HospitalInspections.org

Based on record review and interview, the CEO impeded the survey process and failed to provide requested documentation related to the management of the hospital. The deficient practice is evidenced by failure of the CEO to provide documentation the facility was current with payments of state employment taxes and federal employee Social Security and Medicare withholdings as required by state and federal laws.
Findings:

Review of the Governing Body Bylaws, no date of initiation or review, but provided to the surveyor as the current bylaws, revealed in part, " The CEO shall be selected and employed by Corporation, after consultation with the Board, and shall be its direct executive representative in the management of the Hospital. The CEO shall have authority, and be held responsible for administering the Hospital in all of its activities, subject only to such policies as may be adopted and such or as may be issued by the Corporation, He/ She shall act as the authorized representative of the Board and Corporation if Corporation has not formally designated some other person for the specific purpose. Corporation, through the CEO, shall be solely responsible for the selection of key management personnel for the operation of the Hospital." And "Chief Executive Officer's Responsibility-6.3(g)-Supervising business affairs to ensure that funds are collected and expended to the best possible advantage."

During the entrance conference, the surveyor requested documentation to verify the facility was paying applicable state employment taxes and federal employee Social Security and Medicare withholdings as required by law.
During tour of the facility, interviewed employees verified they were aware of financial issues related to the owner of the hospital and verified many of the departments had experienced shortages of supplies which had not yet affected patient care. S5 and S6 verified there had been no problems with payment of the employees, but were neither were sure about the payment of unemployment taxes and Social Security and Medicare withholdings as well as contributions to the employee retirement plans.

On 09/16/2025 at 12:25 PM, the surveyor reviewed the provided documents requested during the entrance conference. Review of the documents failed to reveal tax and withholding documents and the documents were request for a second time. At the time of request, S3 stated she was not sure she could get them from corporate.

In interview on 09/16/2025 at 2:50 PM, S1CEO verified that the facility had many unpaid debts and each month he "decided which bills would be paid." S1CEO stated he did not have documentation of the tax and withholding payments, but stated he had paid the taxes and withholdings each month as required by law. S1CEO acknowledged that there had been shortages of supplies and the facility often had to rely on supplies from "sister" hospitals. S1CEO stated that at times the pharmaceutical supplier would refuse to send ordered medications because the facility was too far in debit, and then he would partially pay the debt, and the supplier would then begin to fill requested orders. S1CEO verified the hospital owed money to many suppliers including those providing laboratory and pathology services. S1CEO also verified the quarterly payments to the electric company were only partial payments
At the time of exit,09/16/2025 at 4:00 PM, the requested documents had not been provided and the surveyor was not provided alternative evidence of compliance with submission of state employment and federal employee Social Security and Medicare with holdings.