Compliance committee told Nashville General expects CMS Form 2567 in mid‑February; meeting proposed to review plan of correction
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Summary
Nashville General Hospital’s chief compliance officer told the compliance committee two major health‑facility surveys reduced immediate‑jeopardy findings to conditional findings and that the hospital expects the CMS Form 2567 between Feb. 10–15; committee members were asked to meet Feb. 25 to review a plan of correction ahead of the full board meeting.
The Compliance Committee of the Hospital Authority Board heard an update from Chrissy Lewis, chief compliance officer for Nashville General Hospital, that the hospital expects to receive the official CMS Form 2567 (Statement of Deficiencies and Plan of Correction) between Feb. 10 and Feb. 15 and will have 10 calendar days from receipt to file a response.
"We are waiting for the official Form 2567," Lewis said, and added that the organization had worked to lower initial "immediate jeopardy" findings to conditional findings through “perseverance, diligence, and hard work.” She asked the committee to be prepared to consider recommendations tied to the plan of correction when that Form 2567 arrives.
The board chair proposed scheduling a special meeting of the compliance committee on Feb. 25 so members could review the Form 2567 and the hospital’s recommended plan of correction, then present findings and any recommendations to the full board at the board meeting on Feb. 26. The chair asked staff member Janet to confer with committee members about the best time for that meeting; the proposal was described as a scheduling recommendation in the committee meeting, not recorded as a formal, adopted motion in the transcript.
Doctor Elders clarified the timeline of state surveys during the discussion. "We have been talking about an ongoing Tennessee Department of Health survey that started August 18. It exited officially November 26. There was an additional survey on December 1 that exited January 7. There was a revisit on January 13 that exited January 23," he said, and asked that those dates be recorded in the minutes for clarity.
Earlier in the meeting the chair asked whether there were any conflicts of interest; none were disclosed, and the committee approved the minutes from the October meeting by voice vote. With no other business recorded, the committee moved and seconded an adjournment.
No public comments were recorded. The committee noted that formal standing reports would be presented at a later compliance meeting because of time constraints during this session.
What comes next: the hospital expects the Form 2567 to arrive in mid‑February; once received the hospital will have 10 calendar days to respond and the committee plans to meet to review the response and any recommended corrective actions before the full board vote or endorsement.
