HospitalInspections.org

Based on observation, staff interview and record review, the hospital failed to be primarily engaged in providing care to inpatients. The hospital failed to provide 24 hour physician services since March 31, 2022, and failed to maintain an average daily census of 2.0. There have been no inpatient admissions since March 27, 2022. These findings resulted in the Condition of Participation for Basis and Scope not to be met.

A review was conducted of the, "Census Statistics by Patient Status," form for the period from 5/1/2021 to 5/1/2022. When removing the Observation status from the statistics the average length of stay (ALOS) for this period with 640 inpatient days and 118 discharges was 5.42 and the average daily census (ADC) was 1.75. Review of the average daily census by month revealed an ADC of 0 in May 2021, 0.8 in June 2021, 1.74 in July 2021, 4.71 in August 2021, 2.8 in September 2021, 1.26 in October 2021, 1.8 in November 2021, 3.16 in December 2021, 2.93 in January 2022, 1.39 in February 2022, 0.35 in March 2022, 0 in April 2022 and 0 in May 2022

The findings include:

During an observation on 3/17/2022 at 10:34AM, the hospital entrance sign stated, "ER (Emergency Room) is closed temporarily. All other departments remain open. In case of an emergency dial 9-1-1. Walk-in clinic open Monday-Friday, 7AM to 4:30 PM." Outside the Emergency Department (ED) over the ambulance bay the sign letters, "EMERGENCY," had been removed and were lying on the ground. Walking pass the ED bay towards the hospital entrance there was a small directional sign that stated, "Ambulance Entrance," with an arrow pointing left and, "Emergency Walk-in," with an arrow pointed right. At the Emergency Department entrance there were signs on the door that stated, "Closed for remodeling under construction. We apologize for any inconvenience. Call 911 if you have an emergency."

On 5/17/2022 at 10:45AM, an entrance conference was conducted with the hospital Administrator, and Vice President. At that time, they stated that there were no patients in the hospital and that the last patient was discharged on 3/27/2022, so any patients that the surveyor observed on-site were there for outpatient services. They further stated that the Emergency Department had been removed from their licensure on 3/18/2022 and that the hospital was licensed for 50 beds.

On 5/17/2022 at 10:53AM, a tour was conducted of the hospital with staff member C, Licensed Practical Nurse (LPN) and Staff member D, LPN. At that time, they both stated that there were no patients currently admitted to the hospital. LPN C stated that it had been approximately 8 weeks since the last patient admission. She stated that the Emergency Department had been under construction for a while now and that the hospital had the nursing staff assisting with painting and other minor renovation tasks and housekeeping to keep them employed there. They further stated that this coming Friday (5/20/2022) would mark four weeks that staff have gone without receiving pay for their work. They both stated that the hospital administration informed the staff that they no longer had the funds to cover payroll costs and cited ongoing construction issues and the Centers for Medicare and Medicaid Services (CMS) placing a hold on their accounts as the reason. During the tour it was noted that there were no patients in any of the rooms.

On 5/17/2022 at 11:05AM, an interview was conducted with the Phlebotomy (staff who draw blood samples) Supervisor E. She stated that the laboratory department was still running labs for outpatient services. She stated that her understanding was that the hospital was open to the possibility of admitting inpatients, but if doing so there would have to be a doctor scheduled. She also confirmed that the last paycheck received from the hospital was on 4/22/2022. She stated that the reason cited by administration was that CMS held funds due to a form not being completed. They were told that once the form was accepted, the staff would be paid for all back pay. She was asked if she lost any staff due to this and she stated that she did lose one phlebotomist. Due to this, they are only doing labs from 6am to 6pm daily. She stated that if the Emergency Department were to open back up, they had the staff to cover that need for now. She stated that if they lost another phlebotomist, it would leave only her and it would be difficult to replace the phlebotomist and that would not be enough coverage. She said that this would create the need to cross train the Medical Technicians (the people that actually run the samples in the laboratory) in phlebotomy and that would take time. She did not feel like the financial issues would be resolved by Friday, which would result in another missed paycheck. She stated that administration gave a letter to their staff to give to any creditors, landlords, etc stating that the reason was because the hospital was unable to pay their employees.

