3 DMC hospitals submit correction plans to CMS after sterilization, infection control-focused inspection

CMS conducted an unannounced inspection at three Detroit Medical Center hospitals in January following reports of trouble in DMC's central sterile processing department, and the federal inspectors found Children's Hospital of Michigan was out of compliance with federal regulations and cited two others — Harper University Hospital and Detroit Receiving Hospital — for deficiencies.

During inspections on Jan. 30 and 31, investigators said Children's Hospital of Michigan was "not in compliance with federal certification requirements." There, inspectors found disorganized and dirty surgical equipment — for instance, during one observed observation, a staff member found discoloration on an instrument in the OR — and failure to follow proper personal protective equipment protocol, among other deficiencies.

The other two hospitals were found to be "in substantial compliance" with federal certification requirements, but deficiencies included failure to follow personal protective equipment protocol, insufficient surgical instrumentation during busy times, failure to maintain a sanitary environment in an operating room and failure to adequately sterilize surgical instruments in two of 20 random observations of sterilized instrument packs.

CMS accepted all three plans of correction submitted by the hospitals, according to DMC. Children's Hospital of Michigan needs to pass another surprise inspection by May 23 or it could lose its Medicare contract, according to The Detroit News.

"As part of the process, CMS will conduct a follow-up survey to ensure DMC is in compliance with the Medicare Conditions of Participation for hospitals. We will continue to work collaboratively with CMS until all matters are resolved," according to a DMC statement.

The corrective actions plans involve reorganizing DMC's central sterile processing department, implementing an instrument assessment and inventory process and investing in new instruments and equipment, as well as continuing enhanced staff training and education.

This was the second time CMS has inspected DMC's central sterile process in six months — the federal agency dropped by for a surprise inspection in August after The Detroit News published an investigation detailing years of problems with the medical center's sterilization unit. The state also conducted its own investigation.

DMC had to issue a corrective plan then, as well, and passed a surprise inspection in November. However, CMS launched the most recent inspection after reports surfaced that a dirty surgical instrument was delivered to a DMC operating room just one day after the state wrapped up its investigation into the unit.

"While recent findings have shown areas for additional improvement in our CSP department, I have seen a consistent effort on the part of our DMC team members to ensure that our surgical services continue to be safely delivered with the highest quality of care," said Joseph Lelli, MD, Children's Hospital of Michigan's surgeon-in-chief, said in a March statement. "I'm encouraged by the changes made thus far and look forward to being a part of the positive efforts moving forward to create a world-class CSP department."

Copies of all three hospitals' plans of correction are available for download here, via DMC.

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