Ottumwa, Iowa EMTALA Update

From the Ottumwa Courier

Medicare will continue payments to Ottumwa Regional Health Center, rescinding a threat to cut off the hospital for flawed patient care procedures.
ORHC received a notice from Medicare on July 26 that payments would end as of Aug. 11. That decision was based on a series of inspections that showed flaws in patient care in the hospital's mental health unit. A public notice from Medicare was printed in The Courier the next day.

Medicare rescinded the hospital's termination on Wednesday.

Thomas Lenz, an associate regional director with the Centers for Medicare and Medicaid Services, told The Ottumwa Courier that Ottumwa Regional's plan of correction has been accepted and that the hospital passed a new inspection by the state department of inspections and appeals.

"They have confirmed that the hospital has implemented appropriate corrective actions," Lenz said. "We fully expect that the hospital will maintain that standard of care."

Hospital CEO Lynn Olson said Wednesday that the hospital has made changes based on the incidents Medicare cited. It accepted Medicare's position that the hospital violated the specifics of patient care law.

"We have never denied the incidents that were cited in the original investigation," Olson said.

The hospital did contend that an incident July 1, in which Medicare accused the hospital of discharging an unstable patient, was not a violation.

"The only thing that we said was not a violation was the July [incident], was the result of the July 13 inspection where we said we felt that the patient was discharged in a stable condition," Olson said. "Our position on that hasn't changed. We don't believe that the hospital discharged the patient in unstable condition.
What we said then and what we say now is that the documentation of that was [flawed]."

Lenz said the complaints were valid and were indeed violations.

"We believe there was reason to investigate the complaint. That complaint was investigated and substantiated," he said, adding there could still be civil penalties against the hospital. "Because the complaint was valid and substantiated, the hospital may be subject to monetary penalties."

Lenz said those penalties could involve fines for civil rights violations. Medicare is not involved in that decision.

"That's a separate track," Lenz said.

Olson confirmed that civil penalties remain possible for the hospital.

"That's always a possibility in these," Olson said. "Generally they refer it to the Office of the Inspector General and then that office conducts its own investigation."
Neither Lenz nor Olson were sure if the inspector general had initiated such proceedings.

Additional details emerged Wednesday about just how the entire investigation began. Officials previously said the hospital failed an investigation in April and a follow-up investigation in July. It turns out that concerns were raised even before the April investigation.

Lenz said Medicare became concerned about Ottumwa Regional as a result of an inspection at an entirely different hospital. An inspection of that hospital's records raised questions about ORHC and led to the April inspection.

"We were reviewing a complaint at another hospital and identified ... this situation at Ottumwa. It's kind of convoluted, but that's what happened," Lenz said.

Complaints come from four basic sources. Lenz said hospitals are expected to self-report violations, that receiving hospitals can file a complaint if they have concerns about a patient's prior care, patients themselves may file reports, or complaints may arise out of professional reviews.

Medicare considers the complaints about the mental health issue as one continuous issue as opposed to a series of incidents.

"CMS looks at this not as one incident. They look at it as all the incidents. They view this as one continuous process, so when they come back for re-visits, it's not what they find at that visit, it's the whole picture. And they reminded us of that," Olson said.

There will be changes within the emergency room. Olson said the hospital will have social workers with training in psychiatric counseling on call to assist the emergency room doctors. The hospital may expand that to bring in psychiatric nurses for the same purpose.

"It's having someone with specific psych experience available to help the ER doctor fill out an evaluation of that patient," Olson said. "They can still determine if they need a psychiatric consult on top of that. This is an attempt to give them a resource that we haven't had before."
The future remains unclear for the mental health unit itself. The unit had two of the three psychiatric positions filled at the time of the complaints, but both psychiatrists have since submitted their resignations. A statement from Ottumwa Regional said the psychiatrists will leave the hospital in October and November, respectively.

Olson said he is not sure at this time what the impact of the first departure will have.

"It depends on if we recruit another psychiatrist or if we get some temporary help. Just don't know that yet," Olson said. Asked if ORHC is considering contracts with local psychiatrists who are not currently affiliated with the hospital, Olson said that that is an option. "We're looking at all options, including that."
A statement issued by the hospital said the mental health unit will be forced to close if new psychiatrists are not found. The unit is certified for up to 23 patients.