Griffith: Luis Hospital Nearing 100 Percent Compliance With CMS Systems Improvement Agreement

Juan F. Luis Hospital (JFL) CEO Dr. Kendall Griffith has announced that as of March 24, 93 percent of the hospital’s deficiencies cited in a Systems Improvement Agreement (SIA) outlined by the Centers of Medicare and Medicaid Services (CMS) have been addressed.

The announcement came over the weekend on the heels of Gov. Mapp last week signing into law a $7 million appropriation for the hospital to continue corrective action currently underway in order to maintain its CMS certification. JFL came close to losing its certification last fall following a damning report issued by CMS after an audit of the hospital last summer revealed a host of serious violations and deficiencies.

In thanking members of the 31st Legislature and Gov. Mapp for making the funds available to the hospital, Griffith said that while the hospital is nearing completion of the SIA, the initiatives outlined in the costs of the SIA are necessary for JFL to be able to address the deficiencies on a long-term basis.

“This is a major step towards bringing JFL into compliance with the CMS conditions of participation and demonstrates a collective commitment towards ensuring that residents and visitors of St. Croix continue to receive quality care,” said Dr. Anthony Ricketts, chairman of the St. Croix District Governing Board.

According to information issued by JFL, the $7 million appropriation made available in Bill No. 31-0062, will cover the cost of medication and supplies, SIA consultant/legal counsel, information technology, telemedicine, and financing for the mammography unit.

JFL officials, in collaboration with the hospital’s board, recommended the following control measures be incorporated into Bill No. 31-0062 for the management of the funds:

1. The Board has approved the CFO to establish a separate bank account to ensure all disbursements are accounted for in accordance with Bill Number 31-0062.
2. The CFO will have each disbursement reviewed and approved by two board members prior to disbursement being made regardless of the amount.
3. The CFO will report monthly to the Legislature and the Finance Committee all disbursements and fund accounting documents related to the SIA Cost Plan.

Griffith said JFL management and staff have been working to address the deficiencies cited by CMS “through policy changes, reinforcing protocols, ensuring accountability, and taking other corrective actions.” He says he remains confident that the work will result in a favorable outcome when CMS visits the hospital in August to review its compliance with the SIA.

“The changes being implemented will not only lead to corrective measures, but sustainable results. We will achieve these goals because of our collective commitment to the JFL mission: To drive improvement in the health of those we serve while exemplifying compassion and respect,” Griffith said.