Greene County Hospital

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 49894 Based on observations, review of hospital policies and procedures, and staff interview, it was determined the hospital failed to ensure the hospital maintained clean, safe, organized dietary services, directed and staffed by qualified personnel. These deficient practices had the potential to negatively affect all patients, staff, and visitors served by the hospital. Refer to: A 0620 and A 0621.”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 49894 Based on review of the hospital’s Emergency Preparedness Plan documentation and staff interview, it was determined the hospital failed to review and update the hospital’s facility and community-based all-hazards plan and the hospital’s Emergency Communication Plan at least every two years. This had the potential to negatively affect all patients, staff, and visitors served by the hospital. Findings include: Refer to E 0006 and E 0029.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 49894 Based on review of the hopsital’s personnel files, policies, and staff interview it was determined the hospital failed to ensure personnel files were maintained completely and accurately. This affected all personnel hired before January 1, 2026, five of five personnel files reviewed for personnel hired after January 1, 2026, including one of one Registered Nurse (RN), one of one Certified Nursing Assisstant (CNA), one of one Licensed Practical Nurse (LPN), one of one Ultrasound Technician (US), and one of one Environmental Services Technician (EST), and had the potential to negatively affect all personnel employed by the hospital. Findings include: Hospital Policy: Personnel File Contents Policy Revision Date: Not Listed Required Personnel File Contents: Each employee file must include the following: 1. Pre-Employment Documentation: Completed employment application or resume Background check results (as applicable) Drug screening results (if required) Offer letter / employment agreement Documentation of completed and verified pre-employment health requirements, including TB screening results and Hepatitis B vaccination series or signed declination, prior to clearance for duty 2. Job Description Current, signed job description Must include: Duties and responsibilities Required qualifications Physical requirements Signed by employee at hire and with any revisions 3. Licensure / Certification Current professional license (if applicable) Required certifications (examples): CPR / BLS / ACLS Verification of licensure in primary source (if applicable) 4. Orientation Documentation New hire orientation checklist Department-specific orientation checklist Initial competency validation 5. Competency Validation Annual competency assessments Skills checklists Department-specific competency evaluations 6. Education & Training Records In-service attendance logs Mandatory education completion (e.g., infection control, HIPAA, safety) 7. Employee Health Clearance Detailed health records maintained separately in Employee Health files 8. Performance Evaluations Annual performance reviews Counseling or disciplinary actions (if applicable) 9. Required Employee Health Documentation The personnel file must include verification that the employee meets all required health and safety standards. Documentation must include: Tuberculosis (TB) Screening Documentation of baseline TB screening at time of hire (TST or IGRA) Documentation of results and any required follow-up Evidence employee is cleared for duty Hepatitis B (HBV) Documentation of Hepatitis B vaccination series OR Signed declination form if vaccine refused Compliance Requirement Employees who do not meet TB, Hepatitis B, or Influenza requirements must not be cleared for work until compliance is verified. Hospital Policy: Employee Health Hepatitis B Vaccination Program Revision Date: 3/00 ...It is recommended for employees who have the potential for blood and bodily fluid exposure to receive the vaccine... All employees who have the potential for blood exposure will be informed of risks and offered the vaccine on a voluntary basis when they are employed. If they do not desire the vaccine a refusal statement must be signed... Hospital Policy: Annual Tuberculin Skin Testing Policy Number: EHS 20 1. Infection Control/Employee Health will schedule annual Tuberculosis (TB) testing... 3. ...TB testing is a mandatory work requirement... 4. ...Testing will be done on an annual basis. 1. On 5/21/26 at 8:25 AM, Employee Identifier # 9, Human Resources Director, informed the surveyors that he/she had been unable to locate the hospital’s personnel files for any personnel hired before January 1, 2026 since assuming the role in December 2025. Review of the hospital’s personnel files for five employees hired after January 1, 2026 revealed the following: a. Three out of five personnel files reviewed had no documentation of a signed job description, including the CNA, US, and EST. b. Five out of five personnel files reviewed had no documentation of initial and/or annual competency skills validation. c. Three out of four personnel files reviewed had no documentation of Cardiopulmanary Resuscitation (CPR) training, including the RN, CNA, and US. d. Four out of five personnel files reviewed had no documentation of an initial or annual TB screening, including the RN, CNA, LPN, and EST. e. Three out of five personnel files reviewed had no documentation of initial Hepatitis B testing, vaccination status, or declination of the vaccine, including the RN, CNA, and EST. An interview was conducted on 5/21/25 at 4:00 PM with EI # 9, who confirmed the hospital failed to maintain personnel files completely and accurately.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 49894 Based on review of the hospital’s Quality Assurance Performance Improvement (QAPI) Program documentation, hospital policy, and staff interview, it was determined the hospital failed to ensure the performance improvement plan encompassed all services. This deficient practice affected Dietary Services and had the potential to negatively affect all patients, visitors, and staff served by the hospital. Findings include: Hospital Policy: Quality Assurance Performance Improvement Plan Date Published: 8/15/23 ...Scope The Performance Improvement Plan encompasses all services, clinical and non-clinical... 1. Review of the hospital’s QAPI Program data revealed no documentation Dietary Services participated in the QAPI or contributed any data of quality indicators. An interview was conducted on 5/21/26 at 1:10 PM with EI # 3, Interim Quality Coordinator, who confirmed Dietary services did not contribute any data of quality indicators to the QAPI Program.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 49894 Based on observations, hospital policies and procedures, and staff interview, it was determined the hospital failed to ensure: 1. Surfaces were in good repair. 2. Kitchen equipment was free of grease build-up. 3. Staff followed the hospital policy for hand hygiene during food preparation. 4. Staff followed the hospital policy for operation of the three compartment sink. 5. Staff verified chemical concentration of sanitizer for the three compartment sink and dishwasher. 