Hospital works to cure deficiencies

Installing sprinklers, smoke detectors top list of state mandates


The Memorial Hospital is taking steps to correct several fire safety deficiencies found during a recent state inspection.

The corrections will cost a minimum of $35,000, TMH Administrator Randy Phelps estimated.

The Colorado Department of Public Health did an unannounced initial life safety code survey of TMH on Jan. 30.

Several rooms were found to need sprinklers including two operating rooms, a medical file storage room and an area where dirty linen is kept.

Also, some smoke detectors tested in the building did not work.

"We're considering the option of replacing all of the smoke detectors," Phelps said.

Another option is to test all the detectors in the building and replace those that don't work, Phelps said.

No matter what the hospital chooses to do, Phelps estimated it will cost the hospital $10,000 to make the smoke detector corrections and a minimum of $25,000 to install the sprinklers.

After the deficiencies were found at TMH, the hospital was required to submit a corrective action plan to the Colorado Department of Health, which it already has.

"When our surveyors conducted the inspection, they wrote a list of deficiencies," said Jayne Marie Ragan, public information officer for the Health Facilities Division of the state Department of Health. "The facility is then required to respond with how they will correct the deficiencies. We then have to review the hospital's response and accept its corrective action plan, which we've already done with TMH."

TMH has indicated it will correct the smoke detector deficiencies by April and have the sprinklers installed by July.

"Hospital and nursing homes are always subject to inspections," Ragan said. "If we get a complaint about a facility, it is our job to inspect."

In the case of TMH, the recent inspection was not conducted due to a complaint, but because of its plan to convert to critical access designation, Ragan said.By becoming a critical access hospital, TMH makes itself eligible to cost based reimbursements from the federal government for Medicare patients. It has been estimated that the additional reimbursements would result in a $950,000 increase in annual net income for TMH.

The federal government created the critical access program to help rural hospitals stay in business.

Qualifications for becoming a critical access hospital include:

being a rural hospital 35 miles from another hospital.

participating in Medicare.

providing constant emergency room service.

having a maximum acute care inpatient census of 15 patients.

Hospital directors have been working on the conversion process since the TMH Board of Directors approved the conversion last November.

The last step in the process was the Department of Health inspection and the hospital's response to its deficiencies.

The Center for Medicare and Medicaid Services will review the hospital's responses to the deficiencies. If the center is satisfied that deficiencies have been rectified, TMH will become a critical access hospital.

"Presuming the corrective action plan is affective, we will be a critical access hospital," Phelps said.

Critical access has been cited as one source of funding to build a replacement hospital for TMH.

Money used on the up keep of TMH is money that could be put toward a replacement hospital, Phelps said.

"The sad part is you're throwing good money away," he said. "Money that should be dedicated to a new hospital. But we do realize it has to be done."

He compared TMH to owning a worn-out piece of property.

"It's just like an old house or car," he said. "You have to spend a lot of money to keep

it working."

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