Mock survey being performed at hospital

At the February Hot Springs Health Board meeting, CEO Margie Molitor introduced to the board Caroline St. Charles, who is a Heath Tech consultant working as a Chief Clinical Officer. Molitor said, “She is the guru for all of the conditions of participation and compliance, quality, credentialing, anything that has to do with the patient. She is the expert. She is here and doing a mock survey.”

St. Charles said that the last mock survey was approximately three years ago. She explained that hospitals that receive Medicare and Medicaid funds have to be in substantial compliance with the conditions of participation. Those conditions cover things like policies, procedures, nursing, radiology and labs, these are anything that touches anything in the hospital. She said, “So when I do a mock survey, I basically go through the conditions of participation and see whether the hospital is meeting them or not meeting them.”

She also said, “If you have a survey and the state comes in, that’s exactly what they do. The state goes through and looks at the standards and sees if the hospital is meeting them or not.” St. Charles added that “No surveyor looks at everything 100% of the standards because they would be here for a year. The surveyor tends to choose areas where there have been issues in the past or new focus areas.” 

The mock survey for the hospital will take three days to do. St. Charles added that Health Tech publishes productivity standards and they update them every year, which are recommendations to the hospital. St. Charles said the one big change coming in the conditions and participation there are new standards in quality assurance, performance and improvement which are effective at the end of March. 

Molitor continued the meeting with her report and said that they got everything turned in for their SLIB requirements to get the $1.4 million in funding. This money went to the kitchen and materials management. They recently received a partial payment of $461,000 and they are expecting $952,000 more in funds. 

They will also start seeing patients for mammography with their new 3D mammography imaging machine. Molitor said, “That’s very exciting.” 

They are also working to finalize their USDA loan by the end of March. Materials management moved into their space recently as well, which is upstairs and no longer in the basement using the elevators. Nutrition and room service will be moving to the kitchen on March 5. Red Rock Clinic and Public Health continue to work hand in hand on providing COVID vaccinations working off a shared patient list. Molitor said it doesn’t matter which entity you call, they are working off the same list. 

Nina Landis in her quality report said that in their recent meeting Dr. Weyer said everything was good and that they are moving forward to prepare for the mock survey. Landis said, “We’re pretty excited about that.” Landis added that the next big thing they are doing is the “Move to Model” with Cerner, which enables them to standardize. “It’s going to be a lot of work on the front end, but in the end, it will be a huge help to us.” 

Shelly Larson gave her financial report and said for the month of January their days in accounts receivable increased to 56 days and was up about eight days. She said they continue to see the clinics’ accounts receivable increasing primarily because of staffing issues. These individuals were new, out of town, or having their own medical issues. Their days’ cash on hand decreased by 19 days, they were at 171 days and now are at 152. Larson added that without the Medicare advances and the provider relief funds, their days’ cash on hand would be about 35 days. These figures not only reflect the hospital but also their other clinics. 

Miranda Nelson gave her report on the Community Health Needs Assessment. She described their three areas of priorities which are behavioral health, poverty and the opioid crisis. They are working with Jennifer Cheney in the Prevention Coalition. Nelson said some of these actions were put on hold temporarily because of the COVID situation 

Under the poverty section, Nelson reported that the food banks actually got more donations than what they had prior to COVID.  Nelson said, “That was a huge help,” through the Backpack program, the Episcopal Church and the River of Life church. Nelson mentioned the Help Center, which assists residents with paperwork and provides funding for electricity, gas bills and different things like that. Nelson also mentioned that there was a specific class for people who have been through domestic violence and needed help to be back on their own and budgeting. However, that instructor is no longer there and that program has ended.

For the opioid crisis, Nelson mentioned the education process at both the hospital and the Red Rock Clinic. They are going to try with Cerner is that information is mandatory on every discharge, otherwise, the patient gets a verbal education for being sent home on any kind of opioid. As of 2019, there 1,838 opioid medications that were either administered or prescribed. In 2020 the number of opioids given was 1,788 which accounts for the hospital where patients had surgery. 

The board also approved several change orders and Dr. Hallie Bischoff was not in attendance to provide the medical staff report.