NMC Commentary

Has NMC Restored Compliance with CMS Standards?

Yes. Last week, NMC completed a successful CMS (Centers for Medicare & Medicaid) re-survey focused primarily on our care of patients who are suicidal or suffering from severe mental health issues, and when law enforcement can be called into the hospital in potentially violent situations. The results of this survey were positive and remarkable. I am thankful for the full engagement of our staff and our medical staff in transforming our approach to challenging situations and coming out of this process with improved systems that enhance the safety of both patients and staff.

As I shared with you in a December column, NMC has been working through a plan of correction to ensure we are in full compliance with the CMS standards relating to the role of law enforcement and the care of patients with severe mental health issues. The effort has been impressive. There has been full engagement across the entire organization as we improved our processes for caring for mental health patients, strengthened our documentation, and increased our auditing of that care.  We conducted staff education across the entire organization on a very tight timeline to ensure we were all aligned in our new processes and policies.  We provided targeted de-escalation training for key staff, further advanced our partnership with Northwestern Counseling & Support Services (NCSS), strengthened our contract for onsite security services, and improved our ability to use our own trained staff to properly assist in potentially difficult situations. We worked closely with local law enforcement to clarify the roles and expectations within the regulations we must comply with and the laws they enforce. We also made physical changes to our Emergency Department to improve safety and have more planned in the coming weeks, in advance of a much larger renovation in the future. Rather than things now ‘going back to normal’ with the completion of the survey, we are on a continued path forward. We are continuing with staff training, drills of challenging situations, and internal audits to ensure our care and documentation align with policies and standards. So many members of the NMC team have worked tirelessly on these efforts. I am deeply appreciative of their commitment to providing exceptional care for our community and seeing that their co-workers are safe in doing so. They embraced a regulatory challenge and turned it into an improvement opportunity. Many stepped forward to help lead and I am very proud of this team.

We did not do this alone and we are fortunate to have such a strong sense of collaboration in our community. I am grateful for NCSS’s and local law enforcement’s assistance with our efforts to respond to this challenge.  We also deeply appreciate the ability to reach out to colleagues at Rutland Regional Medical Center, Quorum Health Resources, the Agency of Human Services, and other organizations for expertise and guidance. Thank you all.

This issue goes far beyond NMC and our community.  As I shared in December, Al Gobeille, Vermont’s Secretary of the Agency of Human Services, said “Vermont’s hospitals are seeing more people with higher acuity mental health needs coming to Emergency Departments for care. This is causing significant stress on the system and we need to continue to work together across sectors to address it.” We will continue to be a leading voice and active participant in efforts at the state level to improve the systems and infrastructure for how Vermont cares for individuals with significant mental health issues. We will always keep the safety of all our patients and our staff as a top priority.

— Jill Berry Bowen, NMC’s Chief Executive Officer