Eureka Springs Hospital has submitted a final plan of corrective action for issues identified during surveys conducted by the Department of Health and Human Services Centers for Medicare & Medicaid Services that a state health department official had warned could lead to the termination of the hospital’s Medicare agreement.

Jodi Edmondson, the hospital’s human resources director and interim chief executive officer, told the Eureka Springs Hospital Commission at its regular meeting on Monday, Jan 20, that the final plan for correction has been submitted and the hospital is awaiting a response.

A Nov. 26 letter from David Mitchum, a program manager for health facility services with the Arkansas Department of Health, was addressed to former Eureka Springs Hospital chief executive officer Angie Shaw, even though Shaw was terminated from that position nearly two months before the date of the letter. Shaw has since filed a wrongful termination lawsuit in Carroll County Circuit Court.

“Dear Ms. Shaw,” the letter reads. “To participate in the Medicare program, a provider must comply at all times with the Conditions of Participation/ Coverage established pursuant to Title XVIII of the Social Security Act. On the basis of the deficiencies cited at Eureka Springs Hospital Commission on November 7, 2024, your facility is not in compliance with these regulations. We recommend that you notify your Governing Body and/or owners that termination of your Medicare agreement may result.”

A Medicare complaint survey was conducted the week of Nov. 4, 2024, according to documents previously provided to the Times-Echo in response to an open-records request pursuant to the Arkansas Freedom of InformationAct.Among the findings noted in a report from that survey were that the hospital “failed to maintain food and nutrition services” in accordance with state guidelines, noting that patient meals were provided by an unnamed restaurant; failed to have adequate infection control and antibiotic stewardship practices; failed to assure nursing staff was checking crash charts; did not have an effective discharge planning process; did not have an established process for prompt resolution of patient grievances; did not maintain a safe, hygienic environment in a housekeeping closet in the Endoscopy department; failed to provide patient-centered, competency-based training and education on the use of restraint and seclusion; failed to develop, implement and maintain a facility-wide quality assessment and performance improvement program; failed to provide a mechanism for reporting or tracking and trending adverse events; failed to ensure guidance and oversight for an ongoing Quality Assurance Performance Improvement Program aimed at improving outcomes and mitigating risk to patients and staff; failed to create and maintain policy and procedures for conducting disaster drills and failed to conduct disaster drills for 2023 and 2024.”

In its initial response to that report, the hospital said its policies and procedures regarding dietary and patient meals were reviewed and revised and that the hospital would begin serving prepackaged meals to patients on Dec. 9. The hospital also said it had reviewed policies and procedures related to infection control and antibiotic stewardship.

The hospital also reviewed its policies and procedures for monitoring expired supplies and removed expired items from Endoscopy suites, it said in its response to the survey findings, as well as addressing the protocol for ensuring scopes are clean and ready for use.

Expired items also were removed from the ER Room, the hospital’s response says, and policies and procedures for crash cart checks, discharge planning and patient grievances were reviewed.

The hospital also addressed housecleaning deficiencies noted in the survey report and assigned all nursing staff to complete training on the use of restraints and seclusion by Dec. 20.

In addition, the hospital said it has reviewed and revised policy and procedure for quality assurance and reviewed its patient satisfaction survey process. The hospital said it will ensure that complete chart notes are scanned into patients’ charts in a timely manner and will continue to monitor for compliance.

In addition, the hospital said it would install battery-powered emergency lights on its generator by Dec. 31 and will install an emergency stop switch near the generator by Jan. 31.

The hospital said documentation of disaster drills conducted in 2023 and 2024 were located in the CEO’s office.

A separate survey was conducted on Nov. 22.

Among the findings in that survey were that the hospital’s emergency diagnostic laboratory services were not available 24 hours per day and that there were no laboratory staff members or a contract for emergency laboratory services.

The hospital initially responded to the Nov. 22 survey findings on Nov. 26, saying it had taken “immediate corrective actions.”

Hospital commissioner Kent Turner, who at the time was the commission chair, told the Eureka Springs City Council on Dec. 9 that the hospital lab had reopened that day.

At Monday’s hospital commission meeting, Turner praised Edmondson along with nursing director Lana Mills and chief financial officer Cynthia Asbury for their work in responding to the survey findings.

“I appreciate the amount of work that Lana and Cynthia and Jodi and a lot of people at the hospital have put in to try to get past this Department of Health thing,” he said. “ I think there has been an endless amount of work.”