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Complaint Leads To
Unannounced Visit

By Jeanne Sager
HARRIS — May 26, 2006 – The probe into quality concerns at Catskill Regional Medical Center continued this week with a surprise visit from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
The non-profit organization that evaluates healthcare standards for more than 15,000 programs in the nation was in town this week for a surprise visit.
The visit comes just weeks after Crystal Run Healthcare’s Managing Partner Hal Teitelbaum announced he’s pulling his practitioners out of Catskill Regional Medical Center at the end of this month.
Teitelbaum said his physicians have encountered a number of issues concerning the quality of care being provided at CRMC, issues he said were all reported to the state health department.
The state has already made its visits to CRMC, invited inside by the hospital’s CEO, Art Brien.
When JCAHO dropped in on Tuesday, Brien said the letter they presented stated this was a “for cause examination.”
“In other words, they were responding to complaints,” Brien said.
According to Elizabeth Zhani, a spokesperson for JCAHO, complaints were lodged regarding “leadership standards” at CRMC.
JCAHO gave Catskill Regional a clean bill of health on its last visit in 2004.
But the organization will make unannounced on-site visits to accredited organizations if serious concerns are raised about patient safety or standards compliance.
According to JCAHO protocol, the organization might be asked to provide written responses to the complaints, and the complaint may be incorporated into the database used to track healthcare organizations’ performance over time.
JCAHO sets quality standards that hospitals and other healthcare providers must meet in order to obtain accreditation.
A hospital that is in compliance with all standards at the time of a JCAHO visit receives accreditation, as does a facility that addresses requirements for compliance within 90 days of the visit.
Catskill Regional has been accredited as a hospital offering general medical/surgical, psychiatric, long term care acute, rehabilitation and surgical specialty; and as a critical access hospital (defined as a hospital with a patient census of less than 25 that are located more than 35 miles from a hospital or another critical access hospital, or are certified by the state as being a necessary provider of health care services to residents in the area).
CRMC also met accreditation standards for its Medicare-Medicaid Certification-Based Long Term Care.
According to JCAHO, “Medicare/Medicaid certification-Based Long Term Care accreditation is a one day/one fee long term care survey that is based on a sub-set of long term care standards that do not duplicate the Center for Medicare/ Medicaid Conditions of Participation.”
The results of this week’s investigation are expected to be posted on the JCAHO Web-site, Brien said.
During a briefing after the visit, Brien said the investigator had nothing but good things to say about CRMC.
“Nothing but normal comments,” he noted. “This is not an unsafe hospital by any means.
“One of the things the guy absolutely praised through the roof was the nursing care,” he added.
Because JCAHO can make unscheduled visits, Brien said the hospital has to be prepared at a moment’s notice to show they meet accreditation standards.
“We’re JCAHO-prepared every day of the week,” he said. “If you’re a hospital, you’re subject to more reviews than anyone in the world, and each time, it’s a normal review.”
For results of the JCAHO reviews on Catskill Regional Medical Center, visit
According to Zhani if no requirement for improvement is identified, then the hospital’s accreditation status will not be affected and no changes would be made to the current posting.

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