DECH’s corrective action plan meets agency’s approval

The results of a "full federal survey" at Down East Community Hospital (DECH) that was completed April 10 by the Department of Health and Human Services (DHHS) on behalf of the Centers for Medicare & Medicaid Services (CMS) were released on May 20. The release included a 59-page document listing deficiencies found by the survey team and a 91-page Corrective Action Plan developed in response by the hospital. According to Catherine Cobb of DHHS, the hospital's plan was found acceptable after it had been returned for a number of revisions.

In February, DECH had its license downgraded to "conditional" by the license and regulatory division of Maine DHHS. Last month, CMS, the federal agency, had placed DECH in "immediate jeopardy" status because of numerous failings in its emergency department. The hospital was able to clear that status with a plan to correct the problems only a day before its impending removal from participation in the Medicare program on April 15. The full federal survey commenced following complaints that dated to January 2008 and brought the critical access hospital under almost continuous state and federal scrutiny.

In the release of the survey results, six general areas of noncompliance were identified: federal, state and local laws; emergency services; physical plant and environment; organizational structure; provision of services; and periodic evaluation and quality assurance review. The report cites instances and examples under in each area to support the finding of noncompliance.

Specific concerns involve policies and recordkeeping regarding restraint or seclusion of patients; overlapping services performed by practical and registered nurses; emergency department procedures; emergency care for newborns, especially those with in utero exposure to addictive drugs; failures to meet building code requirements for life/fire safety; failures of the governing body to "assume full legal responsibility" for the quality of patient care; inadequate ongoing staff education programs; maintenance of medical records according to the policy established; apprising patients of their rights; monitoring quality of contracted services.

The hospital's corrective action plan was briefly discussed with Robin Popp, a hospital spokesperson, and Jackie MacIntyre, vice president for quality improvement. While the two emphasized that the planners gave equal consideration to correcting all the deficiencies cited, they did acknowledge that significant attention was devoted to obstetric and neonatal care and emergency department services. In both departments, the hospital has begun "100% chart review" of all cases. In addition, they said, changes in policies, job descriptions, upgrades in physician certification, staff education, and other measures have been instituted.

According to MacIntyre, "We're a better hospital already as a result of the process we went through." Popp added, "Quality improvement is what it's all about -- we took a system-wide approach" in dealing with the failings cited. "It's a continuous process, and we'll keep looking at ways to improve." Full implementation of the plan has already begun, the officials said.

According to Roseanne Pawelec, spokeswoman for CMS, the hospital will continue to be monitored, with periodic unannounced visits by the survey team.