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Regaining Conditions of Participation Compliance (CoPs) after Immediate Jeopardy & CMS Termination

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Operational and leadership issues at one 274-bed inpatient psychiatric hospital in the Southeast had been emerging slowly over several years. Eventually, critical patient incidents culminated in regulatory scrutiny, and the hospital experienced a full survey by the Centers for Medicare and Medicaid Services (CMS).

Findings of dysfunctional organizational culture, leadership, and management system inadequacies, and suboptimal patient care outcomes resulted in Immediate Jeopardy and the hospital’s subsequent termination from Medicare. The state Department of Health and Human Services (DHHS) retained Compass Clinical Consulting to help the hospital regain certification.

CRAFTING THE SOLUTION

Over the course of one year, Compass Clinical Consulting led the hospital through strategic leadership changes and helped to develop and implement action plans to bring the hospital into compliance with CMS Conditions of Participation. Namely, Compass helped the hospital to implement a new Nursing management structure while redefining the roles of healthcare technicians and nurses for greater clarity and compliance with CMS requirements. In addition, a new performance improvement plan and a new peer review program were implemented to help ensure the delivery of quality care.

SEEING THE RESULTS

Following a successful survey, the hospital was deemed to be in full compliance with the Conditions of Participation for Acute Care Hospitals and the Special Conditions of Participation for Psychiatric Hospitals. The hospital is once again eligible to receive Medicare and Medicaid funds.

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Read the Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing white paper.

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