6. Dry storage foods were not stored on the floor. 7. All food items not in their original container were properly labeled with date received. These deficient practices had the potential to negatively affect all patients, staff, and visitor’s served by the hospital’s dietary services. Findings include: Hospital Policy: Food Preparation Revision Date: 12/18/25 ...Strict Hand Hygiene- Food handlers must wash their hands thoroughly with soap and water before food preparation, after handling raw food... Prevention of Cross Contamination: Use separate utensils, cutting boards, and surfaces for raw and cooked foods. Clean and sanitize equipment after use... Clean and sanitized environment- Kitchen, utensils, food contact surfaces must be cleaned and disinfected regularly to prevent infection. Hospital Policy: Using Three (3)-Compartment Sink Revision Date: 12/20/25 ...3-Compartment Procedure ...Wash- Fill first sink with warm water and detergent... Rinse- Fill the second sink with warm water. Rinse all soap residue from items. Sanitize- Fill third sink with approved sanitizing solution to the correct concentration. Fully immerse each item for the required contact time according to manufacturer’s guideline and facility policy. Hospital Policy: Using Dishwasher and Chemical Testing Revision Date: 12/17/25 ...chemical testing is to ensure that all dishes, utensils, trays, and food contact equipment are properly cleaned and sanitized to prevent contamination and food borne illnesses... Operating the Dishwasher ...Monitor detergent and sanitizer solution... Chemical Testing Procedures... Obtain the correct test strip for the sanitizer. Dip the test strip into solution. Compare the color results to the test strip. Verify sanitizer concentration is within facility approved range. Document results after each use. Hospital Policy: Receiving and Storage Revision Date: 12/18/25 ...Storage Guidelines Store promptly after receiving. Label and date all food items...keep food off the floor (at least six inches). Hospital Policy: Food Storage, Labeling and Monitoring Revision Date: Not listed Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. All food items must be labeled with the date they are received. 2. All food items that are not in their original containers must be labeled with the common name of the food and the date they are received. 3. Food, such as cake mixes, that are partially used: the remainder of item is to be stored in a Zip Lock bag or other closed container with the item name, date opened and use by date clearly noted on container. ...5. Suggested labeling includes: a. Common Name b. Date of preparation or Use By Date 1. A tour of the kitchen was conducted on 5/19/26 at 11:15 AM. The following was observed: Thick black substance around oven doors and on the floor around the legs of the oven. Edges of countertop broken with exposed particle board. Grease build-up covering the front, sides, top, and baskets of the fryer. Dark bulid-up on edges of pans. 2. An observation was conducted on 5/19/26 at 11:15 AM with EI # 7, Dietary Services Employee, operating the 3-Compartment Sink. During the observations EI # 7 failed to fill the third sink enough to completely submerge washed items. Chemical Testing for the water in the third sink using chemical test strips revealed results of zero (0) sanitizer present. 3. An observation of food preparation was conducted on 5/19/26 at 11:30 AM with EI # 6, Dietary Services Employee. During the observation, EI # 6: Failed to perform hand hygiene before handling raw chicken. After handling raw chicken, EI # 6 failed to remove his/her gloves and perform hand hygiene before handling clean items and entering the walk-in freezer. He/she retrieved items from the freezer with contaminated gloves, then returned to the fryer area, and without removing the contaminated gloves, continued to batter the raw chicken and place it in the fryer. With contaminated gloves, EI # 6 placed items used in the chicken preparation area in the second sink of the 3-Compartment sink, and then dipped them in the third sink. EI # 6 then removed his/her gloves and failed to perform hand hygiene. After the chicken was removed from the fryer, EI # 6, without performing hand hygiene and/or donning gloves, checked the temperature of the cooked chicken with his/her bare hands. 4. A tour of the hospital’s dry food storage was conducted on 5/19/26 at 2:00 PM. The following was observed: a. Large plastic containers of chicken seasoning, sugar, corn meal, flour, and fish fry were not properly labeled with date received. b. A twenty-five pound bag of sugar, along with one case of canned green beans, one case of dill pickles, one case of scalloped potatoes, one case of barbeque sauce, and two cases of foam food containers were stored on the concrete floor. 5. An observation conducted on 5/20/26 at 8:30 AM in the dishwashing area (area containing the dishwasher) revealed EI # 8, Dietary Services Employee, failed to properly verify chemical concentration of sanitizer in the dishwasher water. EI # 8 was unable to read the test strip stating he/she was “color blind.” An interview was conducted on 5/21/26 at 5:00 PM with EI # 4, Dietary Manager, who confirmed the hospital failed to ensure kitchen surfaces were in good repair, equipment was free of grease build-up, staff followed the hospital’s policy for use of the 3-Compartment sink, staff followed the hospital’s policy for hand hygiene during food preparation, items in the dry storage were stored at least six inches off the floor, and staff properly verified chemical concentration of sanitizer in the dishwasher and 3-Compartment sink per hospital’s policy.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 49894 Based on review of the Hospital’s Registered Dietician contract and staff interviews, it was determined the hospital failed to ensure the hospital employed a qualified registered dietitian. This deficient practice had the potential to negatively affect all patients served by the hospital. Findings include: A contract for Registered Dietician dated 2/25/22 was provided to the surveyor on entrance. A phone interview was conducted on 5/21/26 at 9:45 AM with Employee Identifier (EI) # 5, Registered Dietitian, who stated he/she was not employed by the hospital from September 2025 until 5/20/26, when his/her contract was re-instated. An interview was conducted on 5/21/26 at 10:30 AM with EI # 1, Chief Executive Officer, who confirmed the hospital had failed to employ a qualified registered dietitian from September 2025 to 5/20/26.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 49894 Based on review of the hospital’s infection control program documentation, hospital policy, and staff interview, it was determined the hospital failed to ensure: 1. The Governing Body performed a program evaluation and reviewed infection control policies at least annually per the hospital policy. 