RALEIGH, N.C. — Cherry Hospital must undergo a number of organizational and cultural changes before it reapplies for Medicare and Medicaid certification and for state officials to be assured that patient care there is safe.

That's according to a report, obtained by WRAL News, from Compass Group Inc., which the Department of Health and Human Services paid $100,00 to review the state mental hospital.

The independent consulting firm was called in to evaluate Cherry Hospital last month after the Center for Medicare & Medicaid Services revoked the facility's certification, following the death of a patient who died after choking on medication and being left sitting in a chair unsupervised for nearly 24 hours.

Compass Group says in the report that although it does not believe the hospital leadership team should be replaced, it has not demonstrated that it is able to manage change, calling it "overwhelmed by the magnitude" of reversing a problem that has developed over many years.

"I'm actually surprised," Vicki Smith, executive director of Disability Rights North Carolina, a group mandated by Congress to monitor and ensure the safety of patients with disabilities.

"You need decisive, proactive leadership, and our initial reading of the report is that those are the characteristics that this team does not have," she said.

One issue, the consulting group found, is the leadership's poor communication. Policy changes and reforms happen through e-mails and memos and there is limited face-to-face communication and personal involvement in providing instruction and oversight.

Compass Group also looked at five other areas in its 20-page report, including management, clinical care, change management, oversight and organizational structure.

The review found "overarching issues" that affect the hospital's ability to quickly correct serious deficiencies.

The report also says management is reactive. When requested, it will take action to correct deficiencies but does not normally take a proactive approach to assure compliance.

In focus groups, staff members said personal safety is a major issue and they blame senior leadership. There also seems to be little pride in working for the hospital, the report says, and that job security is a higher priority than patient safety.

The review also found "cultural deficiencies are the root of the existing clinical problems" at the hospital and that the nursing staff does not provide direction to support staff.

It recommends a new management structure in the hospital's care model with nurse managers to oversee patient care and be responsible for all staff and teamwork among staff at all levels, including doctors, nurses and social workers.

Officials at the Department of Health and Human Services and Division of Mental Health were reviewing the report Tuesday and did not have an immediate comment.