Hospital has list of issues to tackle

CARTHAGE — Carthage Area Hospital received conditional accreditation from the independent not-for-profit Joint Commission after a July survey found 10 or more requirements for improvement.

The decision was effective Tuesday, according to commission spokesman Kenneth A. Powers, and the hospital has 45 days from that date to submit an action plan to solve the issues. After that, there would be a follow-up survey in four to six months.

In October, hospital Administrator Walter S. Becker said "We had a couple deficiencies but we corrected them," after rumors that the institution would lose its accreditation were sparked by the arrival of a team of surveyors from DNV Healthcare Inc.

The Joint Commission was created in 1951 by U.S. and Canadian health care organizations to help improve hospital care.

DNV Healthcare is a division of Norway-based Det Norske Veritas, a risk management firm founded in 1864 to inspect ships. DNV Healthcare was given the ability to accredit U.S. hospitals by the federal Centers for Medicare and Medicaid Services in September.

Mr. Becker said DNV gave the hospital full accreditation for three years.

In October, Mr. Becker outlined some deficiencies noted in the Joint Commission survey that he said had already been solved, including a lack of connection between the mechanism used to extinguish fires in the hospital's kitchen and the building's fire alarm system, and a lack of updated license information for one physician.

Mr. Powers said the Joint Commission's survey revealed deficiencies in the following standard areas outlined in the agency's manual:

■ Environment of care, which focuses on equipment and other special features that protect the safety of all people in the hospital. This includes fire systems.

■ Human resources, which places importance on educating and training hired staff.

■ Infection control, which requires a systematic infection prevention and control program to be established for all staff, from receptionists to practitioners.

■ Leadership, which is broken into four sub-categories: structure, relationships, hospital culture and performance expectations and operations. It also focuses on leaders collaborating.

■ Medication management, which requires that "an effective and safe medication management system" is developed to avoid causing harm with medications.

■ Medical staff, which requires all licensed independent practitioners to be properly credentialed.

■ Provision of care, treatment and services, which focuses on each step of care, from check-in until discharge.

The full report with more detailed findings should be posted today on Joint Commission's public-access Web site, Mr. Powers said.

Mr. Becker, contacted Thursday evening, declined to be quoted on the record.