DMC's Sinai-Grace averts Medicare loss after failed inspections
Detroit — DMC Sinai-Grace Hospital spent most of last year in jeopardy of losing its federal Medicare funding after inspections found "significant" deficiencies in nursing care and building safety, according to government reports obtained by The Detroit News.
Sinai-Grace lost its Medicare-compliant status for nursing care in March and for the hospital's "physical environment" in April after the federal Centers for Medicare and Medicaid Services requested inspections in response to a substantiated complaint. The hospital ultimately was able to regain its Medicare status in September, and the termination was rescinded.
Inspectors from the Michigan Department of Licensing and Regulatory Affairs on behalf of CMS in February found lapses in wound care at the 402-bed hospital, including one patient who died after a bedsore received insufficient treatment over several hospitalizations and became infected, according to the inspection report.
Inspectors found improvements in nursing care during an April follow-up inspection but discovered "significant" problems with infection control in the building, as well as fire code violations and other building problems.
CMS on May 15 set a termination date of Aug. 13, but termination was postponed until Sept. 13 after the hospital submitted a plan of correction and schedule for building repairs, which allowed it to earn back its Medicare status on Sept. 19.
“Sinai-Grace Hospital addressed all findings identified during the surveys, and on September 19, 2018, received a letter from the Centers for Medicare and Medicaid Services that the hospital was in compliance with all safety requirements," the DMC said in a statement to The News.
"We work collaboratively with state and federal agencies to resolve all findings identified during any survey process.”
Sinai-Grace brings to three the number of Detroit Medical Center hospitals threatened with termination of Medicare funding last year. CMS in November revoked the Medicare status of Harper University Hospital and Detroit Receiving Hospital after inspections in October found "significant" lapses in infection control. Both hospitals remain subject to the possibility of termination.
This comes as DMC CEO Dr. Anthony Tedeschi informed staff in a letter that Scott Steiner, the chief executive officer of Receiving, Harper and Hutzel Hospital would leave the Detroit health system on Feb. 8 for a position in Florida. A replacement was not announced.
Michigan is among states where Medicaid payments are stopped if a hospital is terminated from Medicare, the Michigan Department of Health and Human Services confirmed. Medicaid is a federal insurance program for low-income residents and is paid partially by the state.
According to Minneapolis-based hospital analyst Allan Baumgarten, 47.8 percent of Sinai-Grace's inpatient hospital days are paid by Medicare, and 41.8 percent by the Medicaid program.
"It’s pretty clear that (Sinai-Grace is) very heavily dependent on Medicare for their patients and their revenues," Baumgarten said. "Anything that would threaten or erode the payments they're receiving from Medicare or whether they’d be able to able to accept Medicare payments is significant to a system like theirs."
Medicare termination is rare in the country, where the number of hospitals terminated has decreased annually since 2015, when nine hospitals lost their funding. Two hospitals in the U.S. were terminated in 2018, and three in 2017, according to CMS. The federal agency nationally has investigated about 3,500 complaints annually since 2013, the data show.
Sinai-Grace was inspected again last week after The News reported the facility was unable to treat a heart attack patient during a power outage on Nov. 21 because the cardiac catheterization lab wasn't operational. The patient died after transfer to another hospital.
The Jan. 8 inspection was conducted by LARA, on behalf of CMS. Results have not yet been released.
"During the survey process, our hospital remains an approved provider of services in the Medicare and Medicaid programs," the health system said in a statement on this month's inspection. "Sinai-Grace remains committed to providing our patients with safe, accessible, quality care.”
An inspection at Harper in October found flying insects in an intensive care unit, improperly attired surgical personnel and lapses in sterile processing of surgical instruments.
At Receiving, inspectors discovered the hospital had discontinued surveillance of most surgical site infections due to staff cuts in 2018, including for patients exposed to dirty surgical instruments.
Both Harper and Receiving were found not in compliance with Medicare's conditions of participation for infection control and threatened with termination.
Those inspections were conducted by LARA, on behalf of CMS, after three cardiologists and the top doctor at DMC Heart Hospital claimed they were terminated from their management roles in retaliation for complaints they made about quality-of-care issues. Heart Hospital adjoins Harper and shares many of its facilities and services.
Results of follow-up inspections at Harper and Receiving have not yet been released. Both hospitals remain in danger of termination, CMS confirmed.
Legacy Board not informed
Four DMC hospitals have been threatened with termination from Medicare since 2016. DMC Children’s Hospital of Michigan, Harper and Receiving all stood to be terminated from Medicare in 2016 over problems with dirty surgical instruments uncovered by The News.
A six-month investigation revealed an 11-year history of problems with dirty instruments that delayed surgeries and endangered patients. Harper, Children's and Receiving regained their Medicare status after the DMC invested more than $1.2 million to correct problems at a sterile processing facility.
The DMC is owned by Tenet Healthcare, a for-profit hospital chain based in Dallas, Texas. Tenet acquired the health system as part of its 2013 purchase of Vanguard Health Systems, the DMC's initial for-profit owner.
Former Michigan Attorney General Mike Cox established the Legacy DMC Board in 2011 to monitor commitments Vanguard made to the Detroit community when it purchased the previously nonprofit health system. Covenants of the purchase agreement included $850 million in capital improvements, a continuation of indigent and charity care, and other commitments. Those promises passed to Tenet when it purchased Vanguard.
Joe Walsh, the DMC Legacy Board president, said he's been generally aware of the health system's problems with maintaining Medicare certification. But the hospitals aren't obligated to share information about the quality of care, and they generally do not.
