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Pacific Islands Development Program, East-West Center

With Support From Center for Pacific Islands Studies, University of Hawai‘i

CNMI Healthcare Corp. Submits Extensive Correction Plan
Authorities cited CHC for management, equipment issues

By Tammy Doty

SAIPAN, CNMI (Marianas Variety, Jan. 25, 2013) – The Northern Marianas’ Commonwealth Healthcare Corporation (CHC) submitted Wednesday evening a massive 217-page "plan of correction," or PoC, to the U.S. Centers for Medicare and Medicaid Services, or CMS.

As mandated by CMS to retain federal certification the corporation’s PoC addressed 13 major citations identified in a Sep. 2012 federal site survey.

Since the inspection, CHC has battled immediate jeopardy citations and tight reporting deadlines to avoid a Feb. 11 CMC de-certification date, which would mean losing over $10 million yearly in Medicare and Medicaid reimbursements.

CHC’s chief executive officer, Juan N. Babauta provided Variety with a full copy of its PoC that details its responses to CMS’ citations.

Above and beyond the three immediate jeopardy citations that constituted the top-priority items for the last 3 months (non-functioning CT scanner and defibrillator and lack of critical lab functions), CHC’s PoC addressed a whole host of deficiencies including: personnel licensure and periodic evaluations (in-house and off-island); hospital governing body; quality of care; CEO; patient rights; safety; monitoring radiation exposure; infection control; equipment sterilization and lax operating room procedures.

A large portion of CMS’ report details conversations with CHC staff and leadership concerning various patient-care incidents that highlight finger-pointing at broken equipment, other employees and a general lack of quality controls.

In total, CMS used the word ‘failed’ no less than 67 times in its 215-page survey report.

Governing body & quality of care

CMS detailed 17 items of evidence highlighting the negative impact of the hospital lacking a GB responsible for overall administration.

As a result, CHC created a GB (chaired by the CEO) and held its first meeting on Jan. 15.

The GB will meet monthly and oversee sub-committees tasked with discrete functions such as recruitment, medical records and medical credentialing etc.

Additionally, CHC is seeking outside financial and information-technology consulting experts with support from the Department of the Interior.

Moreover, the CEO and chief operating officer, Esther Muna, enrolled in the on-line Hospital Healthcare Executive Training program via the American College of Healthcare Executives’ mentoring program.

Also providing 12-month virtual support to CHC leadership is the U.S. Public Health Service.

"Based on interviews and record review, there was no governing body involvement in the process of ensuring that the medical staff is accountable for the quality of care provided to patients in the hospital, that members of the medical staff met application requirements for appointment and reappointment to the medical staff, and that medical staff were qualified and trained to provide care and services to patients," reads CMS’ survey.

Rumors have circulated at the hospital for months that a pediatrician is still under California medical license probation status dating from 1992, yet last year the doctor slipped through the NMI’s medical licensure process without a full vetting.

It would appear CMS confirmed the suspicion.

The federal survey cited one example of a doctor hired in Aug. 2012 whose personnel file showed "no documentation of any clinical performance evaluation by the hospital or credentialing committee to verify competency for those procedures/services for which the physician had applied."

Additionally, a physician can only prescribe or dispense controlled substances to patients if they have a certificate from the U.S. Drug Enforcement Administration.

To acquire the DEA certificate, a doctor must possess an unrestricted medical license in at least one state; the same doctor cited above also failed to provide the DEA document.

In total, no less than 11 medical staff personnel files were reviewed for proper documentation and all failed to meet CMS vetting standards.

In response, CHC stated its commitment to reviewing credentials, education and DEA certificates for all medical staff via its credentialing sub-committee currently being formed.


"The governing body must appoint a chief executive officer who is responsible for managing the hospital.

"This STANDARD is not met as evidenced by: Based on observation, record review, and interviews, the governing body did not appoint a chief executive officer who was responsible for managing the hospital," states CMS.

Babauta was called out for failing to: ensure that the hospital provided laboratory services directly or by contract to meet the needs of its patients; or ensure that the hospital was arranged and maintained to ensure the safety of the patients, and provide facilities and supplies for diagnoses and treatment.

Furthermore, the CEO did not ensure adequate hospital supplies and equipment necessary to provide patient care and services; and failed to review medical supply requisition sheets from several inpatient units including the ER, surgical, pediatric, outpatient clinics and psychiatric units.


The nursing department was hit hard in the CMS report as well with seven violations as well as a detailed list of licensure citations.

"Review of personnel files revealed no evidence of BLS (Basic Life Support) certification or evidence of licensure, certifications, orientation, cross-training, annual competency, annual or periodic evaluations."

Five of the nine operating room/recovery room nurses’ files "had no evidence of current RN licensure."

In one case, a nurse had been working for a year in the OR/RR without ever having passed the graduate nurse exam.

As of Jan. 3 the director of nursing, Leticia Reyes, issued the new policy "No license or permit – NO work."

