Assurances fail to quiet debate on DECH issues

Down East Community Hospital (DECH) in Machias has been embroiled in controversy for at least the past 14 months, based largely on several well-publicized events: the death of a patient in January 2008 on hospital property during a storm after he had signed himself out against medical advice; the reported theft by employees of drugs from the hospital pharmacy; the discovery of patient records in the Pennamaquan River that had been taken from the hospital and dumped there; litigation by at least one physician whose employment was terminated by the hospital's board of trustees; and other medical staff dismissals that have sparked community protests.

Unannounced on-site reviews

Complaints against the hospital have led to unannounced on-site reviews, called surveys, by the Maine Department of Health and Human Services (DHHS) through its Division of Licensing and Regulatory Services. The surveys, five in all since January 4, 2008, assessed the hospital's compliance with federal Medicare requirements as well as with Maine licensing standards for hospitals. Although two agencies were involved, one state and one federal, the same team of surveyors from DHHS visited the hospital and conducted the monitoring for both agencies.

Federal officials notified DECH by letter on December 22 that the hospital was found to be out of compliance with certain Medicare "Conditions of Participation" (CoPs). In a letter dated December 24, state officials notified DECH that DHHS would modify the hospital's license to "conditional" for a period of up to one year. Both the federal and state agencies cited deficiencies found in four areas: pharmacy, clinical records, standards of care, and quality and patient safety.

The hospital responded in January with a "plan of correction" that was initially rejected by DHHS but, after revision, was "found to be acceptable as of February 5," according to a letter from the agency to the hospital CEO, Wayne Dodwell. The plan, developed by hospital staff and numbering 325 pages, details policy revisions, action plans, timelines for implementation, responsible personnel, and internal monitoring procedures for the specific weaknesses that were identified in the four areas.

'Setting the record straight'

The DHHS team conducted their most recent unannounced survey at the hospital during the week of February 8. As of press time, the department had not yet issued a public report of their findings. However, the hospital administration was so confident of a favorable outcome based on their "exit interview" with the survey team that they called a press conference on February 13 at which Dodwell announced the team had found DECH in "full compliance with state and federal requirements." The conference, attended by four reporters and a television cameraman, was billed as the hospital's effort to "set the record straight." Present, in addition to Dodwell, were Walter Plaut, chairman of the board of trustees, and about 20 department heads and other DECH employees. Dodwell said the staff was there "because our employees take a huge interest in what's going on C they're proud of what they do and want to show off their pride in their work to you."

Tracing the history of the public controversy, Dodwell said it dates to August 2005 when the medical staff "decided to limit a particular procedure that a physician wanted to do. In December 2005, the board decided not to reappoint him to the medical staff," Dodwell continued. The doctor, whom Dodwell would not name, then filed a lawsuit that, Dodwell said, the hospital intends to defend through Maine's highest court "to be sure all evidence is presented in a fair manner." Dodwell says the issues in the case involve the principle of "peer review," which he called "a process and obligation of the medical staff, overseen by the board of trustees," to maintain professional standards. The doctor in question, Dodwell said, also initiated "a petition campaign in town to disrupt the peer review process."

Plaut added that the physician and "a few [other] disgruntled employees stirred up a small group of citizens" in Machias "who want to derail or sabotage" the hospital's mission. Both officials blame a citizen's committee, known as Save Our Hospital, for instigating complaints that have subjected the hospital to more frequent random surveys by the state and federal agencies than the usual periodic reviews "every two or three years." According to Plaut, the goal of the citizens committee is to force the hospital into receivership, a status he defined as "when a judge takes over running the hospital," a situation he said is bound to produce "unintended consequences."

In addition, the two administrators criticized coverage by local newspapers that they regard as overblown, unfair and inaccurate. They cited a headline in an area daily stating that the hospital was "penalize[d]" by the regulatory agencies, when, they said, there were no penalties imposed. They objected to stories in the town newspaper they said were not "balanced." Several of the department heads referred to the "stress" they experience when they read "demeaning things in the paper" about the staff they believe is "dedicated to providing quality care" to patients. Dodwell said that in "25 years in the hospital business," he has learned "there is always room for improvement," but the "constant criticism creates a distraction for the staff, making it harder to do their jobs and taking our time to deal with it."

The conditional question

Dodwell and Plaut said that many hospitals in the state are cited in surveys for deficiencies and that the issuance of conditional licenses by DHHS is "not rare." Plaut listed a half-dozen or so Maine hospitals he said are currently operating with conditional licenses. The statements of the two administrators about the frequency of conditional licenses in Maine were later contradicted by Catherine Cobb, director of the licensing division of DHHS, when she was contacted by The Quoddy Tides. Asked how many hospitals in the state currently hold conditional licenses, she replied, "One C DECH." Asked when the last previous hospital in Maine was issued a conditional license by her division, she said, "There was one in 2005." These were the only two such instances during her tenure at the agency, Cobb added, a period of "more than three years."

Dodwell was questioned later by phone about the discrepancy between Cobb's statements and those he and Plaut had made at the press conference. Dodwell said he was relying on information contained in an e-mail from Anne Flanagan, assistant director of the licensing division of DHHS, in reply to a query from the hospital's general counsel, Aaron S. King. Dodwell agreed to forward Flanagan's e-mail to The Quoddy Tides in support of his statements about other Maine hospitals currently holding conditional licenses.

Dated February 2 and addressed to King, Flanagan's message states: "In response to your question regarding hospitals that have been monitored following lack of compliance with Federal Conditions of Participation, I am forwarding the following information: Temporary State Jurisdiction with survey date in parentheses: Franklin Memorial Hospital (January 2006), Parkview Adventist Medical Center (June 2006), Riverview Psychiatric Center (Validation, June 2006), Penobscot Bay Medical Center (March 2007), St. Joseph's Hospital (March 2007), Maine Medical Center (Validation, August 2008), Down East Community Hospital (December 2008)."

Based on the content of the e-mail, it appears the question posed by the attorney involved monitoring for federal compliance, not the issuance of state conditional licenses. The Quoddy Tides also contacted Plaut by phone and informed him of Cobb's statements contrary to information presented at the press conference.

In the same telephone conversation with Cobb, she said the February onsite survey at DECH was "the first of several follow-ups" since the issuance of the modified license. "Past compliance at the hospital has been spotty," she said, stressing that it is a "pattern of noncompliance" that is of concern to the regulators. She described the conditional license as "a state action when, over time, the hospital shows an inability to stay in compliance." She added, "The hospital [DECH] should not underestimate the seriousness of the issues. We intend to hold their feet to the fire to maintain compliance even if the full license is restored."

The hospital officials report they are making progress in implementing the corrective action plan now in place as well as resolving some of the hot button issues that have brought negative publicity to DECH over the past 14 months. To improve patient safety and the custody of records and pharmaceuticals, 13 security cameras have been installed in the facility. Policies upgrading standards of care, especially in the emergency department, are in place. A private detective agency, hired by the hospital, has turned up information that Dodwell believes will result in the apprehension, in a month or so, of "one or two" persons responsible for the theft and disposal of medical records. As for the issue of the physician's dismissal in 2005, which Dodwell believes marked the beginning of the ongoing controversy, the suit will probably be settled "sometime between November and next January," he says. Dodwell is convinced the outcome "will resolve all the issues" regarding the case and result in "a community reawakening" when all the facts become public.