"I certainly would have appreciated (being informed)," Walsh said. "They have taken a very legal interpretation of the requirements to inform us of things, and, unfortunately, we have no authority other than matters that are in the commitments.
"They are not required, and they do not provide any information on patient safety and quality in their formal report."
The potential loss of Medicare funding would concern the Legacy Board, however, if it threatened the health system's ability to provide services to the indigent, Walsh added. And the Legacy Board pushed the DMC to correct problems with dirty surgical instruments that threatened funding in 2016.
"If Receiving was going to be shut down, that would jeopardize care for the indigent, and care for the indigent is our number one commitment," Walsh said.
CMS placed Sinai-Grace under the jurisdiction of LARA in February and asked the state to conduct an unannounced inspection in response to a substantiated complaint about nursing care.
The inspectors focused, in part, on the case of a 77-year-old nursing home patient who was admitted for shortness of breath, chronic obstructive pulmonary disease and a urinary tract infection on March 31, 2017.
At the time of admission, a nursing assessment noted that she had a Stage III sacral pressure injury, or bedsore below the base of her spine. No orders were written for dressing changes or wound care, and the sore wasn't measured to assess its severity. There was no documentation of a dressing change until seven days after admission.
The woman was re-admitted on July 31 for a problem with her feeding tube, and her nursing care plan again noted a "big pressure sore" below the base of her spine. A nursing care plan for impaired skin integrity was initiated, but it didn't include measurements of the sore, or orders for dressing changes. A bone scan revealed the woman had a bone infection and sepsis at the site, but the nursing care plan wasn't updated with results of the scan.
Dressing changes and daily wound assessment were documented on nursing flow sheets, but nurses didn't report measurements of the sore or say whether it was improving. The only wound care note to include measurements during her four-week stay described it as a Stage IV wound with exposed bone and tendon, more than two and a half inches wide, and about an inch and a half deep. The measurements weren't added to the nursing care plan.
On Sept. 18 the woman was admitted with a bone and muscle infection in the pressure sore, but no nursing care plan was written for wound care or sepsis, and no orders were written for dressing changes.
A bone scan on Sept. 20 found she had a bone infection of the sacrum and septic arthritis in her left hip. Blood cultures were positive for Staphylococcus capitis, a severe bacterial infection. The blood culture results weren't added to the nursing care plan.
Dressing changes were documented for just four out six days she was hospitalized before her death. The woman died at Sinai-Grace on Sept. 23, 2017.
On behalf of CMS, LARA examined the records of 10 patients and found the facility failed to perform consistent wound care and dressing changes, or to consistently measure and assess wounds. They also failed to perform wound care in a sanitary manner.
In one instance, a staff member failed to use proper hand hygiene procedures after cleaning up stool before changing the dressing on a patient's bedsore, an inspector observed.
"Staff L. cleaned up the stool, removed gloves, and without sanitizing hands, applied a new pair of gloves and started to pack the sacral wound with wet gauze packing, using gloved hands to handle the gauze," the inspector reported.
"When queried, Staff L stated that he was unaware that hands needed to be sanitized between glove changes.
As a result of the problems with nursing care, CMS also requested state regulators to conduct a full-scale inspection of Sinai-Grace, which took place on April 19.
The inspection found improvements in nursing care but revealed problems with infection control, such as a guard failing to change gloves after cleaning up blood, a mobile computer not disinfected after leaving an isolation room, and a medication storage unit and refrigerator in need of cleaning.
Inspectors also conducted a Life Safety Code Survey, or fire inspection, and found fire exits that lacked signage and an exit stairway blocked by mechanical equipment, as well as other fire code violations.
Many doors didn't latch shut, and there were cracked ceiling tiles and sprinklers in need of repair. Some parts of the hospital lacked sufficient generator power to provide emergency lighting during a power outage.
The federal agency on May 15 informed Sinai-Grace officials that they were out of compliance with Medicare's requirement pertaining to the hospital's "physical environment" and that their Medicare participation would be terminated on Aug. 13.
The hospital submitted a plan of correction and a schedule for repairs. The termination was postponed until Sept. 13. Ultimately, CMS rescinded termination after the hospital passed a follow-up inspection on Aug. 2. The hospital was deemed fully compliant with Medicare's conditions of participation on Sept. 19.
"We welcome and take input from the Legacy Board and make decisions related to our services based on what’s best for the city of Detroit," the DMC said Thursday. "We have made and will continue to make significant investments in our hospitals and continue to provide high quality healthcare to our communities."
According to Walsh, the Detroit Medical Center has spent more than the $850 million it was required to spend on capital improvements at DMC hospitals. The Legacy Board also routinely monitors the health system's provision of health care to Detroit's indigent residents and is satisfied those obligations have been met.
"We have no criticisms associated with care of indigent. They met their commitment," Walsh said. "But are they going to continue to spend the money to keep hospitals competitive and manage the brand?"
Still, Walsh worries that the DMCs problems with quality are damaging its reputation as one of the country's leading health care institutions, which could have consequences for the city of Detroit.
"The complaints — and these aren't delineated in the commitments — are, do you run your business in such a way that it will succeed and prosper," Walsh said. "We have talked about the fact that the headlines they continue to generate ... diminish the brand and make it harder for them to continue, well beyond our care and supervision."
Walsh noted the agreement that established the DMC Legacy Board and established the DMC's covenants with the community will end at the end of 2020.
"We believe they've met their financial commitments to improve the hospitals, but are they going to continue to spend the amount of money they need to keep these hospitals competitive?" Walsh said.
"Are they going to manage the brand in such a way to keep their volumes and their market shares? Those are management responsibilities that we really can't directly demand anything."