exeter Hospital on 'Termination Track,' Says State Official

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.