A recent survey of Eureka Springs Hospital conducted by the Department of Health and Human Services Centers for Medicare & Medicaid Services identified several “deficiencies” that could potentially lead to the termination of the hospital’s Medicare agreement, according to a Nov. 26 letter from the Arkansas Department of Health.

The letter from David Mitchum, a program manager for health facility services with the ADH, is 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.

“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.”

According to a report on the survey, an “entrance conference” was conducted with hospital representatives on Nov. 4. An “exit conference” was conducted three days later, on Nov. 7. At that time, hospital representatives were given an opportunity to present additional information for the findings that were discussed. No additional information was presented, according to the report.

Among the findings listed in the report was that the hospital “failed to maintain food and nutrition services according to the Arkansas State Board of Health Rules for Hospitals,” noting that patient meals are 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.

Mitchum’s letter asks the hospital to submit “a plan of correction for each deficiency cited.”

“(P)lease assure that each plan of correction clearly indicates the corrective action to be taken; rebuttals to or explanations for the deficiencies cannot be construed as acceptable plans of correction,” the letter says.

The letter instructs the hospital to enter a “date of completion” for each deficiency — which cannot be more than 45 days from the survey completion date.

“Your written response must be received in our office within ten days of your receipt of this letter or termination action will proceed as scheduled,” Mitchum’s letter says. “If however, we receive an acceptable plan of correction within this time frame, we will conduct an onsite follow- up survey at your facility on or before the 45th day (12/22/2024) at which time your facility must be in substantial compliance with all Conditions of Participation/Coverage before the termination date of 02/05/2025. If compliance has not been regained at the time of the follow-up visit, a recommendation will be made to the Centers for Medicare & Medicaid Services (CMS) that your Medicare provider agreement be terminated.

“You can then expect to receive a letter from CMS advising you of the date upon which the termination will occur and explaining your rights for appeal. “Further, if termination action is taken CMS will give public notice of the date of termination and reasons for termination. Once terminated, you can anticipate being out of the Medicare Program for at least 60 days. Please be advised that under Medicare, a provider is not entitled to a formal hearing prior to termination, but only after the adverse action has actually taken place.”

Kent Turner, chair of the Eureka Springs Hospital Commission, has signed a letter of engagement with Little Rock attorney Gabriel Mallard, of the firm Mallard Gardner, to help craft a response to the survey findings.

“We are pleased that you have engaged Mallard Gardner, PLLC for the limited engagement of conducting a review and analysis of Eureka Springs Hospital Commissions’ compliance with the state and federal requirements for the operation of a Rural Emergency Hospital,” reads the agreement, which is also signed by Mallard. “Specifically, Hospital is retaining the Firm for the purpose of assisting in drafting a correction action plan (“CAP”) for addressing deficiencies cited by the Arkansas Department of Health.”

The hospital’s response to the health department’s report must be submitted by Friday, Dec. 6, Turner said.