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Posted by: John_Hamilton on 03/30/2012 08:43 AM
Updated by: John_Hamilton on 03/30/2012 08:43 AM
Expires: 01/01/2017 12:00 AM
:
Calaveras County Grand Jury Interim Report
San Andreas, CA...The Interim Calaveras County Grand Jury report that centers on recominded changes in Mark Twain Healthcare District Board communications and transparency. The complete report is enclosed...
MARK TWAIN HEALTHCARE DISTRICT
REASON FOR INVESTIGATION
Penal Code Section 925 states in part “… investigations may be conducted on some selective basis each year.” The Grand Jury decided to investigate the Mark Twain Healthcare District due to publicity in the Calaveras Enterprise of turmoil and discord within the healthcare system of Calaveras County.
PROCEDURES
The Grand Jury began their investigation by acquiring the following public documents:
1. Minutes of the Mark Twain Healthcare District Board meetings for the years 2010 and 2011
2. All leases between the Mark Twain Healthcare District, the Mark Twain St. Joseph’s Healthcare Corporation and Catholic Healthcare West
3. The Mark Twain Healthcare District Bylaws
4. The annual independent audits for the Mark Twain Healthcare District for the years 2009 and 2010. The Grand Jury also requested the “Management’s Discussion and Analysis” (MD&A) for those audits. The Chief Financial Officer said they were unavailable because they were not done for those years even though the inclusion of MD&A is accepted practice for annual audits.
5. The 2005 LAFCO report on the Mark Twain Healthcare District. The Mark Twain Healthcare District could not locate their responses to the recommendations made in that report.
6. The 2010 Tax Return for the Mark Twain St. Joseph’s Healthcare Corporation, which operates the Mark Twain St. Joseph’s Hospital in San Andreas, CA.
The following interviews were conducted:
1. All five members of the Mark Twain Healthcare District’s Board of Directors
2. Three members of the Mark Twain St. Joseph’s Healthcare Corporate Board
3. The CFO of Mark Twain St. Joseph’s Hospital and the CFO of Mark Twain Healthcare District Board; the same person serves as CFO of both
4. Physicians who have left Mark Twain St. Joseph’s Hospital in the last two years as well as those who still practice there
Members of the Grand Jury observed regular monthly meetings of the Mark Twain Healthcare District Board that were open to the public. One meeting was a joint session of the Corporate Board and the District Board. Also present at the joint meeting was the attorney of record for each board.
BACKGROUND
HISTORY OF THE MARK TWAIN HEALTHCARE DISTRICT AND HOSPITAL
• In 1945 the Healthcare District Law was passed by the State of California.
• By 1946, in a special election, the Mark Twain Hospital District was formed. The first Board of Directors was appointed by the County Board of Supervisors.
• In l947 the hospital was proposed at the first joint meeting of the new Mark Twain Hospital District Board (District Board) and the County Board of Supervisors.
• In 1948 a bond issue was passed by county voters to start building Mark Twain Hospital.
• In 1951 Mark Twain Hospital was finished and dedicated. The first patient was admitted on September 9th.
WHAT VOICE DID THE VOTERS HAVE BACK THEN?
Since 1946 the members of the District Board have been elected by the voters of Calaveras County to four year terms. The elections are staggered every two years to maintain continuity. The hospital administration was handled through public meetings of the District Board. Any concerned voter could go to the District Board for redress. Until 1990 the voters of Calaveras County had some oversight of the hospital through their elected officials on the District Board.
MARK TWAIN HOSPITAL GROWS
By 1990 small independent hospitals found it almost impossible to function on their own. To provide quality medical care they needed to join with other health care systems. The Mark Twain Hospital District, now called the Mark Twain Healthcare District, formed a partnership with St. Joseph’s Regional Healthcare System in Stockton. This partnership with a private non-profit corporation became the Mark Twain St. Joseph’s Healthcare Corporation we know today.
In 1997 St. Joseph’s Hospital became a part of the Catholic Healthcare West (CHW) system, known today as Dignity Health, instead of an independent “stand alone” hospital. As part of that change, a separate contract was made between the Mark Twain St. Joseph’s Healthcare Corporation and Catholic Healthcare West to provide senior management including Chief Executive Officer (CEO) and Chief Financial Officer (CFO). CHW also managed the day-to-day operations of the hospital and its related services.