2. The Infection Control Program Officer performed routine audits and direct observations of infection control practices. This deficient practice had the potential to negatively affect all patients, staff, and visitors served by the hospital. Findings include: Hospital Policy: Infection Control Program Revision Date: 8/24 ...Program Authority and Oversight ...Program effectiveness is formally evaluated at least annually... Compliance Monitoring and Enforcement The Infection Control Nurse conducts routine audits and direct observation of infection prevention practices... Program Evaluation and QAPI Integration Infection control data is compiled and analyzed on an ongoing basis and formally reviewed at least annually by the governing body. Infection control audits are performed on a routine, ongoing basis, with frequency determined by risk level, department activity, and regulatory requirements. Standard Expectations: Weekly Focused audits in high-risk departments (ER, inpatient units, dietary, sterilization areas). PPE compliance and hand hygiene spot checks. Monthly Formal infection control rounds across all departments. Environmental cleaning audits. Annually: Full program evaluation. Policy review and risk assessment updates. 1. A review of the hospital’s Infection Control Program documentation revealed the Governing Body had not performed a program evaluation and reviewed infection control policies since 2012. Further review of the Infection Control Program documentation revealed no documentation the Infection Control Program Officer performed routine audits and direct observations of infection control practices. An interview was conducted on 5/21/26 at 8:45 AM with Employee Identifier (EI) # 3, Interim Infection Control Program Officer, who confirmed the Governing Body had not performed a program evaluation and reviewed infection control policies since 2012. EI # 3 additionally confirmed there was no documentation the Infection Control Program Officer performed routine audits and direct observations of infection control practices per the hospital’s policy.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 49894 Based on review of the hospital’s Emergency Preparedness Plan documentation and staff interview, it was determined the hospital failed to develop and maintain an Emergency Preparedness Plan based on and including a facility and community-based risk assessment utilizing an all-hazards approach. This deficient practice had the potential to negatively affect all patients, staff, and visitors served by the hospital. Findings include: 1. A review of the hospital’s Emergency Preparedness Plan documentation revealed the hospital’s facility and community-based all hazards risk assessment had not been reviewed and updated since 3/24/11. An interview was conducted on 5/21/26 at 1:48 PM with Employee Identifier # 9, Human Resources Director, who confirmed the hospital’s facility and community-based all hazards risk assessment had not been reviewed or updated since 3/24/11.”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: 49894 Based on review of the hospital’s Emergency Preparedness Plan documentation and staff interview, it was determined the hospital failed to develop and maintain an emergency preparedness communication plan that was reviewed and updated at least every 2 years. This deficient practice had the potential to negatively affect all patients, staff, and visitors served by the hospital. Findings include: 1. Review of the hospital’s Emergency Preparedness Plan documentation revealed no documentation an Emergency Preparedness Communication Plan was reviewed and updated since 3/24/11. An interview was conducted on 5/21/26 at 1:48 PM with Employee Identifier # 9, Human Resources Director, who confirmed the hospital failed to review and update the hospital’s Emergency Preparedness Communication Plan at least every two years.”

“. K3 Building: 0101 K6 Plan Approval: 1961 K7 Survey Under: 2012 Existing K8 HOSP Generator: One Natural Gas, Kohler 100 kW (installed 1998) FACP: Tyco Autocall 4007ES (Master Panel) (instaled 2026) with First Alert FA200CS Communicator (installed 2021) Simplex 4602 (Second Panel) Locking Devices: Full time magnetic locked doors at Lobby Waiting Room and on the entrance/exit door of the E.R. Smoke Detection: Corridor Bed: 20 Census: 5 Type of Structure: 1961 one story unprotected noncombustible, Type II (000). The facility has a complete automatic sprinkler system. (CT Scanner has been relocated into the building as observed on 2026 survey) During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 was NOT MET as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the emergency release switch for all of the full-time magnetic locks of the locked egress doors per the requirements of: 2012 NFPA 101, 19.2.2.2.5.2 (1), and 19.2.2.2.6 This deficiency affects the entire facility. Findings include: During a tour of the facility, the surveyor observed all of the full time magnetic locked doors in the facility failed to automatically unlock upon activation of the emergency release switch. A member of the maintenance staff was present when this deficiency was identified. .”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the magnetic hold open devices for multiple sets of smoke doors per the requirements of: 2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4) This deficiency affects all the cross-corridor doors. Findings include: During a tour of the facility, the surveyor observed the magnetic hold open devices for all pairs of the cross-corridor smoke doors failed to release during loss of power to the fire alarm system. A member of the maintenance staff was present when this deficiency was identified. .”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 53813 . Based on review of documentation, the facility failed to maintain the kitchen hood’s automatic fire-extinguishing system per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 10.2.6 (4), and 11.2.1 This deficiency affects the kitchen’s wet chemical suppression system. Findings include: During a tour of the facility, the facility failed to conduct the semi-annual (6 month) inspection for the kitchen hood’s automatic fire-extinguishing system within six months’ time. The automatic fire-extinguishing system (Ansul system) was last documented as being inspected in 2024 A member of maintenance staff was present when this deficiency was identified. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a magnetic locked egress door per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 21.9 This deficiency affects the entire facility. Findings include: During a tour of the facility, the surveyor observed all exit doors in the facility failed to release from the magnetic lock under loss of primary power to the fire alarm system A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 53813 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.6, and 13.7.1 (1) This deficiency affects the porches, walk-in cooler and freezer and the Fire Department Connection (FDC) sign Findings include: During a tour of the facility, the facility failed to: 1. Provide documentation that the dry sidewall sprinklers installed in 2012 located on all porches and in the walk-in cooler and freezer had been replaced or a representative sample tested within 10 years of installation. 