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An Important Message from Our CEO

  • Category: News
  • Posted On:
  • Written By: Gary Herbst

We take our responsibility to protect the health and safety of our patients very seriously. Part of that responsibility is self-reporting any event, preventable or non-preventable, that caused harm at Kaweah Health. We recently reported two unrelated incidences of drug diversion (when prescription drugs are obtained or used illegally) that were discovered back in December 2020 and January 2021 to the California Department of Public Health (CDPH). Our reporting triggered an unannounced Complaint Validation Survey in March by the Centers for Medicare & Medicaid Services (CMS).

Unfortunately, and sometimes very sadly, addiction to alcohol or drugs and diversion of drugs for personal use are far too common across our healthcare industry. While being a healthcare professional can be a highly-rewarding and gratifying career choice, it also comes with a great deal of complexity, challenge, stress and hard work--all factors that can lead or contribute to addictive behaviors. According to USA Today, “Across the country, more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction, mostly involving narcotics. What sets doctors and nurses apart from other professionals is their accessibility to highly sought-after drugs”.

The two incidences I reference above involved two beloved members of our Kaweah Health healthcare team—a physician and a non-physician employee of a contracted medical group. Each of these individuals diverted drugs for their own personal use. While our investigation revealed that no harm came to any of our patients because of these drug diversions, the non-physician member of our team died from an overdose of diverted medication. We still greatly mourn his death and miss him terribly.

In May, we received a Statement of Deficiencies report (Form 2567) from CMS, detailing their findings, observations and deficiencies identified during their survey of Kaweah Health. This report is deeply disappointing because it describes activities and behaviors that do not meet our performance standards or expectations for patient safety. While we do have robust systems in place to prevent and detect drug diversion, the surveyors found that we did not consistently follow our established practices and policies. It is our responsibility to learn from these mistakes and make sure they do not happen again. In June, we submitted our formal Plan of Correction (POC) to CMS, which details the steps we have taken to correct the deficiencies. CMS accepted our plan yesterday.

Our organization is committed to providing the highest level of safety and care possible to our patients, our employees, our providers and our community. We received the surveyors and their subsequent report with the utmost seriousness and worked tirelessly with experts from across the country to address each and every one of their findings and concerns. Immediately upon discovery of the drug diversion events back in December and January, and over the past several months and in the weeks to come, we have, and will have, implemented extensive process and practice changes. We have also developed new and revised existing policies; rolled out extensive education and training to staff and practitioners; created and implemented new auditing tools and processes; and raised the overall consciousness of Kaweah Health when it comes to matters of impairment, addiction and diversion.

One of our organization’s foundational pillars is “Empower through Education”. As such, we are in constant pursuit of knowledge, skill, and adherence to best practices and we view this survey and its results as a learning opportunity for us. We also have developed a greater awareness of how our healthcare professionals are at greater risk of developing addictive behaviors. Finally, I encourage anyone reading this who is struggling with addictive behaviors, to please, get help by calling the County’s 24-hour Alcohol & Other Drug Substance Use Disorder Access Line at 1-866-732-4114.