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L&C Appeal Review Memo_9!26!11

L&C Appeal Review Memo_9!26!11

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Published by: christina_jewett on Oct 05, 2011
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 Prime Healthcare Hospital appeal September 26, 2011 Page
DATE: September 26, 2011TO: Pam Dickfoss,Acting Director, Center for Health Care Quality, Licensing andCertificationFROM: Howard Backer, MD, MPHSUBJECT:Complainant written appeal pursuant to Health and Safety Code(HSC) 1280.5 Chino Valley Medical Center; Desert Valley Hospital;San Dimas Community Hospital; West Anaheim Medical Center(Complaint Number CA00258305)
This is in response to the written appeals of the complaints investigated by theCalifornia Department of Public Health (CDPH), Licensing and Certification Program.
The original complaint was submitted by Senator Elaine Alquist and AssemblymemberWilliam Monning, in response to allegations in a report submitted by the ServiceEmployees International Union-United Healthcare Workers (SEIU-UHW) that PrimeHealthcare Services, Inc. (Prime Healthcare) operated hospitals had much higher thanaverage rates of sepsis when compared nationally or within California. Prime operatedfive of the six hospitals with the highest septicemia rates in the United States accordingto Medicare claims data. This discrepancy persisted when analyzed with Medi-Calclaims within California; Prime Healthcare operated four of the California facilities withthe highest rates of septicemia as compared to statewide benchmarks.The report recognized that the source of the higher rates could be one or a combinationof higher rates of infection in the communities, infection control practices leading tohealthcare associated infections, or coding practices.CDPH cited violations for infection control practices and issued a deficiency for failure todocument and monitor central venous catheters at Desert Valley Hospital, and issued adeficiency related to collaboration of infection control professionals with senior healthcare facility leadership. The written appeals did not contest the deficiencies cited forHealth and Safety Code, Section 1288.6 and the hospitals responded with correctiveactions. Therefore, the appeal will not address these violations .Surveyors also evaluated specific patient records with diagnosis of sepsis, selectedfrom the hospitals with the highest rates of septicemia according to Medi-Cal claimsdata. This review led to deficiencies delineated on Form 2567 citing 22 CCR, Division5, Chapter 1, Article 70701(a)(1)(G):
Preparation and maintenance of a complete and accurate medical record for each patient 
 Prime Healthcare Hospital appeal September 26, 2011 Page
Basis for Appeal
Pursuant to Health and Safety Code Section 1280.5, the CDPH may accept, consider,and resolve written appeals by a licensee or health facility administrator of findingsmade upon the inspection of a health facility. All four hospitals appealed thesedeficiencies using the same arguments:1. CDPH is basing the deficiencies on an evaluation of clinical judgment of thetreating physicians, over which CDPH has no authority. Moreover, hospitalmedical staff are independent and autonomous from the Hospital Corporation.2. CDPH based the deficiencies on improper coding of diagnoses, over whichCDPH has no expertise or authority.3. CDPH did not accurately identify documentation of sepsis by treating physicians,so is erroneous in designating the records as inaccurate. The criteria that CDPHsurveyors used was not consistent with guidelines in the medical literature.4.
Finally, the hospital’s representative argued that this written appeal must be
considered and resolved by a physician that was not involved in the originalreviews or surveys.
 This review was completed by Dr. Howard Backer, MD, MPH, FACEP. Dr. Backer isBoard certified in both Emergency Medicine and Preventive Medicine Public Health. Hepracticed medicine full-time for 25 years, primarily emergency medicine, but also familyand sports medicine in various settings, including urban, suburban, and rural hospitals.For the past 10 years, Dr. Backer has worked for the California Department of PublicHealth as Chief of the Immunization Branch and for the California Health and HumanServices Agency as Associate Secretary for Emergency Preparedness. Twice, he hasserved as Interim Director of the Department of Public Health and the California StateHealth Officer. Dr. Backer was recently appointed Director of the Emergency MedicalServices Authority.During this assessment, Dr. Backer reviewed the following documents:
Initial report and analysis of Septicemia at Prime Hospitals from SEIU-UHW
Letter of complaint from Senator Alquist dated August 17, 2010
Deficiencies issued via a Statement of Deficiencies and Plan of Correction, StateForm 2567 which is issued to providers for violations
Four Hospital’s State 2567s with Corrective Actions in response to deficiencies
Letters of Appeal from all four of the Prime Healthcare Service hospitals
Patient records noted in the deficiencies and response, supplied by hospitals toCDPH
Pertinent literature on the definition and clinical criteria for sepsis
Coding guidelines provided by Prime Healthcare and available on-line
 Available records referenced in the deficiencies issued and the hospitals responsewere reviewed, not to make clinical judgments of the care, but to evaluate the
 Prime Healthcare Hospital appeal September 26, 2011 Page
patient-specific justification provided; the complex interplay of primary andsecondary diagnoses; the potential for subjectivity of the clinical picture whenreviewing records; and the role of coders in creating the medical record and justifying a diagnosis that may not be prominent or even present in the physicianslist of diagnoses.
Response to appeal
1. Prime alleges that CDPH does not have the authority to evaluate the clinical judgment of the treating physicians.Although it is clearly within the purview of CDPH to perform detailed evaluation ofthe medical records in order to discern health care practices within the hospital,peer review is outside the scope of this survey. The standard of medical practiceis determined by actions of peer providers within the community. The optimalprocess for evaluating clinical judgment is through peer-review by medical staffwith similar training and experience. CDPH makes no assertion of clinicalincompetence or substandard patient care in this survey or review.2. Prime alleges that CDPH has no expertise or authority to evaluate coding.While surveyors were trained in coding practice, the reviewer has determinedthat there is not sufficient basis for determining that the medical records wereincomplete or inaccurate. Coding guidelines are not determined by Title 22,rather are set by an industry association in collaboration with governmentagencies. The coding guidelines for sepsis utilize accepted standards from themedical literature; allow coding for possible, suspected, or probably diagnoses aswell as any condition that was evaluated clinically, treated, or increases nursingcare of length of stay; and allow the coder some leeway to determine thecondition that should be designated as the principal diagnosis. This suggeststhat hospitals can include sepsis in the final list of coded diagnoses when it maynot have been listed as the principal admitting or discharge diagnosis. Notsurprisingly, the coders were sometimes inaccurate in their application of sepsiscriteria, such as documenting high percent of neutrophils when the criteriaactually is elevated immature neutrophils (bands), or failing to distinguish neworgan dysfunction from pre-existing disease. Not all SIRS findings are related tosepsis.
(ii) Systemic inflammatory response syndrome (SIRS) generally refers to the systemic response to infection,trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis.(iii)Sepsis generally refers to SIRS due to infection.The Coding of SIRS, sepsis and severe sepsisThe coding of SIRS, sepsis and severe sepsis requires a minimum of 2 codes: a code for theunderlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemicinflammatory response syndrome (SIRS).

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