By Jodi Hausen,Staff Writer

FARMINGTON – Franklin Memorial Hospital – the only hospital in Franklin County – has been cited for deficiencies that are “of such serious nature as to substantially limit (the) hospital’s capacity to render adequate care.”

The Nov. 28 notification from the federal Centers for Medicare and Medicaid Services is the result of a state Department of Health and Human Services evaluation. Most of the deficiencies relate to poor record-keeping and administration but were alarming enough to officials at CMS to require a second, more comprehensive review for items not yet examined.

Issues included incomplete medical records relating to anesthesia and restraint-use, missing medical staff quality reviews, and sloppy housekeeping and maintenance.

A written statement from DHHS on Tuesday said that CMS, the U.S. agency responsible for Medicare and Medicaid reimbursement regulations, sends two or three similar letters annually to hospitals in Maine, or to about 20 percent of those surveyed. There are 39 hospitals statewide that are surveyed every three years.

“If a hospital were a severe threat to its patients, it would have 23 days from the initial survey” to correct their deficiencies, said Roseanne Pawelec, spokeswoman for CMS, on Monday.

Franklin Memorial will have 90 days from the date a second, unannounced audit is completed to rectify deficiencies.

State inspectors will return to the hospital twice, Richard Batt, president of the health care facility, said during a media briefing Wednesday – once giving 10 days’ notice to assess its progress in correcting deficiencies and an unannounced visit to conduct the Medicare inspection. The state will then decide whether to grant the hospital a conditional one-year license or a full-fledged three-year one. The hospital is currently operating under its full three-year license, which will expire in April, according to both Batt and Maine DHHS Commissioner Jack Nicholas.

“What’s unusual is this threat of a conditional license,” Dr. Rod Prior, the hospital’s medical director, said at the briefing. It seems out of line with the discrepancies state inspectors found, he added.

The hospital received notice of full accreditation from the Joint Commission on Accreditation of Healthcare Organizations, a national accrediting agency accepted for state licensure by most states, on Oct. 27, the day after state auditors conducted an exit interview with hospital officials.

“Substantively, the quality of health care in this hospital is higher than the state average, higher than the national average,” said Batt in an phone interview Tuesday. “People don’t need to be concerned about the quality of care at this institution,” he added.

Batt said the hospital is working to correct and, in some cases, has already rectified many of the issues brought forth by auditors. He also disputes some of the team’s findings.

Auditors found 25 pages of issues for which the hospital must submit a correction plan, including:

*Three out of four medical records failed to specify the reason for the use of chemical restraints in the emergency department and in one case out of four the use of leather ankle and wrist restraints was ordered “as needed,” which is a violation of protocol.

According to the correction plan, emergency care providers were “educated” about restraint policy, forms and protocol on Nov. 4.

“We intend to be extremely rigorous that (the protocol) is always followed,” Batt said Tuesday. None of the restraint cases reviewed involved abuse of patients, and all had appropriate care. The orders were not written correctly, he added.

*Three out of seven surgical records failed to document the time on post-anesthesia visits. The medical director met with the chief of anesthesia and reviewed regulations on or before Nov. 11, according to the hospital’s correction plan.

*No medical staff quality management plan existed between August 1, 2004, and Oct. 12, 2005. Additionally, four emergency room physician’s assistants had no quality-care reviews in their accreditation files since their last reappointments. This deficiency was noted and presumably corrected after the hospital’s last survey in October 2002.

Batt disputes the finding that the hospital did not have a medical staff quality management plan in place.

“Franklin Memorial Hospital has had a quality improvement plan, which included the medical staff, in place for many years. This plan was updated annually and approved by the hospital annually,” he said.

However, the medical staff plan was not written to state requirements, Batt said. A revised plan was rewritten and approved by the hospital’s board Nov. 15.

Missing physician’s assistants’ reviews were a matter of placement. They were stored in the wrong location, according to state regulations, Batt said. It was an oversight not to have corrected that error from 2002, he added.

*Dirty and clean equipment was found stored in the same storage room, a leaking ice machine “was not safe for use,” and the radiology area was dirty and dusty with holes in the walls and floors.

The hospital has replaced the ice machine, cleaned the radiology department and hired contractors to make repairs. Clean and dirty equipment was moved into separate storage rooms.

The 70-bed hospital is the only one serving the rural county of nearly 30,000 people. It offers a broad range of medical, surgical, pediatric, obstetric and gynecological services and is affiliated with the Franklin Community Health Network, the Healthy Community Coalition, Evergreen Behavioral Services and Pine Tree Medical Associates.