PA Hospital's Deficiencies Detailed in CAP

The CMS document released to HealthLeaders Media includes the findings of the original survey as well as Saint Catherine's corrective action plan (CAP) to address the deficiencies.

Typically, CAPs address each deficiency and provide a timeframe for resolution. In its April 3 letter CMS specifies that "to forestall termination of your facility's Medicare provider agreement, it must be determined that the hospital has removed the immediate jeopardy prior to April 19."

The completion date stated in the CAP for resolving each deficiency, however, is May 10.

According to a CMS official "the plan of correction would not constitute a credible allegation of compliance for federal purposes for the simple reason that the correction date is 16 days after the (Medicare) termination date."

Figures from the Pennsylvania Health Care Cost Containment Council indicate that in 2010 Medicare accounted for 49% of Saint Catherine's $22 million in net patient revenue.

The deficiencies indentified in the 51-page survey fall into five broad categories: radiologic services, physical environment, surgical services, compliance with laws, and governing body. Extensive shortages of medical supplies are noted, including a lack of syringes and needles in the intensive care unit and the lack of catheter kits used in the ER to measure blood flow pressure in the heart.

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