The national commission that granted Carroll County General Hospital accreditation last year cited 21 deficiencies the hospital must correct to maintain its approved status.
Hospital officials released the report from the Joint Commission on Accreditation of Healthcare Organizations yesterday, after The Sun filed a Maryland Public Information Act request to obtain it.
Most of the deficiencies involved record-keeping and failure to document whether medical procedures were being followed. Carroll County General earned its lowest score for failing to keep patients' records up to date.
The same defect has put the hospital under scrutiny by the federal agency that administers Medicare payments.
The JCAHO team said it found "lack of evidence of review of surgical and other invasive procedures during 1992."
The team also found such deficiencies as "a lack of . . . monitoring and evaluation of important aspects of surgical nursing care," a failure to review the quality of care given by nonphysician employees and a lack of long-term studies of patient care in the critical care unit, which serves heart attack victims.
Hospital spokeswoman Gill Chamblin said the hospital has been evaluating procedures, but has expanded its reviews of endoscopy and other procedures to meet the commission's standards.
She said the hospital evaluates employees' performances annually and has developed a quality improvement plan to study patient care in the Critical Care Unit.
Carroll County General also must improve record-keeping in areas ranging from the amount of blood ordered for operations to assessments of blood gases done by the respiratory therapy lab. And, it will be required to document reviews of surgical or other invasive techniques to determine whether the procedures were appropriate, and must add long-term monitoring of surgery and anesthesia services.
The Joint Commission gave Carroll County General a three-year accreditation in August 1992.
To maintain accreditation, all hospitals are required to correct deficiencies that surveyors identify as serious, said Stephen L. Davidow, the commission's media relations officer.
Ms. Chamblin described the three-year accreditation as "the maximum" JCAH approves. It's also the minimum term, Mr. Davidow said.
Carroll County General was placed under direct state supervision while it improves its record-keeping to retain its Medicare reimbursement eligibility. Carol Benner, director of the office of licensing and certification programs in the state Department of Health and Mental Hygiene, said last week that the department has not yet conducted a follow-up survey to determine progress.
If the hospital fails to bring its medical records up to federal standards, it faces possible loss of eligibility for Medicare reimbursements. An average of 50 percent of the hospital's beds are filled by Medicare patients.
Accreditation is important to hospitals as a way to assess patient care and get help from specialists, Mr. Davidow said. "We're not punitive. We're educational," he said.
Accreditation also "makes a tremendous difference to DHMH in terms of their renewing a hospital's license," said Dr. Dan McCrone, president of Maryland Medical Services, which determines the need for medical treatment for insured individuals.
Dr. McCrone said the insurer's standard agreement with health care providers does not specifically require JCAHO accreditation, but does require a current state license.
A commission surveyor checked Carroll County General's progress in correcting the 21 deficiencies in January. Ms. Chamblin said the hospital has not yet received a report, "but from what the surveyor told us, the majority of the recommendations [for correcting deficiencies] will be lifted. It was very positive."