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Banal-mun!- Health a human services
93ng Madlm Madlcald Servings
seat-tre- Regional Of?ce

7m 5th Avenue. Suite 1612!!)

Seattla, Wamingmn 96104

FAX: 445-580-7068 .
Division :36 sun-waif. mr??cation mfmamant Bram?an (banal ..

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Fax: 3604147 550' 

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From:
Fax: 
Phune: 206-615?2041
E-mall: as. lean . renolayan?cms . . gov

   

Data and time: Wedneaday, Septambar 09, 2015 13:59:10 MEET
Numbar cf 13

DEQQS:

 

NOTES: Immediate httenticm

muss am: this page only and fax to: (443} ago-c7323
:31: email tn 

234! my signature, I acknowledge :ecaipt cf the CMS netiae letter dated

. Signing and returning this page dues not
constitute any aaknowledgamant m: admissicn of liability wrung
daing? by Peacallaalth 31: 0'th Madical Centex.
Administxatcr/Authorized Representative:

?Tami gig j] ll?hbg?mrnakj

Print ?ame

QM 

Signature?: Date

 

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93:30 111013 Fax 

DEPARTMENT OF 6r. HUMAN SERVICES
Cerium for Medium 6: Medicaid Services

Wea?lmn Division aESurvey and Car??cutlan

Emilia Raglunnl Of?ce -

7'01 Fifth Airman, Quite 1600

Seattle, WA 95104

 
 

mume 4: 

IMPORTANT NOTICE - PLEASE READ CAREFULLY

THIS SERVES Al OFFICIAL NOTICE SENT VIA FACEIWE PURSUANT TO 42 CFR ?488.
N0 HARD COPY TO FOLLOW. 

9. 2015 .

mega-Gaussian. Administrator - Kt ?it. Mid
Fennel-16mm St John Medical Canter

1615 Dalawara Street

Longview, WA 98632.

Re: WE Certi?cation Number: 50-0041
Complaint survey mmpleted on August 26, 2015
Gondi?mrs of Pariieipation Not Met -
90-day tannination effective November 24, 2015
Removed Deanna Status

BMW: "Ra?-is; WI '4

Afuar care?il reviaw of the facts, the Centers for Medicare: and Medicaid Swims has determine!
that PaaceHeaith St John Medical Canter no 1mm was the requizmlanrs for participatian as a pmwder
of services in the Medicare progrmn established under Title of the Social Security Act. The
hospital is nuw placed (in a 90-day termina?on track based on the completion date: of the sway. This
letter server as noti?cation rhat effective November 24, 2015. the. Secrbtitry of the Department of Heulth
and Human Services intands to tcm?nata its pravidm agraemant with PeaceHeal?i St John Medical
Canter. Also. yuur damned status with tha Joim Commission (JG) is removed and you are? placed malts:
the Strata?s jurisdictian. Ynur deemed stains will has matured when you get back in substantial compliance
with Medicare regulatory requirements. .

I. BACKGROUND

To participat? as a pravidar of aarvioes the Madicm and Medicaid magi-rams, a hospital must mam: all
{if the Cnnditioni 0f Participation establiahed by thr: Secretary of Haalth and Human Swim. When a
hospital is found to be: out: afmmpiianoa with the Medicare Condition (11" Participatiun. factility 1m
iongar meets the requirements far pmticipatian as a p?rmidar Cif amines in the Madicara program.

The Swirl Secmity Act Section 1866(b) authorizes the Secretary to trim a. hosPiial?s Medium
prcridar agreement if the: hespital no lungar meats the ragl?niAJIy for a. hospital. {i2 CFR 
439.53 authorizes the Centers for Medicm and Madicaid Savings in mm?naza Madman pmvuier
agreemants when a. provider no longer mm the Cunditian (if Participatiun.

 

 

815(3019 12/013 Has}: 

Page 2.
On August 26.. 2015, the Washington Daparanaat of Health (State Buxvcy agency) a complaint
survey at your facility. The Survey that the following Conditicns cf Participaticn (Call)
were act mat:

42 CPR 482.12 (Slamming Eddy .

42 CFR 432.42 . aim. Contml

'I'hcaa da?cicncica limit the capacity of Pcacchalth St. John Medical Center to furnish services of an
adaquata laval and quality. Tha details cf above: de?ciencies am listcd on the: cf
Dc?ciancica and Plan cf (Fm CMS 2567). 

. PUBLIC NOTICE OF Tammanou AND OPPORTUNITY To CORRECT

In accordance: with ?42 CPR 439.5361), legal notice cf our action will be published in the local

acwapapcr 15 days the mammal: data.

Paaccl?lealth St John Medical Cents: can avoid the 90-day mnninatioa acdcn by correcting the
da?clcaciaa prior to the: affective data of the termination. GMS must and approve acrediblc
allegation of compliance. in sufflcicnt lime to ve?fy, with an 13ka by the State may
agency. that the: de?xdanciaa have been Complete your plan in the space
prole on the OMS-2567 within the next 10 calendar days. An mptahlc plan of which
includes acceptable completion dates. must cantain the following elements: 

1 Plan of cremation for each Spaci?c deficiency cited.

Ir Prccedmc/prccesa for the acceptable plan of mention for can]; deficiency cimd.

- Mm?toring procedm'cs in 61mm the plan of comedian is effective and that speci?c
da?cimciaa cited remain can-acted andz?cr in with the regulatory rcqairamcnta.

- Address prccaas impmvamcnt and how the hcapital has incomcratcd impmvement
acticns into its Quality Aaacssmeat and (QAPI) program. Address
Movement in to likelihood of at the deficient practice.

. A completion data fur of can]: dc?cicacy cited.

a? ?Illa plan must include the. individual responsible: for plan of
correctlca with algrmure and title.

(EMS strangly eaccuragcs Pcacchcalth St John Mcdical Elmer to have its plan cf mactica fully
by no later than: Septembcr 24, 2015. Please send your plan Mammalian to tha State
sway and to (EMS: . 

EMS ?Dlvlalon of Survey and Out?t-alien
Atten?cn: Ailccn Renalayan (Mail Stop 400)
701 Fifth Avenue, Suite 1500.

Seattle. WA 98104

 

Drby email at