A government agency’s recent decision to cut off Medicare and Medicaid payments to the Indian Health Service hospital in Pine Ridge was motivated by the case of a patient who died the day after being brought to the hospital’s emergency department, according to documents released to the Journal.
The documents, released Monday, say the diabetic male patient was brought to the hospital by ambulance at 12:22 p.m. Oct. 16 with high blood sugar.
“He is moaning but denies pain at this time,” says a quote in the documents from the hospital's triage assessment. “He is difficult to understand what he is saying, his mouth and gums are dry and there is dried blood on his tongue.”
A review conducted by the Centers for Medicare and Medicaid Services found that the hospital inaccurately assessed the patient’s Emergency Severity Index level. This allegedly led to an inaccurate determination of the severity of the patient’s condition, which in turn resulted in delays in the patient’s medical screening exam, all of which postponed appropriate emergency care and treatment.
About 4½ hours after being admitted, the patient was transferred to another hospital, which is not named in the documents. The patient underwent surgery at that other hospital the next day, Oct. 17, where he was diagnosed with extensive small bowel ischemia and necrosis. The patient died sometime that day.
In a Nov. 6 letter to the Centers for Medicare and Medicaid Services, Michael Toedt, chief medical officer for the Indian Health Service, defended the hospital’s actions and said the Centers for Medicare and Medicaid Services omitted significant details from the review of the case.
“The patient’s condition was improved on arrival to the tertiary care center due to the actions and treatment initiated at Pine Ridge Hospital,” Toedt wrote. “Many factors could contribute to the patient’s outcome, including comorbidities and care in another facility, and it is not possible to draw a direct conclusion from the care received at Pine Ridge Hospital to the patient’s ultimate outcome.”
Comorbidities are the presence of additional diseases or disorders with a primary disease or disorder.
The Centers for Medicare and Medicaid Services issued a notice Friday that the hospital’s participation in the federal Medicare program will end Nov. 18. That means the hospital will no longer be able to bill the government for services provided to Medicare-enrolled patients, and Medicaid payments will also be cut off.
Members of the Oglala Sioux Tribe on the Pine Ridge Reservation are provided with health care by the federal government pursuant to longstanding treaties and court decisions. The Indian Health Service has funding from Congress to provide that care, but the IHS obtains additional funding by enrolling qualifying Native American patients in Medicare and Medicaid. Medicare is a federal health-care insurance program for people ages 65 and over and for the disabled. Medicaid is a federal-state program that helps pay for health care for the needy, aged, blind and disabled, and for low-income families with children.
The Pine Ridge hospital has suffered negative inspection findings in the past and has recently been bound by the terms of an improvement agreement that it struck with the Centers for Medicare and Medicaid Services in April 2016. The hospital was inspected for compliance with that agreement April 24-27 of this year, when violations of four Medicare standards were found. A re-inspection July 24-27 found a violation of one standard.
Another re-inspection — this one described in the documents as unannounced — was conducted Oct. 17-19, and violations of one standard were found. According to language in Toedt’s letter, the findings associated with the diabetic patient who died were the basis of a finding of “immediate jeopardy” for the facility, resulting in the impending termination of the hospital’s participation in Medicare.
A letter from the Centers for Medicare and Medicaid Services to the hospital says the hospital may request a hearing before an administrative law judge with the Departmental Appeals Board of the U.S. Department of Health and Human Services. The deadline to file a request is 60 days from the receipt of the Nov. 3 letter.
The Centers for Medicare and Medicaid Services also said in its notice of termination for the Pine Ridge hospital that the federal agency is "closely monitoring the relocation of Medicare and Medicaid patients to other facilities."
It has a name, the 400-foot tall, 500-ton crane looming over the west Rapid City skyline and doing the heavy lifting for a $90 million expansion project continuing at the GCC Dacotah Cement Plant.
Plant general manager Steve Post said the crane, being used to build a second tower that will boost the plant’s cement production capacity, is one of just 12 such cranes worldwide and one of five in the U.S.
The massive crane has enticed curious spectators to drive onto plant property to watch it in action, an activity Post would like to curtail, but he understands the interest.
“It’s the single largest crawling crane made anywhere,” Post said. “It’s impressive to see and it’s impressive to watch how they use it.”
The crane was transported in pieces to Rapid City in 38 semitrailers and required more than 3-1/2 weeks to assemble, he said.
The crane even has a nickname, thanks to a plant employee contest, which drew more than 50 entries mostly centered on the massive machine’s red paint job.
In the end, Pluma Roja, Spanish for “Red Feather” was chosen, Post said. The name reflects the ownership of the plant since GCC Dacotah is part of GCC of America Inc., a division of Mexico-based Grupo Cementos de Chihuahua.
The tower is used to heat aggregate, ground and filtered to the consistency of fine flour, to 2,650 degrees.
Heat is supplied by burning low-sulfur Powder River coal from Wyoming, with natural gas also used as an additional fuel. Post said biomass, scrap tires and other solid waste are being investigated as potential alternative fuel sources for the plant.
Once the expansion is complete, the plant’s annual production capacity will increase from 830,000 tons to more than 1.25 million tons.