2. Provide a visible Fire Department Connection (FDC) sign A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain portable fire extinguishers per the requirements of: 2012 NFPA 101, 19.3.5.12, and 9.7.4.1 2010 NFPA 10, 6.1.3.4, and 6.1.3.8.3 This deficiency affects five portable fire extinguishers. Findings include: During a tour of the facility, the surveyor observed 5 portable fire extinguishers sitting on the ground, outside the back of the facility near the generator. A member of the maintenance staff was present when this deficiency was identified. .”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 53813 . Based on observation, the facility failed to maintain a corridor door per the requirements of: 2012 NFPA 101, 19.3.6.3.5 42 CFR 482.41 (b) (1) (ii) FOR HOSPITALS S&C-07-18 This deficiency affects one corridor door. Findings include: During a tour of the facility, the surveyor observed Room 108 had a 5/8-inch gap between the door and door frame when the door was closed and latched, prohibiting the door from being smoke resistive. A member of the maintenance staff was present when this deficiency was identified. .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 53813 . Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 of 2 smoke barriers. Findings include: During a tour of the facility, the surveyor observed an unsealed 2” penetration of multiple white cables, above the ceiling, over the cross-corridor doors, on both sides of the smoke barrier next to Rooms 121/122. A member of the maintenance staff was present when this deficiency was identified. .”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 53813 . Based on observation, the facility failed to provide heating, ventilating, and air conditioning (HVAC) per the requirements of: 2012 NFPA 101, 19.5.2.1, and 9.2.1 2012 NFPA 90A, 4.3.12.1.1 This deficiency affects the entire facility. Findings include: * During a tour of the facility, the surveyor observed the corridor was being used as return air plenum for the HVAC. A member of the maintenance staff was present when this deficiency was identified. .”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 53813 . Based on observation, the facility failed to maintain the areas where smoking is permitted per the requirements of: 2012 NFPA 101, 19.7.4 This deficiency affects 1 of 1 smoking areas. Findings include: During a tour of the facility, the surveyor observed the facility failed to provide a metal container with a self-closing cover device in the approved smoking area. A member of the maintenance staff was present when this deficiency was identified. .”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 19.7.8 This deficiency affects one office. Findings include: During a tour of the facility, the surveyor observed a portable space heating device. This was located in the Pharmacy Office, which is located in a patient sleeping compartment and the facility was unable to provide documentation that the heating element did not exceed 212 degrees. A member of the maintenance staff was present when this deficiency was identified.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41624 Based on review of hospital EMTALA (Emergency Medical Treatment and Labor Act) policy and other policies, emergency department (ED) Central Log, ED medical records, video surveillance and interview, it was determined Greene County Hospital (GCH) failed to: 1. Adopt and enforce a policy to ensure compliance with EMTALA requirements to maintain a central log on each individual that comes to the ED. 2. Register two patients who presented to the hospital’s ED via emergency medical service (EMS) with a chief complaint of motor vehicle accident on the ED Central Log, including Patient Identifier (PI) # 27 and PI # 28. 3. Provide a medical screening exam (MSE) for PI # 27 and PI # 28. 4. Provide an appropriate transfer for PI # 4 who was diverted to GCH for a MSE during EMS transport with a chief complaint of seizure while enroute to another facility. This had the potential to affect all patients presenting to the ED at GCH. Cross Refer to A 2406 and A 2409 for findings.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 41624 Based on review of the emergency department (ED) Central Log, hospital EMTALA (Emergency Medical Treatment and Labor Act) policy, video surveillance footage, and interview, it was determined the hospital failed to: 1. Adopt and enforce a policy to ensure compliance with EMTALA requirements to maintain a central log on each individual that comes to the ED. 2. Register two patients who came to the hospital’s ED seeking assistance, including whether or not the patients refused or were refused treatment, or were admitted and treated, transferred or discharged. This affected two of two patients with a chief complaint of motor vehicle accident (MVA), including Patient Identifier (PI) # 27, and PI # 28, who presented to the ED for emergent care via emergency medical services (EMS) transport on 6/17/25. This had the potential to negatively affect all patients who presented to this hospital requesting emergency care. Findings include: 1. Review of the hospital policy entitled EMTALA revealed the policy failed to include maintaining a central log on each individual that comes to the ED. The surveyor requested the hospital’s policy regarding maintaining a central log for patients presenting to the ED and none was provided. 2. Review of video surveillance still shots provided by the hospital revealed PI # 27 and PI # 28 arrived together at the hospital’s ambulance entrance on 6/17/25 at 12:01:21 AM via EMS transport. Continued review of the video surveillance still shots revealed PI # 27 and PI # 28 at the nurse station for the ED at 12:02:55 AM, then exiting via the ambulance entrance on 6/17/25 at 12:05:AM. Review of the ED Central Log for 6/17/25 revealed a total of five ED patients were registered on the log. PI # 27 and PI # 28 were not registered on the Central Log at 12:02 AM on 6/17/25. The hospital failed to register every patient presenting on hospital property seeking emergent care on their Central Log. An interview was conducted on 6/24/25 at 11:58 AM with Employee Identifier (EI # 1, Chief Nursing Officer and ED Manager, who confirmed PI # 27 and PI # 28 were not registered on the ED central log.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41624 Based on video surveillance footage, hospital policies and interview, it was determined Greene County Hospital failed to provide a medical screening exam (MSE) within the capability of their emergency department (ED) to determine whether or not an emergency medical condition (EMC) existed for two patients that presented via emergency medical services (EMS) transport to the hospital’s ED. This deficient practice affected Patient Identifier (PI) # 27 and PI # 28, and had the potential to affect all patients presenting to the ED needing an MSE. