Lompoc Valley Medical Center could be at risk of losing its Medicare, Medicaid and Medi-Cal certifications after a state inspection of the hospital found several deficiencies, ranging from a lack of infection controls to inadequate employee training and improper food care.
The review, which was done as part of the hospital’s recertification process, was performed during an unannounced site visit from Feb. 6 through Feb. 10 by a team representing the Centers for Medicare and Medicaid Services (CMS), which is a part of the Department of Health and Human Services.
Despite the unfavorable review, LVMC CEO Jim Raggio said Monday that the hospital had addressed all of the concerns raised in the report and that he was fully confident the CMS would revise its determination following another round of surprise inspections slated to take place sometime before June 8.
“We have no fears of us not getting in total compliance with this,” he said Monday. “In fact, we were hoping they were gonna be here today to re-do the survey. I am highly confident we will be in full compliance.”
The CMS released a 128-page report detailing the findings of the inspection and, following that report, the California Department of Public Health sent a letter to LVMC’s leadership to notify them that the hospital's participation in the Medi-Cal program is subject to termination on June 8.
The letter to Raggio from the California Department of Health was dated March 9 and signed by John Dexter, the chief of the Provider Certification Unit for the state. The letter noted that “if CMS revises its determination, you will again be eligible for Medi-Cal participation.”
The certifications, and the surveys that validate them, are critical for LVMC to survive. About 75 percent of LVMC’s business is done through Medicare and Medi-Cal, so continuing without those would not be sustainable, Raggio said.
The areas noted in the CMS report as having significant issues were in pharmaceutical service, infection control, quality assurance and performance improvement, and food and dietetic services. The review was conducted through observations, reviews of files, and interviews with patients and staff.
A sampling of some of the issues highlighted in the report:
- A patient’s medical information was displayed on an unoccupied computer terminal.
- The hospital failed to show evidence that qualified staff were providing training to apply and remove leather restraints, a failure the report deemed “has the potential to place patients, staff and visitors at risk.”
- The pharmacy’s sterile intravenous, or IV, compounding area was tested for viable, or living, airborne microorganisms twice in the past year and “both tests came back positive for microorganisms.” The report notes that the test results were not sent to an infection preventionist or to the hospital’s pharmacy and therapeutics committee. “These failures resulted in the potential, over the past year, for 5,000 patients to be exposed to 3,296 IV medications that were mixed in an area that did not meet” required standards, the report states.
- An infection control preventionist, according to the report, stated that organisms identified in air at the hospital “could have been a potential pathogen in the hospital’s patient population.”
- Several failed controls with medicine, some of them acknowledged in interviews with staff, “resulted in the potential for patients to be exposed to excessive sedation or a delay in receiving pain relief.”
- Pharmacy procedures weren’t followed both in medicine prep and cleanliness of areas.
- There were several deficiencies found in food preparation and qualifications of dietary professionals. These included failures to monitor food temperatures throughout the day on the café’s salad bar and improper or insufficient testing of sanitation fluids.
Raggio said that all of those issues have since been corrected, and many of them were fixed immediately.
Among those addressed right away, he said, was a requirement that the pharmacy counter be cleaned with sterile alcohol when pharmacists are working with IVs. LVMC was found to be in violation of this during the survey.
“Nobody knew there was even sterile alcohol; we used alcohol to do it,” Raggio said. “(But) while the survey team was there, we had sterile alcohol on site before they left.”
Other corrections, he noted, involved re-educating staff on certain policies and procedures.
Despite the negative findings in the report, Raggio said that he and other LVMC administrators welcome outside examinations of their practices. He noted that this was the most scathing report during his time at the hospital.
“In the 20 years that I’ve been here as the CEO, we have never had any issues with compliance or accreditation,” he said. “And we’ve never had problems.”
He said that community members shouldn’t fret over the hospital potentially losing its certifications, which could result in it closing its doors.
“The quality of care here is tremendous,” Raggio said. “There are absolutely no problems at this facility, and we’ve addressed all the recommendations made by the validation survey.”