Review finds Machias hospital in compliance

Posted Feb. 13, 2009, at 10:19 p.m.

MACHIAS, Maine — Officials at Down East Community Hospital announced Friday that a follow-up review of the hospital has shown that the hospital is now in compliance with all state and federal regulations.

The follow-up review by a survey team from the state Department of Health and Human Services took place Tuesday and Wednesday, according to hospital President and CEO Wayne Dodwell.

Dodwell said the members of the survey team reported during an exit interview that the hospital is back in full compliance with all conditions of participation in the federal Medicare program and with all state hospital licensure regulations. Official notification of compliance should come in a report from DHHS in about two weeks, he said.

Catherine Cobb in DHHS’ Licensing and Regulatory Services division confirmed Friday that the follow-up review had taken place but said the official determination regarding compliance has not yet been made. Cobb said the survey team would present its findings for a supervisory review, possibly as early as Monday, before officially determining whether the hospital is in full compliance.

“We did not feel that it went badly,” she said of the latest review. “We’ll make that determination in concert with [Centers for Medicare and Medicaid Services],” the federal agency that overseas health care coverage at U.S. hospitals and ensures compliance with certain federal regulations.

Dodwell said he anticipated another review by the state before the license was fully reinstated. Cobb, however, indicated that there likely would be several follow-up reviews to ensure that the hospital will maintain compliance before the license is reinstated.

Based on a review in December, DHHS had determined that the hospital was out of compliance with the state’s licensing regulations and placed the hospital on a conditional state license. Also, based on that review, CMS warned the hospital that it could face removal from the Medicare reimbursement program.

According to Dodwell, the report from the survey team in its exit interview indicated the hospital had addressed deficiencies in four specific areas and was now in compliance with those federal requirements as well as the state regulations.

Concerns in one of those areas — clinical records — stemmed directly from the discovery last November that confidential patient records had been stolen and were found washed up along the Pennamaquan River. Karen Theriault, the director of health information management and the hospital’s compliance officer, said the hospital has taken steps to ensure that patient records remain secure.

The hospital has installed 13 surveillance cameras around the hospital, and department managers will conduct regular monthly checks to monitor patient files and make sure anything that contains private patient information is safe.

The surveillance cameras also will address another DHHS concern regarding pharmacy security, which stemmed from the theft of prescription drugs by employees. Dodwell said the hospital has taken steps so that those types of thefts are discovered more quickly.

Concerns about standard of care stemmed from discrepancies in administering sedation specifically in the emergency room. Diane Raymond, the chief nursing officer at the hospital, said they have retrained the nursing staff on all the different types of sedation and redefined its policy. Every case in which sedation is given will be monitored and the changes will be monitored for a year, she said.

Also, the hospital has established new procedures to regularly monitor vital signs on incoming patients based on their initial condition when they arrive at the hospital.

The hospital also has made some changes in response to the death of a patient in January 2008 after he had checked himself out of the hospital against the advice of the medical staff. Reid Emery was found dead in a snowbank on hospital property the next morning.

In response to questions, Raymond said the hospital had followed established policies at the time, but has adjusted policies based on a better understanding of patient competence. Although a patient can be coherent, Raymond said the hospital staff also needs to be aware of the patient’s decision-making capacity.

“We’ve learned a lot more about that and we have adjusted our policies to reflect the patient’s decision-making capacities and how better to assess that,” she said.

The hospital has been in turmoil for several months, the result of the dismissal and departure of several physicians. At least one of those cases has landed in Superior Court, and Dodwell said he was limited in what he could say about the case. Walter Plaut, chairman of the hospital board, said the decisions regarding the dismissal of a physician were based on a peer review and recommendations from the medical staff. He said the hospital would take the case to the state’s highest court if necessary to defend those decisions.

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