Stonington Institute Receives 13 Condition-Level Violations for Operational and Governance Failures

In August 2013, the Centers for Medicare and Medicaid Services (CMS) determined that the Stonington Institute violated 13 conditions of Medicare participation, risking termination of its CMS provider agreement. These condition-level deficiencies related to a range of issues, mainly around how the operations and governance of the facility were not independent from the rest of the business entity’s other program services.

Governing body failures were among the deficiencies cited by CMS. CMS found that the governing body bylaws and the information discussed at governing body meetings were not specific to the facility. CMS also found that the facility failed to ensure that “the governing body maintained separation from other campus programs and/or demonstrate independent compliance from the rest of the business entity.”

The Stonington Institute also violated the Medicare condition of participation for maintaining an effective quality assessment and performance improvement (QAPI) program. CMS determined that the facility failed to maintain a QAPI program separate from other campus programs. CMS also noted that even though the QAPI council met monthly, “repeated issues that included data presented on protective hold and clinical documentation issues were discussed from month to month without the benefit of new/alternative recommended actions from improvement.”

CMS also cited the facility for deficiencies related to its medical staff. The medical staff’s credentialing information was not separate and/or specific to the facility. The medical staff and its licensed independent practitioners served all of the campus programs and were not limited to facility practice.

The facility was also cited for nursing service deficiencies. CMS found that the facility failed to provide acute care nursing services to patients and failed to ensure that emergency equipment was available within the facility. An interview with a RN (registered nurse) in the acute psychiatric facility revealed that whenever a patient required a “physical hold,” or if a cardiac or respiratory emergency occurred, he/she would have to routinely notify staff from other campus programs (which were not part of the facility) for assistance. CMS also found that the facility failed to provide its nursing staff with direct access to the medication room. Staff were required to leave the facility in order to access the medication room shared between another campus program.