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Sullivan County Memorial Hospital Addresses Deficiencies

July 25, 2019–A regular Sullivan County Memorial Hospital (SCMH) Board of Trustees meeting was called to order on July 25, 2019, by Chairperson Melba Fordyce at 5:10 PM. Trustees present were Jean Page, Jo Hall, Ron Camp, and Bill Lewis. Also present were Jerry Dover, Chief Executive Officer; Tina Sears-Hamilton, Director of Patient Care Services; and Amy Michael, Chief Operating Officer.

MINUTES: Chairperson Fordyce called for a motion to approve the regular meeting minutes from the June 20, 2019 Board of Trustees meeting minutes. Trustee Page made a motion to approve the minutes, Trustee Hall seconded the motion. Trustees Lewis, Hall, Camp, and Page voted yes.

CEO REPORT: The City of Milan’s Utilities Department had taken steps to monitor voltage and has agreed to replace the underground cable and the three main transformers with a single 250KV unit. Mr. Dover gave appreciation to the city for their cooperation.

The MRI/ER parking area is almost complete. The cement area had to be replaced further down the driveway than originally anticipated.

Stamped architectural drawings from Korff & Associates for the windows in front of the hospital and exterior project been received. Request for bids can now be sent out to companies.

The dietary and laundry department windows have been replaced. The only thing left to do is to complete the trim work on the inside. This is to be completed tomorrow.

The new Radiology C-Arm for pain management has arrived at the hospital. As soon as the physicist inspects the C-Arm and approves it, training will be provided and then it will be able to be put into use.

The gas service company installed a dedicated shut off valve and new digital gas meter to the hospital. The gas service company requested to change out the meter due to the age of the meter.

Mr. Dover reviewed the K Tags from the recent hospital State licensing survey. K Tags are deficiencies in the hospital’s plant and maintenance operations. Regulations changed in between the recent survey and the prior survey. Previously the hospital was grandfathered in several areas. The grandfathered clause has gone away which resulted in the hospital being required to meet current standards.

There were five areas of focus in the deficiencies fire/sprinkler system, medical gas, electrical/generator, HVAC dampers, and door structure. Some of the other issues included the oxygen shed needs to be replaced. The current shed is made of wood. Since there are combustible materials in the shed, the shed has to be made out of metal.

A hard path sidewalk has to be constructed from the dining room patio to another hard surface area to allow for egress continuity around the building to the parking lot. Additional emergency lighting and exit lights needs to be installed. Ceiling and wall fire stops need to be installed in some areas.

The deficiency report was received on July 2, 2019 with ten days allowed for the hospital to submit a plan of correction. The plan of correction was sent on July 12, 2019. All deficiencies are to be completed within 30 days of the survey exit. However due to many of the corrections need contracted companies to complete the work a request was submitted requesting an extension.

Libby Allen, NP is leaving the Green City Clinic. Currently shoe works part time in the Green City Clinic. She is moving her practice to Iowa which will allow her to have a full-time practice. Two interviews have been conducted for her replacement.

FINANCIAL REPORT: The June 2019 financial report was presented to the Board. The hospital had a gain of $41,903 for June. Year to date the hospital has a gain of $215,699.

Ms. Michael conducted the annual review of the Code of Conduct and the Board of Trustees Resolution for the hospital’s Compliance Program with the Board. No changes were presented to be made to the Code of Conduct or the Resolution.

Ms. Michael presented the 2019 Utilization Review Plan for the Board to review. No changes were presented to be made to the Plan.

PATIENT CARE REPORT: The Board reviewed the June hospital and clinic patient care reports.
Ms. Sears-Hamilton reviewed the deficiencies received on the C Tags from the hospital State licensing survey conducted on June 10 -12, 2019.

The C Tags are deficiencies in the area of infection control, pharmacy and patient care departments. The deficiencies report was received on June 21, 2019.

The hospital then had ten calendar days to submit a Plan of Correction to the State. The Plan of Correction was submitted for the C Tags on July 1, 2019. The approval letter from the State was received on July 16, 2019 accepting the hospital’s Plan of Correction for the C Tags.

Ms. Sears-Hamilton informed the Board no correspondence has been received from Livanta on the EMTALA investigation. Initially KEPRO, CMS’s quality improvement agency for our region was reviewing the investigation.

However, their contract ended with CMS on June 30, 2019. Livanta is the quality improvement agency that replaced KEPRO.

EXECUTIVE COMMITTEE OF THE STAFF REPORT: The July report was reviewed by the Board.
OTHER REPORTS: The May and July Quality Assurance/Improvement, Infection Control, Risk Management and Safety meeting minutes were reviewed by the Board.

There was no meeting in June.


NEW BUSINESS: Trustee Lewis made a motion to approve the SCMH Code of Conduct as presented to the Board. Trustee Camp seconded the motion. Trustees Hall, Page, Lewis and Camp voted yes.

Trustee Lewis made a motion to approve the Board of Trustees Resolution for the Compliance Program.

Trustee Camp seconded the motion. Trustees Hall, Page, Lewis and Camp voted yes.

Trustee Lewis made a motion to approve the Utilization Review plan for 2019 as presented to the Board.

Trustee Hall seconded the motion. Trustees Hall, Page, Lewis, and Camp voted yes.

Trustee Page informed the Board State Senator Dan Hegeman will be in Milan on September 17, 2019 at 12:30 at the Nutrition Site to meet with members of the community.

By the request of Trustee, Ron Camp, Chairperson Fordyce entertained a motion to go into closed session.

Trustee Lewis made a motion to go into closed session pursuant to Missouri Statutes, section 610.021 (1) (3).

Trustee Page seconded the motion. Trustees Hall, Camp, Lewis and Page, voted yes.

The Board went into closed session at 6:05 PM.

The Board went back into open session following the closed session. Still in attendance were the Trustees, CEO, and COO.

Being no further business, Trustee Hall made a motion, seconded by Trustee Lewis to adjourn the meeting.

Trustees Page, Hall, Camp, and Lewis voted yes.

The meeting adjourned at 6:20 PM.

Next regular scheduled meeting will August 22, 2019 at 5:00 PM.