RISKAlert Report Updated: July 15, 2018
Guam Memorial Hospital is at risk of losing CMS Medicaid reimbursements, unless dozens of deficiencies
are fixed include medical issues and facility issues by July 25th according to scathing 78-page report.
The island’s only public hospital could lose Medicare funding for the Skilled Nursing Unit (SNU) by July 25th
and its main facility if it fails to achieve “substantial compliance” with the federal participation requirements
for nursing homes participating in the Medicare and/or Medicaid programs by July 25. It will deny to reimburse
admissions, and If substantial compliance is not achieved by Oct. 25, CMS will terminate the provider agreement.
In a scathing 78-page report, regulators reported the results of an unannounced survey which was done
for recertification, complaint revisit and complaint investigation and uncovered issues including not checking
credentials for medical personnel, not reporting medical errors, and medical issues that put patients in an
immediate jeopardy situation.
The report said GMH failed to ensure that its performance improvement activities tracked adverse patient events, analyzed the cause of the adverse event, and implemented preventive action, the survey report states. Major
adverse events that hurt patients were not reported even 12 months after the event had occurred.
The CMS survey took issue with egress doors that had locks that do not meet federal requirements. “Failure to provide egress doors as required increases the risk of death or injury due to fire,” the survey stated. The facility also lacked proper emergency lighting. An emergency power supply location was not provided with battery-powered emergency lighting, and the primary generator did not have battery-powered light. A Battery-powered light in a secondary generator room was not functional when tested during the survey.
LESSONS LEARNED
1. Losing CMS Certification may reduce the Guam Memorial Hospital’s revenue by 50-70%.
Make sure to keep your CMS Certification current to avoid a financial crisis!
2. Many deficiencies were blatant and cite recurring problems that MUST BE CORRECTED
IMMEDIATELY to avoid more problems.
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