HOSPITALS HAVE “LICENSED BEDS”
By 1997 the Mark Twain St. Joseph’s Hospital was licensed for 48 beds. A “licensed bed” does not refer to a real bed. A “licensed bed” is a legal term that gives the hospital the right to admit a patient and provide all the services necessary during their hospital stay. A hospital with 48 “licensed beds” may choose to keep some of those beds in reserve until needed.
If a hospital decides they need additional beds, they must apply to government agencies. No beds are possible without a license. It is a lengthy and complex process.
WHERE DID THE HOSPITAL’S “LICENSED BEDS” GO?
In 2010 the Corporate Board decided to give up 23 of those 48 “licensed beds” to receive a better financial reimbursement from government health insurance. This allowed the hospital to become a Critical Access Hospital. The title of Critical Access Hospital may only be applied for by small rural hospitals with no more than 25 “licensed beds”. A Critical Access Hospital sounds very important but changed the hospital very little. The hospital still sees the same kind of patients they have always seen but the length of time a patient stays in the hospital is now determined by government regulations, which limit how many “licensed beds” this kind of hospital may have. If the hospital wants to return to a 48 bed facility, it must reapply for those 23 beds. Applying to increase the number of “licensed beds” may or may not be granted and the process takes about a year to complete.
WHERE DID OUR HOSPITAL'S DOCTORS GO?
During the years 2009 and 2010 a number of physicians, who had privileges to care for their patients in the hospital, left Mark Twain St. Joseph’s Hospital. The physicians who were interviewed by the Grand Jury left due to conflicts with management over concerns about the quality of patient care. They indicated recent changes by hospital management involving patient care and operational procedures were their reasons for leaving. The physicians felt they no longer had any substantive input in the daily running of the hospital. They stated that they left after trying every avenue within the system to solve the problems they faced.
WAS ANYONE AWARE OF THESE PROBLEMS AS THEY WERE HAPPENING?
Based on conducted interviews, the hospital senior management was aware of the physicians’ concerns as they were happening. When the physicians were unable to have a constructive dialog with senior management through procedures outlined in the Medical Staff bylaws, they tried to approach the Mark Twain St. Joseph’s Healthcare Corporate Board. The physicians were told by the Corporate Board that they could not have access to the Board directly but must go through senior management instead. Several physicians then went to the District Board but were told that it was the senior management who were responsible for resolving those issues. The Mark Twain District Board believed they had no “right” to an opinion about anything that happens within the hospital or the Corporate Board. Having no other avenue, the doctors left looking for places to practice where their concerns would be heard.
ACCESS TO THE MARK TWAIN HEALTHCARE DISTRICT BOARD
In July 2011 the Grand Jury made multiple attempts to locate the names of current elected members of the Mark Twain Healthcare District. They first tried to find a website for the District but could not find one. Next, they tried to find information on District Board members on the official Calaveras County website and none was available. A phone call to the Local Agency Formation Commission (LAFCO) located a few names of members who were no longer on the District Board. The Grand Jury then telephoned the Calaveras County offices looking for a contact person for the District Board. They were given the name, phone number and address of a secretary. The address was the Mark Twain St. Joseph’s Healthcare Corporate Office. The Grand Jury subsequently discovered that the Mark Twain Healthcare District did not and still does not have a separate office. The Mark Twain Healthcare District uses the same office as the hospital administration and Corporate Board. The Grand Jury contacted the secretary and received the names of the District Board members.
It was discovered that the required public notices of District Board meetings and agendas were only posted on the bulletin board in the hallway of the administrative portion of the hospital outside the Corporate and Administration offices.
WHAT VOICE DO VOTERS HAVE IN CALAVERAS COUNTY HEALTHCARE?
It needs to be noted here that the District Board members are still elected by the citizens of Calaveras County every four years and the District is still charged with the responsibility to levy taxes to support healthcare in the county.
Mark Twain St. Joseph’s Healthcare Corporation is a private non-profit corporation whose board meetings are not open to the public. They do not answer to the District Board and are not subject to the Healthcare District's bylaws.
HOW DOES THE MARK TWAIN ST. JOSEPH’S HEALTHCARE CORPORATE BOARD CHOOSE ITS MEMBERS?