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy Number: None Original Date: 6/1/2021 Purpose: To establish guidelines for tracking the care provided to each individual seeking care in a dedicated ED for a medical condition or seeking care in areas on hospital property...for an EMC as required of any hospital with an ED by EMTALA... ...Hospitals have three main obligations under EMTALA: 1. Any individual who comes and requests must receive a MSE to determine whether an EMC exists... Hospital Policy: MSE Policy Number: None Revision Date: 07/2021 Policy Statement: All individuals who present to the ED, on hospital property, or through ambulance transport requesting or appearing to need examination or treatment will receive a MSE performed by qualified personnel to determine the presence of an EMC. 1. Review of video surveillance still shots provided by the hospital revealed PI # 27 and PI # 28 arrived together at the hospital’s ambulance entrance on 6/17/25 at 12:01:21 AM via EMS transport. Continued review of the video surveillance still shots revealed PI # 27 and PI # 28 at the nurse station for the ED at 12:02:55 AM, then exiting via ambulance on 6/17/25 at 12:05:AM. No evidence was provided by the hospital that PI # 27 and PI # 28 received a MSE before leaving the hospital to determine if an EMC existed. An interview was conducted on 6/24/25 at 11:58 AM with Employee Identifier (EI # 1, Chief Nursing Officer and ED Manager, who confirmed PI # 27 and PI # 28 arrived via EMS transport with a chief complaint of motor vehicle accident on 6/17/25 and did not receive a MSE.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 41624 Based on medical record (MR) review, hospital EMTALA (Emergency Medical Treatment and Labor Act) policy, hospital central log, transfer log, and interview, it was determined Greene County Hospital failed to provide an appropriate transfer for one of nine emergency department (ED) MRs reviewed with a disposition of transfer. This deficient practice affected Patient Identifier (PI) # 4, and had the potential to affect all patients transferred from this hospital’s ED. Findings include: Hospital Policy: EMTALA Policy Number: None Original Date: 6/1/2021 Purpose: To establish guidelines for tracking the care provided to each individual seeking care in a dedicated ED for a medical condition or seeking care in areas on hospital property...for an emergency medical condition (EMC) as required of any hospital with an ED by EMTALA... ...Hospitals have three main obligations under EMTALA: ...2. If an emergency medical condition (EMC) exists, treatment must be provided until the EMC is resolved or stabilized. If the hospital does not have the capability to treat the EMC, an “appropriate” transfer of the patient to another hospital must be done in accordance with the EMTALA provisions... ...What are the requirements for transferring patients under EMTALA? EMTALA does not apply to the transfer of stable patients, however, if the patient is unstable, then the hospital may not transfer the patient unless: - A physician certifies the medical benefits expected from the transfer outweigh the risks, OR - A patient makes a transfer request in writing after being informed of the hospital’s obligations under EMTALA and the risks of transfer. - In addition, the transfer of unstable patients must be “appropriate” under the law, such that (1) the transferring hospital must provide ongoing care within its capability until transfer to minimize transfer risks, (2) provide copies of medical records, (3) must confirm that the receiving facility has space and qualified personnel to treat the condition and has agreed to accept the transfer... 1. PI # 4 was brought to the ED via emergency medical services (EMS) transport for a medical screening exam after EMS diverted to Greene County Hospital enroute to another facility (Hospital A) on 6/14/25 at 7:55 PM. PI # 4 had a chief complaint of seizure. Review of the central log revealed PI # 4 was registered at 7:55 PM on 6/14/25. Review of the MR revealed PI # 4 received a MSE at 8:19 PM by the physician. The physician documented in his/her History of Present Illness that he/she cleared PI # 4 for continuing to Hospital A. Continued review of the MR revealed the registered nurse documented the following on 6/14/25 at 7:55 PM: “MSE done, mode of departure was ambulance.” “Patient was never moved from stretcher, personnel continuing their route to hospital.” Further review of the MR revealed there was no documentation the risks and benefits of transfer were explained to PI # 4, that PI # 4 consented to the transfer, nor that Hospital A was contacted and PI # 4 was accepted by a provider for transfer, and that the MR containing the MSE was sent with PI # 4 at time of transfer. Review of the ED transfer log for 6/14/25 revealed PI # 4 was not listed on the log as a transfer. An interview was conducted on 6/26/25 at 1:45 PM with Employee Identifier # 1, Chief Nursing Officer and ED Manager, who confirmed there was no documentation a transfer form was completed on PI # 4 which included risks and benefits of transfer, PI # 4’s consent to transfer, an accepting provider at Hospital A, nor that the MR was sent with PI # 4 at time of transfer.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47295 Based on review of the Rules and Regulations, monthly meeting reports for the Governing Body, review of weekly manager’s meeting notes, and staff interviews, it was determined the Governing Body failed to ensure compliance with the Conditions of Participation was maintained and that quality patient care was provided in a safe environment. These deficient practices had the potential to negatively affect all patients served by this facility. Findings: Refer to Tags A 0091, A 0392, A 0454. A 0458, A 0467, A 0583, A 1103, and A 1110.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47295 Based on the review of nursing schedules, nurse staffing policy, and hospital diversion logs, it was determined the facility failed to ensure: 1. Staffing was adequate to provide safe care to all patients admitted to the facility for treatment. 2. The hospital could treat all patients seeking emergency treatment and not be diverted elsewhere due to lack of staffing. This deficient practice had the potential to negatively affect all patients who presented to the facility for treatment. Findings: Refer to Tag A 0392.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 47295 Based on review of the laboratory (lab) calibration logs, Emergency Department (ED) diversion logs, and staff interviews, it was determined the facility failed to ensure lab services were available to meet the needs of the patients, resulting in patients: 1. Being denied admission for treatment to the detox program. 2. Diverted from seeking emergency treatment at the facility. This deficient practice had the potential to negatively affect all patients served by this facility. Findings: Refer to Tag A 0583.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 47295 Based on the review of nursing schedules, nurse staffing policy, diversion policy, and hospital diversion logs, it was determined the facility failed to ensure: 1. Staffing was adequate to provide safe care for patients presenting to the Emergency Department (ED) for treatment. 2. Laboratory and radiology testing was available for patients presenting to the ED. 3. Diversion Logs indicated an end time for the eight days the ED was on diversion in May 2025 and June 2025. These deficient practices had the potential to negatively affect all patients who presented to the ED for treatment. Findings: Refer to Tag A 1103 and 1110.”

