Health Care

Wesley hospital failed accreditation survey, calls follow up ‘exceptionally positive’

Wesley Medical Center in February failed an accreditation survey that health care organizations can use to prove their eligibility to participate in Medicare and Medicaid programs.

The hospital missed the mark on 47 standards during a Feb. 15 assessment conducted by the Joint Commission, resulting in a “preliminary denial of accreditation,” according to an accreditation quality report published on That means surveyors have justification for denying accreditation but the decision can be reviewed and appealed before a final determination is made.

A hospital spokesman said Wesley has addressed all of the problems identified. He called a follow-up survey on April 1 “exceptionally positive.”

The nonprofit Joint Commission, which describes itself as the nation’s oldest and largest standards-setting and accrediting body in the health care industry, has more than 250 standards that address a breadth of issues like patient rights, infection control, medication management and prevention of medical errors.

To receive Medicare and Medicaid certification, a health care organization must pass a survey conducted by a state agency or by a national accrediting organization that has “standards and a survey process that meet or exceed Medicare’s requirements,” according to the Joint Commission’s website. Accreditation through the Joint Commission is voluntary and is awarded to hospitals and some other types of health care businesses for three years. Labs are accredited for two years.

The Joint Commission’s February survey found Wesley’s hospital, 550 N. Hillside, had problems identifying patients at risk for suicide; telling patients about follow-up care and treatment before discharging or transferring them; ensuring orders for medication are “clear and accurate”; maintaining “complete and accurate” patient records; and safely using restraints or seclusion.

It also noted the hospital was out of compliance on standards that address fire safety, hazardous materials and waste, infection prevention and control, and staff competency.

Wesley Healthcare’s market director of marketing and public relations in an emailed response to questions said the hospital learned of “a number of issues that required resolution prior to moving forward with the re-accreditation process” following the Feb. 15 survey.

A follow-up survey on April 1 “found that all of the commission’s initial findings had been successfully resolved,” the marketing director, Dave Stewart, said.

The hospital remains accredited at this time, Stewart said.

But keeping that status relies on a future decision by the Joint Commission.

Wesley’s laboratory goes through a separate accreditation process. It was last accredited in July, according to

“The Wesley Healthcare team took the report very seriously, and has since implemented corrective action plans to fully address each of the commission’s findings,” Stewart wrote in the email, adding that several of the problems “reflected environmental and infrastructure issues.”

“Corrective actions were quickly taken to ensure that our facilities were compliant with Joint Commission standards. Wesley remains an accredited facility by The Joint Commission. Our most recent survey was exceptionally positive, and we are confident that we will move forward with the re-accreditation process without further incident.”

Accreditation decisions usually take two weeks to two months after a survey, a Joint Commission spokeswoman confirmed this week.

She didn’t immediately know the date of Wesley’s follow-up survey or whether one had been conducted when The Eagle asked for that information.

As of Wednesday, the last survey date for Wesley hospital listed on was Feb. 15.

The Joint Commission spokeswoman said the nonprofit’s goal is to identify issues and “give the health care organization a chance to rectify any problems” before the commission makes a final accreditation decision.

Organizations that aren’t in compliance with its standards “have to put a plan into place that says how they’re going to get those met” and then implement them before accreditation is awarded, she said.

The commission awards accreditation to health care organizations that are in compliance with all of its standards during an on-site survey or has addressed problems and improved within 60 days.

A preliminary denial of accreditation decision happens when there’s an immediate health or safety threat to patients or the public, “significance noncompliance” with commission standards, patterns or repeat findings that put patients at risk for “serious adverse outcomes,” false or untruthful statements made, or when a health care organization doesn’t fix problems noted during previous surveys, according to the commission’s website.

It denies accreditation after all opportunities to review and appeal a decision have been exhausted.

Stewart, the Wesley Healthcare market director, said the hospital is confident the preliminary denial “will be reviewed and updated in the near future.”

The last time Wesley hospital had issues was in 2016, when the Joint Commission awarded it accreditation but required a follow-up survey after finding nearly three dozen performance problems.

The hospital received special awards for being a top performer on key quality measures in 2012, 2013 and 2014, according to the Joint Commission’s accreditation quality reports.

“Wesley remains deeply committed to delivering the highest level of quality care to every patient, every time,” Stewart said. “We view this experience as an opportunity to continue enhancing the level of our patient care, operations and facilities.”

You can find information about how a hospital rates at

To see accreditation decisions and accreditation quality reports issued by the Joint Commission, go to

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