On 5/17/2022 at 11:20 AM, an interview was conducted with Radiology Technician G. He stated that there were a lot of the department staff that had long drives into work and were unable to do so without a paycheck given the current gas prices, so he elected to cover as much as he could to help out. He stated that he has all the supplies he needs to carry out the functions of the radiology department and confirmed that the department was functional. He stated that currently they are only performing diagnostic X-Rays and the CT machine was down waiting on parts to arrive. He was not sure if it is a supply chain issue or financial issue. When asked about his paycheck he stated that the hospital has a communication application that it uses to disseminate information to its employees. He showed the surveyor the message sent to employees regarding pay issues, and it stated that the payroll was suspended by CMS due to failure to submit a form and that the state is helping get it resolved. He stated that it was only one missed paycheck at this point. He stated that there were a few staff that were upset about it and the department did lose their ultrasound technician. He stated it had been months or more since the last patient was admitted. When asked about the hours of operation of the department he said it was open Monday through Friday, 8:00 AM to 4:30 PM.

On 5/17/2022 at 11:38 AM another interview was conducted with LPN C. She stated that there is currently nothing going into or out of pharmacy. The pharmacy is currently locked with no way to get in. The outpatients do not receive any medications from the hospital. The nurses will occasionally complete port flushes and have those supplies available to them in the pharmacy. If a port flush was needed today, the Registered Nurse Charge would have to go into the pharmacy with staff to get it as they have the key.

On 5/17/2022 at 11:40AM, an interview was conducted with the Director of Nursing (DON) who stated that the Emergency Department closed for renovations back in March. We do not have 24 hour provider services, so that was why there were no inpatient admissions. She stated that they would not have anyone to respond in a timely manner to patient concerns or changes in condition. She further stated that if they were able to open the Emergency Department, they would be required to have a 24 hour provider. When asked about payroll she stated they were told the cost reports were due and CMS had a hold on some funds that were due to the hospital until the cost report is completed. They have not had the funds. This Friday will be two payrolls that they have not been paid for. As far as getting resolved, it is in administration's hands. The accountants are working. They hired an outside accounting firm to get it all done. They haven't said anything about why it was not completed before this. She went on to state that she had lost a few staff, but they still had a few loyal ones hanging on. She stated they had one nurse and a Firewatch person on for night shift and a nurse on call just in case a physician did want to admit. She stated that she was confident if a patient were admitted they would have the staffing and supplies needed in place. She stated that the Midnight census was done daily and sent to administration, infection control and the DON. It was logged on paper and had the date and time of admit and discharge. When asked, she stated that she believed the average length of stay was 3-5 days. She was asked to have the Administrator provide the hospital budget and plan.

A review was conducted of the admission/transfer/discharge log for the hospital, and it revealed that the last inpatient was discharged on 3/15/2022. A review of the Emergency Department log revealed that the last Emergency Department patient was treated and discharged on 3/8/2022.

A review was conducted of the "Census Statistics by Patient Status," form for the period from 5/1/2021 to 5/1/2022. When removing the Observation status from the statistics the average length of stay (ALOS) for this period with 640 inpatient days and 118 discharges was 5.42 and the average daily census (ADC) was 1.75. Review of the average daily census by month revealed an ADC of 0 in May 2021, 0.8 in June 2021, 1.74 in July 2021, 4.71 in August 2021, 2.8 in September 2021, 1.26 in October 2021, 1.8 in November 2021, 3.16 in December 2021, 2.93 in January 2022, 1.39 in February 2022, 0.35 in March 2022, 0 in April 2022 and 0 in May 2022. The total number of inpatient admissions from 5/1/2021 to 5/1/2022 was 124 and the total number of observational patients was 78.

A review of the schedule for medical providers revealed that the last day that the hospital had coverage by a medical provider was March 31, 2022.

On 5/18/2022 at 11:20AM the Administrative Secretary was asked about the physician schedule as the surveyor was only provided schedules up to 3/2022. At that time, she stated that there have not been any physicians scheduled for coverage due to the ED being closed down and having no inpatients.