Demand for cement is expected to rise 3 percent a year through 2024, Post said.
The plant was founded as the state-owned South Dakota Cement Plant in the 1920s and sold into private ownership in 2001. South Dakota’s Board of Economic Development is assisting GCC Dacotah’s upgrade with a rebate of up to 60 percent of the sales and use taxes paid as part of the project cost.
The amount of the anticipated rebate is about $1.6 million, which will be paid through the state’s Reinvestment Payment Program.
The overall project is progressing very nicely, Post said. Targeted completion date is near the end of the second quarter of 2018, dependent on several factors, including weather.
“You gain ground one week and the next there’s a few things we fall behind on," he said. "Overall everything is on track."
PIERRE | Gov. Dennis Daugaard has announced he will appoint Don Kirkegaard of Sturgis to serve as South Dakota secretary of education.
Kirkegaard, 59, is currently the superintendent of the Meade School District. He also serves as president of the South Dakota Board of Education Standards. He will resign from both positions to become secretary.
“Don Kirkegaard is a leader in education in South Dakota, and I thank him for taking on this role,” said Daugaard. “With his years as a school administrator and his service on the State Board of Education Standards, he will be an able leader for the state department.”
Kirkegaard has been superintendent in the Meade School District since 2011.
Courtney Mack, Meade School Board president, said Daugaard spoke with her and board vice president Mike Issacson about the appointment on Thursday.
"The governor said Don wanted the board's support before he would say 'yes' to taking the position," Mack said. "Don said he wouldn't go unless he had 100 percent support from the board."
The board, in a special executive session meeting Monday afternoon, gave Kirkegaard its approval, which means the school district must now find an interim superintendent to fill out the remainder of the school year.
"I think it's a loss for the Meade School District but a win for the whole state," Mack said.
Kirkegaard will begin his new job Jan. 1. He succeeds Melody Schopp, who will retire Dec. 15. Mary Stadick Smith, the department’s deputy secretary, will serve as acting secretary during the interim.
As for what he wants to accomplish as secretary, Kirkegaard said he wasn’t certain about the governor’s agenda beyond the current emphasis on workforce development.
He wants to be a sounding board for his colleagues and a good spokesman for the governor and the department.
But before he leaves Sturgis, he needs to find a new principal for the Sturgis middle school. “It will be a busy time,” he said.
A number of city fee increases moved forward Monday night at the Rapid City Council meeting. Now, it’s up to a few area citizens to see if a final decision will ultimately be made by the public.
The increases include changes in rates for the city’s water, pools, golf courses, cemetery, ice rink, parks, construction permits and ambulance services.
At the meeting’s outset, a resolution to raise the city’s fees for a plethora of services drew concern from Lane Johnson, president of the G.R.E.A.T. Swimming and Rapid City Racers swimming clubs. Johnson explained that the new lap lane rates — which will rise from $7 per hour per lane to $8 — will cost his nonprofit organization an additional $2,000 in 2018 compared with 2017.
Over the past five years, those rates have risen 88 percent, Johnson added.
Doug Lowe, the city’s recreation division manager, then explained that the service and fee rate increases were based on the city’s research of regional, state and national averages for each service and for the overall rate of recovery for each department. For example, the city’s Aquatic Department’s average rate of recovery is 47 percent, Lowe said, meaning the fees people pay to use the facilities cover about 47 percent of the cost to operate the facility.
The remaining 53 percent is covered by general fund monies collected from all Rapid City taxpayers. The national rate of recovery average for aquatics departments is 50 percent. The other increases were based on the same type of calculations, Lowe said.
Other increases in the resolution include the doubling of the fee for construction permits from $75 to $150 for a property between one and five acres and from $100 to $200 for properties larger than five acres. Ambulance rates will also rise from $11.83 to $13.50 per mile of transport and from $150 to $200 for any event requiring a stretcher or hospice visit.
Those fees are in line with the city’s cost of providing the service and the reimbursement provided by Medicare, according to Public Works Director Dale Tech and Rapid City Fire Chief Rod Seals.
Who pays the tab?
Other fees increasing under the new resolution include ones for using the city’s parks, ice rink, golf courses and cemetery, with Lowe estimating the rise at about 5 percent across the board.
Alderman Steve Laurenti boiled down the debate on the matter to the question of who pays for the facilities: users or taxpayers?
“That’s what we’re really talking about,” Laurenti said, adding that users should pay their way to use the facilities.
The resolution was approved, 8-2, with Alderwoman Lisa Modrick and Alderman Ritchie Nordstrom in opposition.
At the council’s Oct. 16 meeting, the same resolution but without the new fee structure was approved when it was amended to incorporate the city’s new rates for water and wastewater usage.
Monday night, though, the water rate hikes — which will cause an average Rapid City household’s water bill to rise by 43 percent over the next five years — were finalized for 2018 when the council approved amendments to two city ordinances that cleared the old water and wastewater rates from the city’s codes. The vote, 8-2, saw Alderman John Roberts and Alderwoman Becky Drury in opposition.
