Case Study

Reinstating Medicare Certification for a Critical Access Hospital’s Skilled Nursing Facility


A Northern California critical access hospital (CAH) contacted Wipfli/HFS Consultants because its skilled nursing facility (SNF) had failed three surveys.

The first annual survey occurred in 2015, and that began a journey culminating in January 2016 when our firm’s consulting nurse leader, Jan “Corky” Rockwell, RN, came on board on the day of the fourth and final survey. She found an organization in need of her expertise in skilled nursing administrative leadership. Unfortunately, the skilled nursing portion of the CAH failed the fourth survey and received a letter of decertification.

It was clear that the facility had failed survey after survey because the actions it implemented laid out in a plan of correction had not met regulatory compliance. There was no substandard care or abuse, just those hard to manage regulatory standards that must be managed at all times.


The failed survey was followed by six months of challenging dialogue with Noridian, the Medicare Administrative Contractor (MAC), to get the bar removed that would prohibit a reopening of the facility. During this time, all residents had to be relocated; many to out of state facilities that removed them from their support systems. The organization was required to show proof of where residents went, as they were not able to move into swing beds in the CAH. Statistics show that when elderly residents are moved out of their environments, 30 percent die due to the significant change. So, Rockwell and her colleagues made the care of residents a top priority. Additionally, the challenge of retaining staff in the community to be ready for reopening the facility was addressed by moving staff to the acute side to ensure salaries and livelihoods were maintained.


The next four months involved meetings with the California Department of Public Health (CDPH) to navigate the regulatory and political back and forth of negotiations and demonstration of trust and leadership, to assist this organization to get back on a path to recertification. After four months, the organization was allowed to admit three patients. The last six months of 2016 was used to revise systems and educate staff from the basics to the complex.

Education provided and new systems were put in place to:

  • Establish an ongoing sustainability audit for medication errors to ensure documentation was complete shift by shift;
  • Implement a fall risk program;
  • Establish a wound and skin care program that generated updates to the plan of care weekly along with correlating documentation;
  • Laboratory tracking system to force documentation and checks along the chain of events from order to MD notification and re-order;
  • A quick look reference binder of all high frequency procedures for caregiver staff that distills massive knowledge into functional pieces;
  • Required and needed education over a six-month period on abuse, procedures, documentation, etc. that has filled five 3-inch binders.

However, the most important step was to identify a new Director of Nursing (DON) and provide the requisite training and role modeling to ensure a sustainable plan of correction and the leadership required, should this facility be recertified. Our consultant participated in selecting an ICU nurse from the facility and working diligently with her, side by side, to address issues and train her in both the regulatory and administrative responsibilities that come with the role of the DON.


In late December 2016, CDPH showed up for an unannounced certification survey. The new DON was on site, and although Rockwell was on vacation for the Christmas holiday, she got on the phone to provide coaching. On December 29, 2016, good news was received when it was learned that the facility passed its survey. It is a tribute to the excellence of Wipfli/HFS’s consulting staff that the newly installed DON was able to lead her first-ever survey, and the outcome for the facility and the community was Medicare recertification. It is not often that such an opportunity occurs to bring a facility back to life. It was a significant milestone and success for Wipfli/HFS consultants in California.


For information on our clinical operations practice, including work with critical access hospitals, please contact Gwynn Smith at 510-768-0066, or

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