A review was conducted of the Hospital 's Governing Body minutes. On 5/6/2022 there was a "Special Meeting," conducted. The minutes stated:
"Administrator called a special meeting about the holding of our funds from CMS. I, the Administrator, have drafted a letter and wanted you to see it before it was sent. I will copy all of you when I email it (see attachment). The hospital payroll is today, May 6th and we have no money to pay our staff. I need everyone to know that meeting payroll has been a struggle for the past few months. We have been with several unexpected expenses beyond our control, and we have had to ask The Hospital Owner to put in his personal funds for us to pay the staff. The Owner cannot put his personal funds into the hospital payroll at this time. The Owner had to put up to one million dollar bond for the Construction Company O lawsuit. The judge has ruled in favor of Healthmark, but has not released The Owner's money, we were hoping to use it to help with payroll. CMS is holding our Medicare and Medicaid funding because the cost report was not done ...The previous Chief Financial Officer did not do any state or local reports for the entire year, and CMS will not release our funding until the report is completed. To complete the report our audited financials, need to be completed. We have ...our accounting firm from Atlanta onsite building a year's worth of financials. We have paid them a fifty thousand dollar retainer and they have used twenty nine thousand already. They said they have at least two more weeks of work before they can send the financials to another firm to be audited. At that time, we can complete the CMS report and have them release our funds. They are fining us daily $1,000 dollars for it not being completed. I need the board's help to get in touch with our legislature to get someone's attention so we can get some help in getting CMS to release our funds on the good faith we are working on the financials to complete their report. If we are to stay open, I need our county and city's support, which they have not contacted us. Healthmark is not in the position to borrow any more money, we are not able to get any loans due to not being able to prove we have positive income to pay them back. We are letting the staff know after our talk that they will not be receiving pay. If staff walks that is something I cannot control. I will have a recommendation to The Owner that we cannot function and may have to close the hospital. The only areas we need staff is an Registered Nurse and fire watch person, and lab tech on duty 24/7. I am hoping before today is over someone will reach out to me letting me know CMS will release out money. Doctor J asked for the Board to meet again tonight at 6pm for an update. She also asked Doctor K and Doctor L to make some personal calls to the county, city and state elected officials to let them know about the hospital's situation. The Chairman of the Board is not on the call, he had called today asking we call him after 1pm to let us know what is going on with him, maybe pertaining to the board position we will let you know."

Another, "Special Meeting," was conducted on 5/11/2022. The minutes stated:
The Administrator called a special meeting to update the Board on The Chairman of the Board stepping down as the Chairman of the Board, update on the holding of our funds from CMS, and the hospital payroll from May 6th. The Chairman of the Board called and let us know that he is not physically or mentally able to continue to be the Chairman of the Board for Directors for Healthmark. We will have to vote on a new Chairman saying he is stepping down as Chairman.
The Administrator express concern that neirther the Governor nor Senator have responded to our letter from May 6th. We may have to lay off employees until we get out funding released. Doctor L has asked if we were thinking about closing the hospital and what it would take to do so. The Administrator said AHCA usually needs a 30 day notice, but we do not want to close, but we may have to if staff walks out, and we have no employees to operate the hospital. AHCA is coming today to do a walk-thru of the Emergency Department and advise us on what else needs to be completed before we can add it back to our license.
The Administrator mentioned that The Chairman of the Board has not heard anything from ... The Judge on The Owner's Million Dollar Construction Company O bond. Staff N said he would call ... The Judge and see if he could find out what it would take to get The Judge to release the funds. On a prior call with The Vice President, The Administrator and the Chairman of the Board, The Chairman of the Board had said "It is The Owner's money NOT the hospital." There have been a few employees that have reported us to the Department of Labor about not being paid. We called the Department and explained our situation and he was very understanding and said to just keep him informed.