Nurses without licenses are not allowed to practice and graduate nurses are required to submit a GN permit issued by NMI’s Board of Nursing prior to hire and are allowed to practice for one year only.

A passing NCLEX grade is also required.

CHC stated in its POC that all GNs currently possess the required permits and that the licenses will be reviewed monthly.

CMS also cited a lack of registered nursing supervision of nursing staff.

Again the survey contained detailed examples of nurses failing to administer doctor-ordered tests and treatment plans — including pain medication and blood-sugar tests — without documented reasons.

"There was no indication that the physician was informed so that alternative patient care measures could be explored."


Citations run throughout the report that overlap into safety violations but some discrete items listed include: lack of staff vaccine immunizations; failure to monitor radiation exposure; secure drugs; ripped x-ray aprons; lack of food safety licenses for dietary kitchen staff; and lack of proper disposal of hospital waste to name but a few.

"The hospital did not ensure that the full-time employee who serves as director of food and dietetic services is qualified by experience and training; did not ensure that administrative and technical personnel were competent in their respective duties."

CHC responded that a registered dietician was hired in 2012 and recently completed the "Serving It Safe" program offered by the National Food Service Management Institute as well as several other training courses.

Dietary staff members have also completed five food safety training modules with more to follow.

Also rectified was the bio-hazardous waste grinder which was repaired last December with the chemotherapy waste removal/disposal currently under repair.

All fire extinguishers were inspected/certified also in December and all obstructions to fire-extinguishers and/or fire-alarms were removed with unit managers re-trained on fire-life-safety.

"While reviewing staff employee health files, two registered nurses working in the emergency department were noted to have incomplete health screens related to not having a Measles-Mumps-Rubella vaccination."

Variety can attest to viewing first-hand on Tuesday CHC’s rectification of the vaccination citation as employees were packed three-deep in the administration hallway as they waited their turn at the immunization station.

Patient Rights

"A hospital must protect and promote each patient’s rights," states CMS, "This CONDITION is not met."

CHC failed to ensure patients were well informed about their illness, possible treatment and likely outcomes, as well as the right to considerate and respectful care in a safe and secure environment.

The facility also failed to maintain adequate stock levels of daily patient care supplies; and failed to ensure patients had the right to confidentiality of their clinical records.

In just one of numerous incidences chronicled, CMS’ tour of the emergency department revealed a 7-inch-thick stack of documents identified as an "ER Medication Accountability Log Sheet" on a shelf inside a dirty utility room across from the trauma room.

The documents included "personal identifiable information including the patient’s name, the medical record number, the dose and names of medications given to the patient, as well as the registered nurse issuing the medications."

CMS’ site survey report becomes very graphic when recounting a long list of individual patient incidents.

In one particularly vivid example, CMS recounts how a patient was left with a broken surgical suture needle embedded in his fractured leg during surgery, which then required a second surgical procedure to remove.

A staff physician’s explanation to CMS stated "the incident could have been prevented if the C-arm (an imaging scanner) was not broken at the time of the surgery."

The physician added that "nursing staff also failed to conduct a sponge and needle count before the incision was closed."

Nursing staff countered by saying "the count was not indicated [requested]."

While the incident was reported to hospital administrative staff CMS cited CHC for "no indication that the incident had been investigated to prevent recurrence and help ensure the safety of patients at all times."

Administrative staff stated that the hospital "did not currently have a quality coordinator who was responsible for conducting such review and investigation."

The most horrifying examples came from the most vulnerable patients among us – children – who were denied adequate care because of lack of specialists and supplies.

CMS detailed one case of a 4-year-old drowning victim admitted to CHC’s emergency room in respiratory distress last April.

The toddler was intubated [breathing tube inserted] due to continued seizure-like activity but a referral letter by the pediatrician should give any parent pause.

"Unfortunately, due to a lack of specialists and lack of supplies, the only central line that could be placed was an expired 2 Fr PICC line into the femoral vein."

The total break-down of internal hospital systems not only directly endangered patients but also extended to the facility itself.

"Fire door monthly testing for emergency operational readiness resulted in an average compliance rate of 68 percent (threshold 100 percent)."

CMS’ overall quality assessment could not have been more candid.

"There was no documented evidence of hospital quality assessment performance improvement minutes or quality management reports…no documented evidence of governing body minutes to ensure oversight of the quality program…no evidence of a program coordinator to facilitate the number of departments participating, and the processes involved to ensure monitoring, analysis, improvement planning, and documentation."

Needless to say, a quality management coordinator is now a top priority at the hospital as well as implementing clear reporting, follow-up and review procedures for all errors and incidences of inadequate conditions of care.

At the heart of the QM program is implementing new laboratory policies and procedures and staff refresher training in every area.

Beginning Feb. 10 employees will be re-trained on the subjects of: patient rights and responsibilities; referral for spiritual counseling and discharge planning; medical records accountability and private health information.

As the CEO stated in his PoC cover letter to the U.S. Department of Health and Human Services, "We are hopeful that these plans are acceptable to CMS."

The community strongly seconds that hail-Mary sentiment.

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