In the wake of the drug-overdose death of a contractor in Kaweah Health Medical Center’s emergency department in December 2020, the county’s largest hospital, was given just 90 days to correct dozens of policy and procedure deficiencies or lose federal funding.
Kaweah Health’s leadership was given 10 days to respond.
Cutting It Close?
The tight timeline apparently led to a frenzy of administrative review resulting in three versions of the Medical Center’s so-called plan of correction (POC), with the final version accepted by the California Department of Public Health (CDPH) on June 29. The date of termination was August 10.
Had the hospital failed to comply, it faced loss of its federal Medicaid and Medicare funding, which made up some 28 percent of its patient revenue in the last fiscal year. During the process, Kaweah Health was granted 10 additional days to present its POC. The POC was submitted on the extended June 1 deadline, with revisions forwarded on June 10 and June 29.
The final POC was accepted by the CDPH on July 8, six weeks ahead of the August 10 date of termination.
To complete the document, Kaweah Medical hired consultants from the Greeley Company, specialists in pharmacy practices, medical staff organization and leadership, patient safety, and “sustained compliance with the Medicare Conditions of Participation,” according to the POC.
More than 30 “deficiencies” were documented in the CDPH inspection report on Kaweah Health Medical Center, all of which had to be addressed in the POC.
Public Knew Nothing
The threat to end Kaweah Health’s CMS funding followed a rigorous examination by CDPH of the organization’s policy and procedures, resulting in a report highlighting the extensive failures that led to not only the death of a staff member, but also to the death of a patient the same night. It also found evidence of other staff members using illicit drugs, sometimes while on duty, and the theft of drugs by staff, including medications on the DEA’s list of controlled substances.
While leadership at Kaweah Health learned of the threat to end its CMS revenue stream on May 12–a result of the CDPH investigation–it did not make public any information regarding the deaths, drug theft and resulting fallout until July 9, and it came in the form of a blog post from CEO Gary Herbst on Kaweah Health’s website.
The blog post did not mention the 90-day notice of termination of Kaweah Health Medical Center’s Medicare certification or the pending removal of its “deemed status by virtue of Joint Commission accreditation.” “Deemed status” is the CMS’s metric for an organization’s maintenance of expertise in areas critical to continued funding.
CDPH’s investigation and report of extensive policy and enforcement deficiencies came after Kaweah Health reported the death in December of its staff member and the alleged theft of drugs by one of its ED physicians to the CDPH, as required by law. Visalia Police were also notified.
The investigation was performed by auditors from the CDPH, who were acting on a directive from federal authorities at Health and Human Services Centers for Medicare & Medicaid Services (CMS).
On July 21, Herbst announced the CDPH found Kaweah Health Medical Center in “substantial compliance” with the changes it promised to make in its 158-page POC.
The Plan of Correction
In the same July 21 blog post, Herbst also reported “observations made by the surveyors that need our attention” during a compliance inspection performed by the CDPH. He did not specify which areas were still in need of improvement.
In the investigative report, a pair of CDPH auditors found Kaweah Health Medical Center was deficient in eight areas–identified as “oversights” in the report–and the POC lays out changes Kaweah Health has made to address them. At the center of the corrective effort is the formation of a group of committees tasked with overseeing future compliance with requirements mainly focused on controlling the hospital’s dangerous drug supply, as well as reporting incidents of drug diversion and use by staff and medical providers.
Most prominent among the committees formed to ensure compliance with CMS demands is the
Quality Improvement Committee (QIC). The QIC–composed of executive-level members responsible for various areas of the hospital administration–oversees the subcommittees monitoring specific areas of compliance through audit reports on a monthly basis. The POC states the QIC will address “immediate patient safety concerns … in the moment.”
Fixing the Drug Problem
The QIC will rely on subcommittees to make it aware of problems similar to those that led to the deaths in the emergency department on December 22, 2021. Chief among them is the MIDAS Event Triage and Ranking Committee (METER)–the MIDAS system allows hospital employees and medical staff to make anonymous reports of patient safety issues.
The METER will review incident reports and forward them to the CEO and “executive team” when those incidents cause harm to a patient or the hospital, require the initiation of life support or result in a death, or are “sentinel events.” METER will also forward reports of incidents that require the hospital alert regulatory agencies, and incidents of illegal activity by employees and medical personnel, drug theft, abuse, neglect, harassment, reports from other regulatory agencies, and “any other verified or unverified event that places the hospital at significant risk, including the risk of adverse publicity.”
Additional committees–including one overseeing medical staff reporting processes–will carry out similar monitoring tasks, and new policies are now in place to ensure leadership is aware of possible violations. Those new policies specifically address how drug theft by members of the medical staff is to be reported and how the administration will be notified of those incidents, and they attempt to ensure the hospital’s leadership is made aware of potential problems.
Also addressed is how the hospital will keep a closer eye on medical personnel and staff who are in rehab for drug abuse or are known to have previous drug-abuse issues. Those individuals will be required to submit to random drug tests and will be monitored by the Well-Being Committee.
Several new policies and procedures will attempt to end the theft of unused drugs, as well as creating schemes for monitoring their use, possession, wastage and disposal.
‘Utterly Offensive and Unprofessional’
In his initial blog post of July 9, CEO Herbst declared he and fellow administrators do not expect further visits from the CDPH to ensure Kaweah Health remains in compliance, and the cover letter sent to CDPH investigators with the third revision to the POC was largely cordial and businesslike, expressing appreciation and welcome.
However, the process of answering state regulators’ questions appears not to have been without at least some friction. In the cover letter for the third revised POC, Herbst takes the regulators to task for a question on euthanization policy in the emergency department, expressing “offense” on the part of the hospital’s administration.
“Despite the tremendous amount of time, attention and resources it has taken for our organization to satisfactorily respond to your survey observations, findings and concerns, we have consistently conducted ourselves with the highest level of professionalism,” Herbst wrote. “It is for this reason that we take great offense to your … question where you ask, ‘Please indicate how the hospital will ensure staff follow its (policy) on euthanizing services in the ED.’ Ms Ramos and Ms. Chang, we do not euthanize patients at our hospital and we find it an utterly offensive and unprofessional comment.”
Currently, a 2016 state law allows doctors to prescribe fatal doses of drugs to terminally-ill patients. A bill introduced in the State Senate in February would amend the California End of Life Act to speed up the euthanization process for patients close to death, and it will require hospitals that do not allow physicians to participate in the program–such as Kaweah Health Medical Center–to provide those patients with information on the law and where to receive such services.
Should the bill become law, Kaweah Health will be required to formulate a euthanasia policy. So far, SB380 has been approved by the Senate and received OK’s from the State Assembly’s health and judiciary committees, making eventual passage likely.