“EMERGENCY SERVICES CFR(s): 482.12(f) Emergency Services This Standard is not met as evidenced by: 47295 Based on review of the monthly meeting reports for the Governing Body, review of weekly manager’s meeting notes, and staff interviews, it was determined the Governing Body failed to ensure emergency services were available 24/7. This deficient practice had the potential to negatively affect all patients served by this facility. Findings include: A review of the Governing Body Meeting Minutes revealed the following documents: Patient Care/Infection Control/Quality Control For November 2024 Monthly Report Patient Care/Infection Control/Quality Control For December 2024 Monthly Report Review of the November report revealed the following documentation: “Positive Viral Diseases reported for Emergency Department (ED) patients in November: 0 Covid, 0 influenza (flu), 0 respiratory syncytial virus (RSV), and 0 streptococcus (Strep). These counts are low due to a laboratory (lab) shortage in supplies.” Review of the December report revealed the following documentation: “Viral Diseases reported for ED patients in December: 9 Covid, 0 flu, 10 RSV, and 0 Strep. There were no flu or Strep tests done in December because the lab was out of tests.” Review of the lab notes for the weekly manager’s meeting (which includes all department heads and Employee Identifier (EI) # 3, Chief Executive Officer (CEO)) revealed the following documentation on the Weekly Report form: Dated 5/5/25 to 6/2/25: “We are currently out of flu and RSV testing, calcium, sodium, and Hemoglobin A1C testing.” 6/2/25 to 6/9/25: “We are currently out of flu, Strep, and RSV testing, calcium, glucose, potassium, total protein, Verifier I and Verifier II controls, sodium, and Hemoglobin A1C testing. We are low on Sample supply tray tips (17). Once the sample supply tray tips are out, we will no longer be able to perform testing on the Chemistry analyzer. We are also low on alcohol, chloride, carbon dioxide blood testing (ECO2), cardiac testing, and B-type natriuretic peptide test (BNP).” 6/9/25 to 6/16/25: “We are currently in a lab crisis. Labs that can’t be ordered are as followed: albumin, alcohol, alkaline phosphatase, alanine aminotransferase test (ALT), amylase, aspartate aminotransferase (AST), blood urea, blood cultures, calcium, cholesterol, creatine kinase (CK), chloride, creatinine, digoxin, high-density lipoprotein test, ECO2, glucose, potassium, lipase, magnesium, sodium, phosphorous, dilantin, total bilirubin, total protein, triglycerides, blood urea nitrogen (BUN), uric acid, basic and complete metabolic profiles, lipids, liver function, and renal profile. We are currently holding the one box of flu and RSV.” 6/16/25 to 6/23/25: “We received most of the Fisher supplies. We are currently still out of Digoxin until other supplies arrive (it is on backorder). We are currently low on creatine kinase MB, troponin, and BNP. Controls on the Beckman will expire on 7/5/25. We are currently still holding the box of flu and Strep.” According to EI # 2, Lab Director, supplies were not ordered in May because they did not have the means to pay for them. A copy of requisition requests for lab supplies revealed four requisitions signed by EI # 2 and dated 6/19/25. An interview on 6/25/25 at 1:30 PM with EI # 2 revealed on 6/12/25 the lab ran out of tips for the Vitros XT 3400 machine and were unable to run labs on that machine from 6/13/25 until 6/24/25 when supplies were delivered. The Governing Body and hospital leadership failed to act and ensure services for patient care was available 24/7 after being made aware, since November 2024, of the inability to perform critical laboratory tests due to a lack of supplies.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47295 Based on the review of policies, Staffing Plan for Hospital Nursing Services, nurse staffing schedules, diversion logs, patient census logs, and staff interview, it was determined the facility failed to ensure staffing was adequate to meet the needs of the patients admitted and those seeking emergency treatment. This deficient practice had the potential to negatively affect all patients presenting to this facility for treatment. Findings include: Policy Name: Nursing Staffing Department: All Hospital Units Policy Number: none Revision Date: 07/2023 Purpose: To ensure that appropriate nursing staff levels are maintained to deliver safe, high-quality care in a rural hospital setting, considering unique challenges such as limited workforce, financial constraints, and geographic isolation. Policy Statement: This hospital commits to staffing nursing units with an appropriate number and mix of qualified nursing personnel based on patient acuity, census, available resources, and regulatory requirements... Staffing Ratios: Medical/Surgical Unit: 1 Registered Nurse (RN)/Licensed Practical Nurse (LPN): 4 to 6 patients (adjusted based on acuity) Detox: 1 RN or LPN per shift, with Certified Nursing Assistant (CNA) support Emergency Department (ED): Minimum of 1 RN and 1 additional clinical staff 24/7... Policy Name: Diversion Status Department: Emergency Department Policy Number: none Revision Date: 07/2023 This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients. Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care. Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations... A diversion log must be started and maintained by the ED Charge Nurse. 