DEPARTMENT OF HEALT H & HUMAN SERVICES

Centers for Medicare & Medi caid Services

Western Di vision of Survey and Certifi cation
Denver Regional Offi ce
196 1 Stout Street, Room 08-148
Denver, CO 80294\

CENTERS FOR MEDICARE & MEDICAID SERVICES

Refer to: WDSC-R8-kh

Send via Email: duane.marcellais@ihs.gov

Send via Fedex: Tracking Number 7757 4209 1865
CMS Certification Number: 430084
TERMINATION NOTICE-PLEASE READ CAREFULLY
March 1, 2016
Duane Marcellais, Acting Administrator
Rosebud Indian Health Service Hospital
POBOX400
400 Soldier Creek Road
Rosebud, SD 57570

Re: Involuntary Termination of Rosebud Indian Health Service Hospital: Effective

March 16, 2016
Dear Mr. Marcellais:
The Centers for Medicare & Medicaid Services (CMS) notified you, by a letter dated December
4, 2015 (see attached), of our intent to terminate Rosebud Indian Health Service Hospital at 400
Solider Creek Road, Rosebud, SD 57570. This letter is to notify you that in accordance with 42
CFR 489.53(a), the Secretary of the Department of Health and Human Services has imposed a
mandatory termination of Rosebud Indian Health Service Hospital ' s provider agreement based
on failure to attain compliance with the Conditions of Participation (CoP) requirements. As
indicated in the February 12, 2016 letter (see attached) extending the termination date, this
involuntary termination is effective: March 16, 2016.
The Social Security Act Section 1866(b)(2) authorizes the Secretary to terminate a hospital ' s
Medicare provider agreement if the hospital no longer meets the regulatory requirements for the
hospital. On November 16-19, 2015, federal surveyors completed a recertification survey at
your facility. CMS informed you on November 23 , 2015 (see attached), that condition level
deficiencies posed an immediate and serious threat to the health and safety of patients
(Immediate Jeopardy). The Immediate Jeopardy was abated on December 11 , 2015 (see
attached).
On February 9-12, 2016, federal surveyors conducted a revisit survey and cited ongoing noncompliance with CoPs at the completion of the revisit (see attached 2567). This termination is
based on the findings reflected in the attached 2567, including but not limited to the following
CoPs:

1. 42 CFR 482.12 Governing Body (A0043)

2. 42 CFR 482.21 QAPI (A0263)
3. 42 CFR 482.22 Medical Staff (A0338)

Duane Marcellais, Acting Administrator

Rosebud Indian Health Service Hospital

4.
5.
6.
7.

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42
42
42

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CFR 482.23 Nursing Services (A0385)

CFR 482.24 Medical Record Services (A0431)
CFR 482.41 Physical Environment (A0700)
CFR 482.55 Emergency Services (AllOO)

Based on the continued non-compliance from a survey cycle beginning on November 19,
2015, CMS has involuntarily terminated the provider agreement with Rosebud Indian Health
Service Hospital. As a result of the serious nature and circumstances of this involuntary
termination, should Rosebud Indian Health Service Hospital desire to re-enter the Medicare
Program as a provider of hospital services, Rosebud Indian Health Services must provide
CMS with reasonable assurance of its capacity to maintain compliance with the Medicare
requirements for certification, as provided for in the Social Security Act 1866 (c) (1) and in
regulation 42 CFR 489.57.
As communicated to you in CMS' notification to Rosebud Indian Health Service Hospital,
dated December 4, 2015, the Medicare program will not make payment for covered hospital
services furnished to patients whose plan of treatment was established on or after the
termination date. For Medicare patients whose plan of treatment was established prior to
March 16, 2016, payment for covered services may be made for up to 30 calendar days after
the date of termination. (See 42 C.F.R. 489.55(a)).
Termination of your participation in the Medicare program will also result in termination of
your Medicaid agreement. CMS is forwarding a copy of this letter to the South Dakota
Medicaid State Agency. CMS is also sending a copy of this letter to the Medicare
Administrative Contractor, Novitas Solutions, Inc. You should contact that office to make
arrangements for filing a final cost report, in the event that you have admitted and billed for
any Medicare patients.
Appeal Rights
Ifyou disagree with the findings ofnoncompliance cited in the survey conducted
February 9-12, 2016, you or your legal representative may request a hearing before an
administrative law judge ofthe Department ofHealth and Human Services, Departmental
Appeals Board. Procedures governing this process are set out in Federal regulations at
42 C.F.R. 498.40, et seq. You must file the hearing request electronically by using the
Departmental Appeals Board's Electronic Filing System (DABE-File) at
https://dab.efile.hhs.gov no later than sixty (60) days from the date ofreceipt of this letter.
Also, you must send a complete copy of the hearing request, all written communications
concerning this survey and any other supporting documentation to Linda Bedker RN,
MN, MPH, CAPTAIN, U.S.P.H.S., Manager; Certification and Enforcement Branch;
Centers for Medicare & Medicaid Services; Denver Regional Office; 1961 Stout Street,
Room 08-148; Denver, Colorado 80294, or via email to
Linda. Bedker@cms.hhs.gov
Requests for a hearing submitted by U.S . mail or commercial carrier are no longer
accepted as of October 1, 2014, unless you do not have access to a computer or Internet

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Duane Marcellais, Acting Administrator

Rosebud Indian Health Service Hospital

Page

service. In those circumstances you may call the Civil Remedies Division to request a
waiver from e-filing and provide an explanation as to why you cannot file electronically or
you may mail a written request for a waiver along with your written request for a hearing.
A written request for a hearing must be filed no later than sixty (60) days f rom the date of
receipt of this letter, to the Department ofHealth & Human Services; Departmental
Appeals Board, MS 6132; Director, Civil Remedies Division; 330 Independence A venue,
S.W.; Cohen Building-Room G-644; Washington, D.C. 20201; (202) 565-9462.
A request for a hearing should identify the specific issues and the findings of fact and
conclusions of law with which you disagree. It should also specify the basis for
contending that the findings and conclusions are incorrect. You may be represented by
counsel at a hearing at your own expense.
If you have any question regarding this matter, please contact CDR Kimmine Hudson at (303)
844-7127, email: kimmine.hudson@cms.hhs.gov.

Sincerely,

~
ic~
Associate Regional Administrator
Western Division of Survey and Certification

Enclosures:
23 day Termination-U (November 23 , 2015)
IJ Abated (December 11 , 2015)
90 day Notice Intent to Terminate (December 4, 2015)
Extend Termination Date (February 12, 2016)
CMS FORM 2567 (February 22, 2016)
Copies via e-mail to:
[HS Great Plains Area Office
South Dakota Department of Health, Office of Health Care Facilities, Licensure & Certification
Novitas Solutions, Inc
CMS Denver Regional Office, SB & CEB
CMS Denver Regional Office, Office of the Regional Administrator
Office of the General Counsel, Denver Office
CMS Denver Regional Office, Medicaid Program Management Branch
CMS Denver Regional Office, Medicaid Financial Management Branch

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