A review of the most recent utility bills for the hospital was conducted with revealed the following:
Utility Company T Statement Total balance due - $12251. 17
Utility Company U Total amount due - $3051.96
Billing Date - 5/2/2022
Garbage Company V -Total account balance due - $2049.10

Review of QAPI minutes revealed that the hospital does have plans in place to expand services to generate more revenue. However, considering what is stated above, it is unclear how the hospital would fund these expansions to get them generating revenue for the hospital. The plan did not include how the hospital planned to fund projects.
Plans included:
- Freestanding Pharmacy with a startup cost of $7,500 and target completion date of June 2022 with a barrier of licensure.
- Not for profit clinic with a startup cost of $5,000 and a target completion date of July 2022 with barriers of corporation start-up and licensure.
- Endoscopy suite with a startup cost of $25,000 and a target completion date of December 2022 and a barrier of Approval by Office of Planning.
- Hyperbaric Chamber with no startup cost up front (The machines would be free to the hospital, but the hospital would have to pay $200 for each patient use as part of the contract) with a target completion date of August 2022 with a barrier of Approval by Office of Planning.
- Wound Care Center with a minimal startup cost and a target completion of August 2022 and a barrier of licensure.
- Pulmonary rehab with a minimal startup cost and target completion of August 2022 with a barrier of licensure.
- Nuclear Stress Testing with a minimal startup cost, a target completion of August 2022 and no known barrier.
- HIDA scan with minimal startup cost, target completion of August 2022 and no known barrier.
-PACS Imaging System with a startup cost of $26,000, target completion of December 2022 and a cost barrier.
- DEXA scan with minimal startup cost, target completion of December 2022 and no known barrier.
- Mammography with minimal startup cost, target completion of December 2022 and a cost barrier.
- Infusion center with minimal startup cost, target completion of July 2022 and no recorded barrier.

On 5/18/2022 at 2:33PM an interview was conducted with the hospital Administrator. She stated that the intermediary between the hospital and CMS apologized and said that he had just seen her email requesting assistance and she had sent it 3 weeks ago. When asked about how the hospital is working to get revenue coming, she stated that the ideas are not just thoughts. The pharmacy had already applied for the licensure. They were painting in it today and putting flooring down. It will be ready for an AHCA visit June 14th. It is in motion. The not-for profit clinic rationale is that because they are a for profit hospital, they have never qualified for the grants given during COVID. So, she felt like they were hurting more than most at this time.

She stated that she spoke to the AHCA Field Office Manager about removing the Emergency Department for a time for renovations. She stated during a normal month they write off about $300,000 for non-emergent care coming in through the Emergency Department and patient not being able to pay. The thoughts were to help the non-emergent patients that are not insured and have them seen. If they needed an admission, they would be able to handle that and any radiology or laboratory services. That way they can help be seen at a lower cost and if it turned out that they needed acute care they could be admitted to the hospital directly. She stated that there is an old clinic on the property that would take minimal effort to get up and running for that. She stated that staffing would be the only thing. She said that there were staff from their Rural Health Clinic that had expressed interest in getting it started. She stated that she hoped doing so would allow the hospital to reduce the amount that they had to write off to bad debt and help the Emergency Department break even. She stated at this point there are no barriers to opening the Emergency Department, but she would not do so until she could be sure that she could pay her staff. Se stated that she received a call today that was promising in which it sounded like the intermediary was doing everything they could to get the funds released.

She stated that she thought the outpatient services could keep the hospital open, but they would definitely lose more staff. She said that she had spoken to other surveyors about hyperbaric chambers. They have an area that already has the oxygen and water run to it and that the hyperbaric company did not require the hospital to pay for the machines but pay them $200 for each use. She was not sure if there would need to be upgrades to the building given the oxygen and possible fire risks. If she was able to get that going, she also planned to open a wound care clinic alongside it. She also stated that they have a podiatrist that was interested in renting office space from them and conducting procedures in their Operating Rooms once they were up and running.

She went on to say that the unbudgeted repairs that were required, plus them running behind 8 months and the costs tripling during the pandemic wore on the millions that had been in reserves at the time. She said that it was amazing that they had survived this long, and it was only because they were being a cautious as they could while trying to improve their hospital. She said that they had a very good team at the hospital and she herself was born in the city and had a personal stake in seeing the hospital succeed.

She stated that she did not believe there was any possibility of the utilities being cut off at this time. She said that the hospital did have a loan application started and that the bank president had assured them that they will fund as long as they are able to provide proof of a positive revenue stream. She was asked directly how much the hospital had on hand at this time and she replied that $50,000 was all they had.