The extra public hearings required of ordinances — resolutions require two public hearings and one city council approval while ordinances require four hearings and two city council approvals — gave some local citizens, most notably Tonchi Weaver of Citizens for Liberty, a chance to voice their frustration with the rate hikes.
Weaver took issue with putting the new rates and fees into a resolution instead of an ordinance, given the lower public hearing and council approval requirements. The council’s “Policies and Procedures” handbook labels resolutions as “any determination, decision or direction of the governing body of a municipality of a special or temporary character ...."
“Water utilities are not special, out of the ordinary or temporary, and I think that is actually kind of sneaky to want to do these rate adjustments through resolutions,” Weaver said.
City Attorney Joel Landeen countered that the fees were incorporated into one resolution for clarity and ease of access, and conceded that part of the reason was also to make it easier to change rates. In the past, Roberts later added, the difficulty of changing ordinances may have prevented the water rates from rising, which hasn’t occurred since January 2013.
At the prodding of Alderman Chad Lewis, Tech then explained that the city’s Mountain View water treatment facility will need to be replaced in the near future, requiring that the city begin to build up its reserves in case of an emergency or ahead of any project to build a new facility.
“I would classify it today as functionally obsolete,” Tech said, adding that the facility was built in the 1960s and finding replacement parts when something broke was nearly impossible. “We can keep it limping along, but there will come a point when it becomes unserviceable.”
The rate hikes are to cover the increased operating and maintenance costs associated with the city services and to raise the city’s water reserve and wastewater reserve funds. The city hopes to raise the water fund to $6.6 million and the wastewater fund to $4.5 million by 2022. Currently, they are at about $2 million and $159,000.
Drury and Robert’s main contention was that the increases should be spread over a longer period of time to reduce the impact on people with fixed incomes.
But the council’s final say on the matter may not be so final after all.
“We are ready with petitions,” said Weaver at the end of her comment on the matter.
Ride-hailing ordinance moves forward
Later in the meeting, the council approved an amended ordinance crafted to regulate the incipient arrival of the ride-hailing industry to Rapid City. The ordinance, which will come before the council again on Nov. 20 for final approval, was approved unanimously.
Within the proposed amendments to an ordinance originally written to regulate the city’s taxicab businesses, companies such as Lyft and Uber, or as the city calls them, “transportation network companies,” would be required to apply for a license from the city before beginning operations. The aforementioned resolution altering certain fees for city services also includes a new $1,500 fee that must be paid annually by TNCs operating within city limits.
Individual drivers will not be required to apply for a license or pay any fees to the city, but information including the driver's name, proof of insurance, active vehicle registration and a background check are required by Lyft from prospective drivers hoping to join its fleet. Any problems with drivers will be addressed by the TNC, not the city. The ordinance prohibits accepting cash payments and picking up passengers attempting to hail taxis without using the transportation network company’s digital network.
If it moves forward without delay, the ordinance could take effect as soon as late December, city spokesman Darrell Shoemaker said. Lyft officially launched across South Dakota on Oct. 24.
“This ordinance is a win for (Rapid City),” said council president Jason Salmun during a brief discussion of the ordinance. “One for public safety. Two, this helps fill the gaps in our transportation network.”
Lewis added that the potential for reducing drunken driving, traffic and parking issues in the downtown area were just a few more reasons to support the measure.
“I’d like to welcome Rapid City into the 21st century,” he said.
In other action, council members:
• Approved the addition of a one full-time employee to the Rapid City Police Department as body-camera technology is implemented across the department for patrolling officers. The Police Video Evidence Technician, as the position is called in RCPD documents, will manage the storage and retrieval of digital video evidence captured by officers' cameras. The recently awarded Department of Justice grant to RCPD and the Pennington County Sheriff’s Office will cover the first two years of the employee’s salary —between $41,677 and $62,797 — RCPD Chief Karl Jegeris said at a committee meeting last week. At the end of the two-year period, Jegeris said, the department plans to absorb the position into its Records Division and cut an employee from the division, meaning the department would not need to request additional funds once the grant money is spent.
• Approved salary raises for nonunion city employees in 2018. Salaries for nonunion employees between steps 1 and 17 will see a 2.5 percent raise while employees between steps 18 and 33 will receive a 1.25 percent raise. Cost-of-living raises will be 25 percent of the city’s sales tax percentage growth for 2017 with a minimum of 0.5 percent and maximum of 2.5 percent.
• Acknowledged the city’s sales tax collections for the month of August, which came in at $2,345,429, a 2.17 percent increase compared with collections in August 2016. For the first eight months of 2017, collections are up 1.7 percent compared with 2016, at $16,712,117.
• Approved a $370,000 project to improve three separate sections of the city’s winding bike path. The work will include resurfacing and regrading a quarter-mile stretch behind Cleghorn Fish Hatchery at 4725 Jackson Blvd., repaving a portion of the route just west of the Central States Fairground and Lacrosse Street, and rerouting the path just west of Billion Auto - Kia at 1400 Cambell St. The rerouting will be completed after work is finished to stabilize the eroding bank of Rapid Creek behind Billion Auto.