The current Corporation bylaws specify that their board will be made up of eight members. The membership is comprised as follows:
• Two (2) from the Catholic Healthcare West organization
• One (1) citizen from the County chosen by Catholic Healthcare West
• One (1) citizen from the County chosen by Mark Twain Healthcare District Board
• Two (2) who can be either District Board members or citizens of the County
• One (1) citizen from the County chosen by the above six members of the Corporate Board
• One (1) Chief of Staff (physician) who is elected by the Medical Executive Committee of the hospital
The three members chosen by the District Board serve only as long as the Corporate Board’s bylaws permit. The District Board members who represent the voters can be removed anytime the Corporation changes its bylaws to exclude them.
It is the Corporate Board's bylaws that control the makeup of the Corporate Board. This private non-profit corporation is not accountable to Calaveras County voters. The Mark Twain Healthcare District Board members are elected by and accountable to the voters.
The Corporate Board meetings are private and what goes on is not made public unless a statement is issued. The Brown Act may or may not apply to these meetings.
The Calaveras County voters have a voice in how their hospital is run as long as the Corporate Board allows the three members of the Mark Twain Healthcare District Board to sit on the Corporate Board.
In 2019 the future of healthcare in Calaveras County will be decided for our citizens. This is the year the partnership contract runs out between Catholic Healthcare West, the Mark Twain St. Joseph’s Healthcare Corporation and Mark Twain Healthcare District. A new arrangement between the parties will be constructed or new partners will be chosen.
RESULTS OF THE INVESTIGATION
Finding 1
The Mark Twain Healthcare District Board has had a limited turnover in its elected members. Since there are no term limits it is possible for a District Board member to serve for decades if reelected.
Recommendation
The Grand Jury recommends that the District Board incorporate term limits within their bylaws to bring new and fresh perspectives to the board at regular intervals.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
Finding 2
The Mark Twain Healthcare District's office (CEO, CFO, secretarial help, financial committee), website and telephone number are identical to that of the Mark Twain Healthcare Corporation. Even the District Board’s files are archived within the Corporate offices. This has allowed the Corporation to control access to the elected District Board and its records.
Recommendation
The Grand Jury recommends separating the District Board’s office, staff, telephone number, document storage facilities, and website from that of the Mark Twain St. Joseph’s Healthcare Corporation and Senior Management (CHW) of the hospital.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
Finding 3
Information from the private Corporate Board was either incomplete or not communicated to the full District Board until it was too late for the District Board to have any influence even though two elected District Board members sit on the Corporate Board. Since elected District Board members are the legal liaison between the District Board and the Corporate Board, they are responsible for all communication pertaining to public issues on healthcare within the county.
Recommendation
The Grand Jury recommends information move freely and readily in both directions between the District Board and the Corporate Board. Some mechanism should be devised by the boards to assure that this happens such as, but not limited to, Corporate Board meeting minutes being shared with the full District Board.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
Finding 4
The Mark Twain Healthcare District has three seats on the Corporate Board only as long as the Corporate Board’s bylaws read the way they currently do. If the bylaws were rewritten to exclude the District Board’s representation on the Corporate Board, the electorate would lose its voice concerning healthcare in this county.
Recommendation
The Grand Jury urges both Boards to create a structure that guarantees the District Board a place on the Corporate Board regardless of changes in power or personalities.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
Finding 5
The District Board's Financial Committee or their CFO submitted incomplete information to the independent auditors for the annual audit. The Management’s Discussion and Analysis (MD&A) as required by law was never prepared.
Recommendation
All pertinent and legal financial requirements should be followed by agencies handling public funds.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
The Financial Committee of the District Board
The CFO of the District Board
Finding 6
The public has lost confidence in the healthcare provided in the county.
Recommendation
The Grand Jury recommends that the Calaveras County Board of Supervisors receive an annual report from the District Board on the state of healthcare in the county and the hospital. The Management’s Discussion and Analysis (MD&A) portion of the annual independent audit is an overview of the Healthcare District’s financial health and should be included in this annual report. This report should be made public.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
Financial Committee of Healthcare District Board
Board of Supervisors
Finding 7
The Grand Jury finds that the required public notices of District Board meetings and agendas were only posted on the bulletin board in the administrative area of the hospital. Although this minimally meets the requirements of the Brown Act, it limits public access to those notices.
Recommendation
The Grand Jury recommends that the Mark Twain Healthcare District post the date, time and agenda of the District Board meetings in the newspaper and in public places such as the Post Office or Library.
RESPONSE REQUESTED
Mark Twain Healthcare District Board
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