Mount Carmel says feds completed full surveys; found areas that 'need improvement'

File photo - Mount Carmel West (WBNS-10TV)

COLUMBUS (WBNS) – Health inspectors found while Mount Carmel West is “in compliance” after making corrections to its pharmaceutical services, the Mount Carmel Health System is still being threatened with losing its Medicare funding due to deficiencies the federal government deemed are “significant.”

In a letter sent to Mount Carmel West dated March 25, the Centers for Medicare and Medicaid Services notes that “the hospital was found in compliance with the Condition of Participation of Pharmaceutical Services during the survey completed on March 8, 2019. However, we have determined that the deficiencies during this survey are significant and limit your hospital’s capacity to render adequate care and ensure the health and safety of your patients. In addition, the number of deficiencies were found in other Medicare requirements.”

The exact specifics of what inspectors found is not known and won’t be made public until Mount Carmel submits another round of plans of correction.

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Mount Carmel put out a statement Wednesday saying that health inspectors completed full surveys for Mount Carmel West and St. Ann’s hospitals this month.

Thirty-four of the patients impacted by the dosing scandal were at Mount Carmel West; one was at Mount Carmel St. Ann’s in Westerville.

The statement attributed to Mount Carmel CEO and President Ed Lamb read in part:

“As expected, CMS and ODH recently conducted another survey that included all areas of Mount Carmel West and its associated facilities. One of the results was that pharmacy services is now in full compliance at Mount Carmel West.

As part of this more expansive survey, CMS identified other areas that need improvement—particularly as it relates to the physical environment of the facilities. We immediately began correcting items identified by CMS surveyors while they were still on site, and will submit a formal plan that addresses every finding. As of today, all items have been corrected or are in the process of being corrected. Once our plan is accepted, we expect CMS to return for a follow-up visit to assess and confirm that all appropriate actions are complete and effective.”

A spokeswoman said that the areas that need improvement are at facilities located at Mount Carmel West, East and Grove City.

CMS completed its survey at Mount Carmel West on March 8. A similar survey was conducted at St. Ann’s in Westerville on March 15. The hospital says it expects similar results.

Mount Carmel has fallen under heavy public scrutiny in wake of a patient overdosing scandal.

To date, 35 patients are believed to have received excessive or potentially fatal doses of pain medications or other drugs between 2014 and 2018.

All of the patients were under the care of Dr. William Husel, who the hospital fired in December following an internal investigation. Husel’s medical licenses has been suspended and 30 current caregivers — including pharmacists and nurses — have been placed on leave for their roles in approving or administering the drugs.

Twenty-five nurses were recently put on notice by the state board of nursing that they could face discipline for their roles in the scandal.

“Mount Carmel has made and continues to make changes throughout our system to prevent the improper actions that may have led to the deaths of patients under Dr. William Husel's care. We remain committed to cooperating fully with all authorities and regulators as they investigate this matter, including the Centers for Medicare & Medicaid Services (CMS) and the Ohio Department of Health (ODH),” Mount Carmel said in a statement.

CMS had threatened to pull Medicare funding from Mount Carmel based on its initial survey in January that found the hospital’s lack of internal structures as it relates to the ability to access powerful pain medications placed patients at risk.

Mount Carmel avoided that initial threat of “immediate jeopardy” status by enacting a series of corrections — including now requiring that nurses and doctors gain permission from the pharmacy prior to using medication to remove ventilators from patients. All hospital caregivers have also been retrained, the hospital says.

Nearly all of the patients impacted by the scandal were on ventilators when they were given medications like fentanyl and other drugs, records show.

During its initial inspection of Mount Carmel West in January, health inspectors with the Ohio Department of Health found that in 24 of the 27 patient cases they reviewed that Dr. Husel used an override function on the hospital’s automated medication dispensing system to gain access to pain medications. These efforts bypassed the hospital’s pharmacy, which was unaware at times that Husel and other caregivers had accessed the drugs, a source close to the matter told 10 Investigates.

The hospital initially said that all of the patients impacted were near death and in intensive care. Twenty-nine of the patients are believed to have received potentially fatal doses of medication while the other six received doses that “went beyond providing comfort” but likely were not the causes of their deaths.

The hospital has since conceded that five of the patients could have potentially seen their conditions improve through treatment.

“In the meantime, nothing changes our ability to treat patients covered by Medicare or Medicaid. CMS also conducted a full survey at Mount Carmel St. Ann's and its associated facilities. We anticipate similar results from that survey and will follow the same process. There is nothing more important to Mount Carmel than the safety of our patients and their trust in us. We continue to learn from these events, and we are confident that we have processes in place to ensure the safety of our patients and their families,” the statement from Mount Carmel said.

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