January 18, 2019

Our Reference:	CCN 371340, Complaint Intake #OK00052658, OK00052721

Douglas Swim, CEO
Memorial Hospital of Texas County Authority
520 Medical Drive
Guymon, OK  73942

Dear Mr. Swim:

Section 1865 of the Social Security Act (the Act) and Centers for Medicare & Medicaid Services (CMS) regulations provide that a provider entity accredited by a CMS-approved Medicare accreditation organization will be "deemed" to meet all of the applicable Medicare conditions and requirements.  

Section 1864 of the Act requires the State Agency to conduct a survey of a deemed hospital on a selective sampling basis, in response to a substantial allegation of noncompliance, or when CMS determines that a full survey is required after a substantial allegation survey identifies substantial noncompliance. 

We have reviewed the reports of the October 9, 2018, survey and October 11, 2018, EMTALA survey conducted by the Oklahoma State Department of Health (OSDH) and found that your hospital was not in compliance with the following Medicare Conditions of Participation and EMTALA requirements:

				42 CFR 485.618  Emergency Services
				42 CFR 485.641  Periodic Evaluation & QA Review
				42 CFR 489.24(a)  Medical Screening Exam
				42 CFR 489.20(r)(3)  Emergency Room Log
						
We have determined that the deficiencies substantially limit your hospital’s capacity to render adequate care and prevent it from being in compliance with all the applicable Medicare Conditions of Participation for hospitals. Hospitals must meet all provisions of Section 1861(c) of the Social Security Act, be in compliance with all of the applicable Medicare Conditions of Participation, and be free of hazard to patient health and safety in order to participate as providers of services in the Medicare program.  

The deemed status of your hospital was removed on January 18, 2019, as a result of the findings of substantial noncompliance.

The date on which the Medicare agreement of Memorial Hospital of Texas County Authority terminates is April 18, 2019.

Termination can only be averted by correction of the deficiencies, through submission of acceptable plans of correction (PoC) and subsequent verification of compliance by OSDH. A listing of deficiencies for the October 9, 2018, and October 11, 2018, surveys are enclosed for your response.   

The Form CMS-2567 with your PoC, dated and signed by your hospital’s authorized representative, must be submitted to Terri Cook, OSDH, via email at MedFacEnforcement@health.ok.gov by January 28, 2019.  This will ensure that the OSDH will be able to schedule a timely survey of your hospital to evaluate your compliance with the applicable Medicare Conditions of Participation and EMTALA requirements.  

The criteria for acceptable plans of correction are as follows:

1.	The plan for correcting the specific deficiency cited;   
2.	The plan for improving the processes that lead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice;  
3.	The procedures for implementing the acceptable plans of correction for each deficiency cited;  
4.	A completion date for the implementation of the plans of correction for each deficiency cited;  
5.	The monitoring and tracking procedures that will be implemented to ensure that the plan of correction is effective and the specific deficiency cited remain corrected and in compliance with regulatory requirements; and 
6.	The title of the person responsible for implementing the acceptable plan of correction.

Copies of the Form CMS-2567, including copies containing the hospital’s PoC, are releasable to the public in accordance with the provisions of Section 1864(a) of the Act and 42 CFR 401.133(a).  As such, the PoC should not contain personal identifiers, such as patient and staff names.  However, it must be specific as to what corrective action the hospital will take to achieve compliance.

A follow-up survey will be conducted at your hospital to verify compliance.  If CMS determines that the reasons for termination remain, you will be informed in writing of the continuation of the termination process. You will again be asked to submit acceptable plans of correction and one final revisit may be conducted before the termination date. A provider is not entitled to a hearing before termination, but only after termination actually takes place under Medicare regulations.

The deemed status of Memorial Hospital of Texas County Authority will be restored when it is determined to be in substantial compliance with the applicable Medicare Conditions of Participation and the OSDH will discontinue its survey jurisdiction.

You may contact Dodjie Guioa at 214-767-6179 or by email at dodjie.guioa@cms.hhs.gov if you have questions regarding this matter.

Sincerely, 				

Karen Hillman, Manager
Enforcement Branch

Enclosure:  CMS-2567

cc:  Accrediting Organization, OSDH