1. Review of the Staffing Plan for Hospital Nursing Services provided to the surveyor by Employee Identifier (EI) # 1, Chief Nursing Officer (CNO) on 6/25/25 revealed the following statement: “The clinical staff works all three units each shift: (Med Surg; ED; and Detox).” Review of the staffing schedule for May 2025 and June 2025 revealed on 5/21/25, 5/28/25, and 6/16/25, there was one RN and one CNA scheduled for dayshift and the same on nightshift and not one RN for Detox and one RN for the ED as directed in the facility policy. On 6/17/25, there was one CNA working nightshift and one RN working 11:00 PM to 7:00 AM and not one RN for Detox and one RN for the ED as directed in the facility policy Review of the patient census for 5/21/25 revealed five patients were seen in the ED and there were three patients on the Self Recovery unit. Review of the patient census for 5/28/25 revealed eleven patients were seen in the ED and there were three patients on the Self Recovery unit. Review of the patient census for 6/16/25 revealed eight patients were seen in the ED and there were three patients on the Self Recovery unit. Review of the patient census for 6/17/25 revealed five patients were seen in the ED and there were two patients on the Self Recovery unit. An interview conducted on June 26 at 3:00 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the facility was not following their own policy for staffing the hospital. 2. Review of the Hospital Diversion Logs for May 2025 and June 2025 revealed the hospital was on diversion on the following dates due to a nursing shortage: 5/21/25, 5/28/25, 6/12/25, 6/16/25, 6/17/25, and 6/19/25. An interview was conducted on 6/26/25 at 4:42 PM with EI # 4, ED Medical Director, who confirmed the ED physician on call is the one who makes the decision to go on diversion. The facility failed to ensure staff was available to meet the needs of both patients admitted to the facility and those seeking emergency treatment.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 47295 Based on medical record (MR) review, review of the Rules and Regulations, and interview with staff, it was determined the facility failed to ensure the ordering physician dated, timed, and/or authenticated all orders. This deficient practice affected two of three inpatient MRs reviewed, including Patient Identifier (PI) # 8 and PI # 10, and had the potential to negatively affect all patients admitted to the facility. Findings include: Rules and Regulations Medical Staff Greene County Hospital ...Medical Records ...9. All clinical entries in the patient’s medical record shall be accurately timed, dated, and authenticated... 1. PI # 8 was admitted to the facility on 5/17/25 with a diagnosis of medical detox. Review of the MR revealed the admission orders from 5/17/25 were not signed, dated, or timed by the admitting physician. An interview conducted on 6/26/25 at 2:43 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the orders were not properly authenticated with a physician signature, date, and time. 2. PI # 10 was admitted to the facility on 6/13/25 with a diagnosis of multisubstance drug abuse. Review of the MR revealed the admission orders from 6/13/25 were not dated or timed by the admitting physician. An interview conducted on 6/26/25 at 2:39 PM with EI # 1 confirmed the orders were not properly authenticated with a date and time.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 47295 Based on medical record (MR) review and staff interview, it was determined the facility failed to ensure a medical history and physical was completed and documented by the physician within 24 hours after admission. This deficient practice affected one of three inpatient MRs reviewed and had the potential to negatively affect all patients admitted to the facility. Findings include: Patient Identifier (PI) # 8 was admitted to the facility on 5/24/25 with a diagnosis of medical detox. MR review revealed a blank History and Physical form. An interview was conducted on 6/26/25 at 2:43 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed there was no documentation of a history and physical being completed.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 47295 Based on medical record (MR) review and staff interview, it was determined the facility failed to ensure nurse’s notes and withdrawal assessments were completed for each patient. This deficient practice affected two of two substance abuse MRs reviewed and had the potential to affect all patients admitted to the facility. Findings include: 1. Patient Identifier (PI) # 8 was admitted to the facility on 5/24/25 with a diagnosis of medical detox. MR review revealed no documentation of nurse’s notes on 5/21/25 or 5/23/25. An interview was conducted 6/26/25 at 2:43 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there were no nurse’s notes documented on 5/21/25 or 5/23/25. 2. PI # 10 was admitted to the facility on 6/13/25 with a diagnosis of multisubstance drug abuse. Review of the MR revealed no Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score completed on 6/16/25. An interview was conducted on 6/26/25 at 2:39 PM with EI # 1, who confirmed there was no documentation of a CIWA score on 6/16/25. EI # 1 also confirmed the score should be assessed and documented daily by the nurse.”

