TCMH Successfully Passes State and Federal Recertification Survey

Texas County Memorial Hospital underwent a state and federal hospital recertification survey the second week of July, and successfully passed, board members heard at their monthly meeting.

The survey, which is conducted every three to five years, evaluates a hospital’s operations under normal conditions to ensure compliance with regulations established by the Centers for Medicare and Medicaid Services. Surveyors arrive on site, unannounced and spend up to a week examining various aspects of the hospital, including patient care, staffing levels, safety protocols, record-keeping practices, and adherence to specific regulations.

The state and federal surveyors arrived unannounced on Monday, July 7, and left on Wednesday, July 9. Their visit was shorter than expected.

A notice of deficiencies was received the following Tuesday, July 15, noting just one citation related to life safety.

“The deficiency was regarding the grounding electrical system in the surgery center,” Courtney Owens, TCMH chief nursing officer, said. “When the hospital transitioned from the old surgery area to the new surgery center, the testing of the grounding electrical system was overlooked. This occurred because the new system is designed to self-test.”

Owens explained that a plan of corrections for the grounding electrical system issue was submitted to the surveyors, and it has been accepted.

“Successfully passing this rigorous survey showcases the hard work and dedication of our entire team – from our physicians and nurses to our administrative support staff- all of whom are committed to providing the best possible care for our community,” Owens said.

Bill Bridges, TCMH chief executive officer, commended Owens for her excellent preparation for the hospital survey. “Courtney has been preparing the nursing departments for about four months for an unannounced survey. She provided them a checklist of items to review, and they were ready when the surveyors arrived,” Bridges said.

“Everyone performed exceptionally well; the departments were ready and prepared for the survey,” Owens added. “We are proud of our team.”

In other news, Owens reviewed quarterly patient satisfaction scores with board members.

“We are pleased to report that the hospital’s inpatient scores have increased by five percent,” Owens said. “This improvement reflects the quality of care our patients receive during their stay at the hospital.”

Owens also presented the hospital’s second-quarter Quality Assurance and Performance Improvement (QAPI) data. She highlighted initiatives in social services and case management, focusing on the social determinants of health (SDOH). The healthcare team gathers information about SDOH to understand patients’ home environments and potential impacts on their health after discharge. The TCMH healthcare team is dedicated to supporting both patients and their families in this process.

Owens noted that the medical-surgical, intensive care, and obstetrics departments are now assessing SDOH during interviews with inpatients aged 18 and older, aimed at improving patient care and outcomes. Inpatient assessments cover six crucial areas: access to food, housing, transportation, utilities, medications, and safety. She shared a positive development for second quarter, mentioning that 18 patients received resources following positive SDOH screenings, contributing to the hospital’s health equity objectives.

Additionally, Owens explained ongoing efforts within the Pharmacy department’s QAPI to enhance patient safety by addressing medication errors through improved scanning and reconciliation practices.

She pointed out that the Medical-Surgical department is furthering its QAPI goals by actively educating staff on medication verification protocols, resulting in a notable achievement of 91 percent proper verification for administered medications in the second quarter.

On another note, Owens reported a commendable 1.5 percent blood culture contamination rate for the lab, a significant reduction from two percent in the previous quarter. This improvement is crucial as lower contamination rates help prevent unnecessary antibiotic treatment and reduce extended hospital stays.

Owens concluded by praising the collective focus of all departments on consistently meeting their QAPI plans, which is essential for maintaining high-quality patient care.

Bridges recently met with representatives from Jason Smith’s office to discuss the potential impact of the “One Big Beautiful Bill.” A significant focus of their discussion was the $50 million allocated in the bill for rural healthcare to offset Medicaid and other funding cuts, as well as the uncertainty surrounding the distribution of these funds.

“One major concern is that all states will receive the same amount of funding, regardless of whether they have a rural healthcare system,” Bridges stated. “Additionally, there are questions about how rural hospitals are classified and who falls into that classification.”

Bridges shared his concerns with board members and plans to visit Washington, D.C., in September to meet with as many legislators as possible for further discussions during his trip.

In attendance at the meeting were Dan Prater, Senior Manager at Forvis Mazars, LLP, and Dana Frese, President and CEO of Healthcare Services Group. Prater delivered a presentation regarding the roles and responsibilities of non-profit boards.

Linda Pamperien, TCMH chief financial officer, presented the June financials, which reflected a decrease of $170,561 in overall revenues from budgeted monthly expectations. Pamperien attributed the drop to a decrease in inpatient volumes.  June inpatient admissions were at 74, which is up one admission from the same time frame in 2024. There have been 503 admissions year-to-date.

The financial report reflected that the hospital’s profit/loss report showed a negative bottom line for June, with a decrease of $192,919 and a year-to-date loss of $818,414. The earnings before interest, depreciation, and amortization (EBIDA) for the respective month were positive at $70,081 and the year-to-date EBIDA was positive at $766,046.

Present at the meeting were Owens; Bridges; Prater; Frese; Owens; Pamperien; Helania Wulff, public relations and marketing director; Christopher Baldwin, MD, chief of staff; and board members, Jim Perry, OD; Joleen Durham; Jennifer Hugenot; Jerri Crump; and Ross Richardson. Bill Bridges joined via teleconference.

Due to a scheduling conflict, the next meeting of the TCMH board of trustees is on Tuesday, September 2, at 12 p.m. in the hospital board room.