FARMINGTON – Franklin Memorial Hospital administrators recently received a letter from the state listing the hospital’s deficiencies, but many of those have already been addressed, hospital President Rick Batt said Wednesday.
The hospital was given a conditional one-year license in October after a state licensing inspection uncovered procedural problems, particularly in documenting quality improvement processes.
“The state did not find any evidence that the quality of care in this organization is deficient,” Batt said.
As a result of the state survey, the hospital also received a letter from the Centers for Medicare and Medicaid Services on Monday. It stated that, due to “significant deficiencies with respect to compliance,” the agency is keeping the hospital under Medicare State Survey Agency jurisdiction until the hospital is in compliance with all the conditions of participation. The hospital’s requirement to “submit a plan to correct its Medicare deficiencies does not affect its accreditation, its Medicare payments or its status as a participating provider of hospital services,” Richard Shaw, branch chief for the centers, wrote in the letter.
The hospital has been monitoring almost 500 items in the quality improvement program, Batt said, but hasn’t been consistent in documenting them. The hospital could chose to monitor many fewer, he said. They are paring down the parameters that employees will be required to track in the future.
“For the ones we keep, we’ll be very rigorous in our record keeping,” he said.
For example, hospital employees were not vigilant in documenting when action was taken to change a procedure or a setting on a refrigerator.
“In those instances where we were taking action, we didn’t document those actions,” Batt said. It’s referred scientifically as “closing the loop,” he added.
Franklin Memorial does use more indicators than the average hospital, according to Geoffrey W. Green, deputy commissioner for operations and support for the Department of Health and Human Services, the agency responsible for hospital inspections and licensing.
The issue was with “the process that they were using to follow through when their indicators showed that they were not meeting benchmarks that they had set for themselves,” Green said Thursday. “It’s the essence of a quality improvement program that you use the benchmarks to drive quality initiative. We think that Rick and the hospital has taken this very seriously and we are confident that the deficiencies will be corrected quickly and well,” he added.
“It’s one of the better hospitals in the state,” remarked Lynn Kippax, director of public and media relations for the Department of Health and Human Services.
The hospital staff took action immediately after an exit interview with the survey group in late October and is so confident of its progress it has invited the survey group to return early this month. But Kippax said Thursday that a determining visit will be unscheduled; at that time, the team will determine whether to issue a one-year or three-year license.
“I’m totally confident that we’ll have made rapid progress to correct the procedural deficiencies,” Batt said.
“We anticipate that the (survey) group will return in December, and based on the nature of the conversations that the department has had with Franklin Memorial Hospital, we anticipate that the outcome will be positive,” Green said.
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