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 47295 Based on medical record (MR) reviews, policies and procedures, Emergency Department (ED) diversion logs, and staff interviews, it was determined the facility failed to ensure laboratory (lab) services were available to all patients 24 hours a day. This deficient practice had the potential to negatively affect all patients served by this facility and did affect Patient Identifier (PI) # 11, one of one inpatient death records reviewed. Findings include: Policy Name: Diversion Status Department: Emergency Department Policy Number: none Revision Date: 07/2023 This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients. Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care. Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations... 1. A review of the ED Diversion Logs revealed the ED was on diversion on 6/12/25, 6/13/25, 6/16/25, 6/17/25, and 6/19/25 due to the hospital’s inability to process critical labs. 2. A review of the lab calibration logs revealed the lab ran out of reagents and tips for the Vitros XT 3400 machine on 6/12/25. The lab was unable to process critical labs beginning on 6/13/25 to 6/24/25. An interview was conducted on 6/25/25 at 1:10 PM with Employee Identifier (EI) # 2, Lab Director, who confirmed critical labs were unavailable for processing and reporting to meet the needs of the ED and inpatient services from 6/13/25 to 6/24/25. An interview was conducted on 6/26/25 at 3:45 PM with EI # 5, Assistant Counselor/Tech for the Self Recovery Unit. EI # 5 stated from 6/13/25 to 6/24/25, the lab was unable to run an alcohol level which is required for admission to the self recovery unit. He/she confirmed that three patients were put “on hold” for admission approval due to the inability to process required admission labs. 49603 2. PI # 11 was admitted to the facility on 6/4/25 with a diagnosis of Pneumonia Unspecified Organism. Review of the medical record for PI # 11 revealed a physician’s order for a Metabolic Panel to be collected on 6/4/25, 6/5/25, 6/6/25 and 6/9/25. Review of the lab results dated 6/4/25, 6/5/25, and 6/6/25 revealed no sodium, calcium or anion gap results which are included in a Metabolic Panel. Further review of lab results dated 6/9/25 revealed no sodium, calcium, potassium, or anion gap results which are included in a Metabolic Panel. An interview was conducted on 6/26/25 at 2:39 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed all lab services were not available to all patients 24 hours a day.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 47295 Based on the review of policies, laboratory (lab) calibration logs, diversion logs, radiology department issues form, and staff interview, it was determined the facility failed to ensure: 1. Emergency Department (ED) services were integrated with other departments within the hospital, including laboratory and radiology services. 2. Lab services were available to the ED for eleven days, starting on 6/13/25 and ending on 6/24/25. 3. Diversion Logs indicated an end time for the eight days the ED was on diversion in May 2025 and June 2025. These deficient practices had the potential to negatively affect all patients presenting to the ED for treatment. Findings include: Policy Name: Diversion Status Department: Emergency Department Policy Number: none Revision Date: 07/2023 This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients. Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care. Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations... Review of the Hospital Diversion Logs for May 2025 and June 2025 revealed on 5/24/25 and 6/13/25 the hospital was on diversion due to not having radiological testing available. On 5/24/25, diversion started at 4:00 AM due to “No radiology.” No end time was documented. On 6/13/25, diversion started at 7:00 PM due to “Radiology Down.” No end time was documented. Review of the Radiology Department Issues form revealed on 5/7/25 and 6/19/25, the computed tomography (CT) images would not electronically send. The radiologist is contracted and off site. This necessitates the need for electronic delivery of images for interpretation. Further review of the Radiology Department Issues form revealed on 6/21/25, the employee scheduled to work called in sick. There was no available radiology staff to work the shift. Review of the diversion logs revealed the facility was on diversion due to not having critical laboratory testing available on 5/24/25, 6/12/25, 6/13/25, 6/16/25, 6/17/25, and 6/19/25. On 5/24/25, diversion started at 4:00 AM due to “No labs.” No end time was documented. On 6/12/25, 6/13/25, 6/17/25, and 6/19/25, diversion started at 7:00 PM due to “No labs.” No end time was documented. On 6/16/25, diversion started at 11:30 PM due to “No labs.” No end time was documented. On 6/25/25 at 1:10 PM, a review of the laboratory calibration logs and interview with Employee Identifier (EI) # 2, Laboratory Director, revealed critical labs were unavailable for processing and reporting to meet the needs of the ED patients from 6/13/25 to 6/24/25. An interview conducted on June 26 at 3:00 PM with EI # 1, Chief Nursing Officer, confirmed the facility was not ensuring laboratory and radiology services were available 24/7 as required.”

“EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b) Personnel This Standard is not met as evidenced by: 47295 Based on the review of policies, the Staffing Plan for Hospital Nursing Services, nurse staffing schedules, diversion logs, patient census logs, and staff interview, it was determined the facility failed to ensure staffing of the Emergency Department (ED) was adequate to meet the needs of the patients and ensure patient safety. This deficient practice had the potential to negatively affect all patients presenting to the ED for treatment. Findings include: Policy Name: Nursing Staffing Department: All Hospital Units Policy Number: none Revision Date: 07/2023 Purpose: To ensure that appropriate nursing staff levels are maintained to deliver safe, high-quality care in a rural hospital setting, considering unique challenges such as limited workforce, financial constraints, and geographic isolation. Policy Statement: This hospital commits to staffing nursing units with an appropriate number and mix of qualified nursing personnel based on patient acuity, census, available resources, and regulatory requirements... Staffing Ratios: ...ED: Minimum of 1 Registered Nurse (RN) and 1 additional clinical staff 24/7... Review of the Staffing Plan for Hospital Nursing Services provided to the surveyor by Employee Identifier (EI) # 1, Chief Nursing Officer (CNO) on 6/25/25 revealed the following statement: “The clinical staff works all three units each shift: (Med Surg; ED; and Detox).” Policy Name: Diversion Status Department: Emergency Department Policy Number: none Revision Date: 07/2023 This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients. Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care. Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations... Review of the Hospital Diversion Logs for May 2025 and June 2025 revealed the hospital was on diversion due to a nursing shortage on 5/21/25, 5/28/25, 6/12/25, 6/16/25, 6/17/25, and 6/19/25. On 5/21/25, 5/28/25, 6/12/25, 6/17/25, and 6/19/25, diversion started at 7:00 PM due to “Nursing shortage.” No end time was documented. On 6/16/25, diversion started at 11:30 PM due to “No nurse.” No end time was documented. Review of the staffing schedule for May 2025 and June 2025 revealed on 5/21/25, 5/28/25, and 6/16/25, there was one RN and one CNA scheduled for dayshift and nightshift. There was no RN scheduled for the ED 24/7 as directed in the facility policy. On 6/17/25 there was one CNA working nightshift one RN working 11:00 PM to 7:00 AM. There was no RN scheduled for the ED 24/7 as directed in the facility policy. Review of the patient census for 5/21/25 and 6/17/25, revealed five patients were seen in the ED on each day. Review of the patient census for 5/28/25 revealed eleven patients were seen in the ED. Review of the patient census for 6/16/25 revealed eight patients were seen in the ED. There was only one RN on duty in the facility on the above dates requiring the nurse to leave inpatients without a nurse available while he/she cared for emergency room patients. An interview conducted on June 26 at 3:00 PM with Employee Identifier # 1, Chief Nursing Officer, confirmed the facility was not following the policy for staffing the ED in order to ensure patient safety.”