Bear Valley Community Hospital

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 43035 Based on record review and interview, the facility failed to maintain an Emergency Preparedness Program (EPP). This was evidenced by missing documentation for arrangement with other facilities. This affected four of four residents and could result in the failure to react during an emergency. Findings: During record review and interview with the Director of Facilities (DOF) on 4/30/24, the EPP was requested and reviewed. At 1:54 p.m., the facility was unable to provide transfer agreements of arrangements with other facilities or other providers to receive residents in the event of limitations or cessation of operations to maintain the continuity of services to facility residents. Upon interview, the DOF stated that they would provide the memorandum of understandings. As of 5/1/24 requested records were not received by the California Department of Public Health.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 43035 Based on record review and interview, the facility failed to maintain an Emergency Preparedness Program (EPP). This was evidenced by missing information in the emergency power supply system policy and procedure. This affected the four of four residents and could result in the failure to properly react during an emergency. Findings: During record review and interview with the Director of Facilities (DOF) on 4/30/24, the EPP was reviewed. At 2:31 p.m., the facility was missing a written and specified policy and procedure for maintaining emergency power during an outage such as, how back up fuel would be acquired and how long back up fuel could sustain emergency power. The facility was unable to provide a plan for how it will keep emergency power systems operational during an emergency. Upon interview, the DOF confirmed the finding and stated that they were not aware of the regulation.”

“K3 BUILDING: 01 K6 PLAN APPROVAL: 1991 K7 SURVEY UNDER: 2012 EXISTING STRUCTURE TYPE: ONE STORY, CONSTRUCTION TYPE V (111), FULLY SPRINKLERED. Resident Certified Beds: 9 Resident Census: 4 The following reflects the findings of the California Department of Public Health, during a *Full Medicare Validation Life Safety Code Survey. The findings are in accordance with 42 Code of Federal Regulations (CFR) §485.623(c)(d)(e), National Fire Protection Association (NFPA) 101 - Life Safety Code, 2012 Edition, and NFPA 99 - Health Care Facilities Code, 2012 Edition. Representing the California Department of Public Health: 43035”

“LICENSURE OF CAH CFR(s): The CAH is licensed in accordance with applicable Federal, State and local laws and regulations. This Standard is not met as evidenced by: 47682 Based on observation, interview and record review, the facility failed to ensure compliance with the State of California Title 22 Regulations (T 22 - health facility laws) when the facility did not have an active program flex (flexibility granted to a hospital in how they meet specific licensing regulations) from the California Department of Public Health (CDPH) to allow one (1) of two (2) licensed operating rooms (OR) to be rendered inoperable and used for storage. This failure resulted in a lack of OR redundancy and reduced capacity with the potential to hinder the hospital’s ability to provide life-saving surgery in an emergency. Findings: During a review of the “California Code of Regulations, Title 22, Licensing and Certification of Health Facilities and Referral Agencies, Article 8, Regulation 70805,” (Title 22), “Title 22” indicated, “Spaces approved for specific uses at the time of licensure shall not be converted to other uses without the written approval of the Department.” During a concurrent observation and interview on April 8, 2024, at 2:10 PM, with the Surgical Technician (ST), in Operating Room 2 (OR 2), OR 2 was noted to be full of supply racks and stored equipment which made the room unusable for surgery. ST stated, facility had two operating rooms, but only one was functioning. ST further stated, OR 2 was just used for storage at the moment. During an interview on April 11 at 11:20 AM, with the Operating Room Director (ORD), the ORD stated, we have used OR 2 as storage for years with a waiver, it was on the door until a couple of days ago. The ORD stated, she did not know it was expired. The ORD stated, she had been with the facility since 2000 and OR 2 was never used for surgeries. The ORD stated, facility would not be able to operate in OR 2 with all the stored supplies. The ORD further stated, “We just need to get that new flex approved.” During an interview on April 11 at 11:50 AM, with the Chief Nursing Officer (CNO), the CNO stated, facility was licensed for two operating rooms and OR 2 was currently being used for storage. The CNO further stated, “It requires a flex. We don’t have an active flex, the renewal is still pending. We had a waiver that expired December 2023. Mid December we applied for a renewal, as far as we know it has not yet been approved.” A review of the facility’s program flex history indicated, facility was seeking a Program Flexibility for Title 22, California Code of Regulations, Section 70805 to use OR 2 for the storage of supplies and equipment. Program flex status remained pending.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 46696 Based on observation, interview, and record review, the facility failed to ensure necessary supplies and equipment for patient care were safe, maintained, and readily available for a universe of five patients, when there were nine pairs of sterile gloves, six intra venous (I V - in to the vein) needles (Needles used for gaining access to a patients vein to deliver medications and fluids) were found in the medical unit supply room, and one (1) box of suture needles were found to be expired in Operating Room 1 (OR 1) . This failure had the potential for expired supplies to be used in patient care increasing risk for infection and prolonged hospitalization. Findings: During an observation on April 9, 2024, at 10:30 AM, in the medical surgical supply room, six IV needles were found in IV start baskets with expiration dates of April 16, 2023. It was further observed that nine pairs of size six sterile gloves were found with an expiration date of March 2024. During a concurrent observation and interview on April 9, 2024, at 11:15 AM, with Registered nurse (RN 1), in the medical surgical supply room, the expired 18-gauge needles and sterile gloves were observed. RN1 stated, these expired supplies should not be on the floor, they place patients at risk for infection if we use them. During a concurrent observation and interview on April 9, 2024, at 11:20 AM, with the Infection Control Practitioner (ICP), in OR 1, an expired box of suture needles dated March 2024, was observed stocked in the OR room 1 supply cabinet. The ICP stated, these supplies were expired, and they should not be stocked as they would pose an infection control risk for the patients, and this was not following the facility policy. During a review of the facility’s undated, policy and procedure (P&P) titled, “Care of Sterile supplies”, the P&P indicated, “All sterile supplies shall be checked for package integrity or other compromising conditions before use. 5.1 Items shall be considered contaminated for the following reasons: 5.1.1. Outdated (if supplier has indicated date of expiration on the product).””